title: "Awake" clipping of cerebral aneurysms: report of initial series.
abstract: OBJECTIVE Risk of ischemia during aneurysm surgery is significantly related to temporary clipping time and final clipping that might incorporate a perforator. In this study, the authors attempted to assess the potential added benefit to patient outcomes of "awake" neurological testing when compared with standard neurophysiological testing performed under general anesthesia. The procedure is performed after the induction of conscious sedation, and for the neurological testing, the patient is fully awake. METHODS The authors conducted an institutional review board-approved prospective study of clipping unruptured intracranial aneurysms (UIAs) in 30 consecutive adult patients who underwent awake clipping. The end points were the incidence of stroke/cerebrovascular accident (CVA), death, discharge to a long-term facility, length of stay, and 30-day modified Rankin Scale score. All clinical and neurophysiological intraoperative monitoring data were recorded. RESULTS The median patient age was 52 years (range 27-63 years); 19 (63%) female and 11 (37%) male patients were included. Twenty-seven (90%) aneurysms were anterior, and 3 (10%) were posterior circulation aneurysms. Five (17%) had been coiled previously, 3 (10%) had been clipped previously, 2 (7%) were partially calcified, and 2 (7%) were fusiform aneurysms. Three patients developed synchronous clinical neurological and neurophysiological changes during temporary clipping with consequent removal of the temporary clip and reversal of those clinical and neurophysiological changes. Three patients developed asynchronous clinical neurological and neurophysiological changes. These 3 patients developed hemiparesis without changes in neurophysiological monitoring results. One patient developed linked clinical neurological and neurophysiological changes during final clipping that were not reversed by reapplication of the clip, and the patient had a CVA. Four patients with internal carotid artery ophthalmic segment aneurysms underwent visual testing with final clipping, and 1 of these patients required repositioning of the clip. Three patients who required permanent occlusion of a vessel as part of their aneurysm treatment underwent a 10-minute intraoperative clinical respective-vessel test occlusion. The median length of stay was 3 days (range 1-5 days). The median modified Rankin Scale score was 1 (range 0-3). All of the patients were discharged to home from the hospital except for 1 who developed a CVA and was discharged to a rehabilitation facility. There were no deaths in this series. CONCLUSIONS The 3 patients who developed neurological deterioration without a concomitant neurophysiological finding during temporary clipping revealed a potential advantage of awake aneurysm surgery (i.e., in decreasing the risk of ischemic injury).
authors: Departments of 1 Neurosurgery and.
authors: Saleem I
authors: SI
authors: Abdulrauf
authors: Anesthesiology and.
authors: Peter
authors: P
authors: Vuong
authors: Anesthesiology and.
authors: Ritesh
authors: R
authors: Patel
authors: Departments of 1 Neurosurgery and.
authors: Raghu
authors: R
authors: Sampath
authors: Departments of 1 Neurosurgery and.
authors: Ahmed M
authors: AM
authors: Ashour
authors: Departments of 1 Neurosurgery and.
authors: Lauren M
authors: LM
authors: Germany
authors: Departments of 1 Neurosurgery and.
authors: Jonathon
authors: J
authors: Lebovitz
authors: Anesthesiology and.
authors: Colt
authors: C
authors: Brunson
authors: Anesthesiology and.
authors: Yuvraj
authors: Y
authors: Nijjar
authors: Anesthesiology and.
authors: J Kyle
authors: JK
authors: Dryden
authors: Departments of 1 Neurosurgery and.
authors: Maheen Q
authors: MQ
authors: Khan
authors: Departments of 1 Neurosurgery and.
authors: Mihaela G
authors: MG
authors: Stefan
authors: Departments of 1 Neurosurgery and.
authors: Evan
authors: E
authors: Wiley
authors: Departments of 1 Neurosurgery and.
authors: Ryan T
authors: RT
authors: Cleary
authors: Departments of 1 Neurosurgery and.
authors: Connor
authors: C
authors: Reis
authors: Saint Louis University Hospital Database.
authors: Jodi
authors: J
authors: Walsh
authors: Saint Louis University Center for Outcomes Research, St. Louis University, Missouri.
authors: Paula
authors: P
authors: Buchanan
mesh_terms: D000328:Adult; D006801:Humans; D002532:Intracranial Aneurysm / Q000601:surgery*; D064795:Intraoperative Neurophysiological Monitoring / Q000379:methods*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000517:prevention & control*; D011446:Prospective Studies; D014656:Vascular Surgical Procedures / Q000379:methods; D014851:Wakefulness
keywords: ACoA = anterior communicating artery; CVA = cerebrovascular accident; EEG = electroencephalography; ICA = internal carotid artery; LOS = length of stay; MCA = middle cerebral artery; MEP = motor evoked potential; NIS = National Inpatient Sample; SSEP = somatosensory evoked potential; UIA = unruptured intracranial aneurysm; VA = vertebral artery; aneurysm treatment outcomes; awake craniotomy; basilar artery aneurysm; cerebral aneurysms; mRS = modified Rankin Scale; temporary occlusion testing; vascular disorders