Kashkoush Ahmed I, Jankowitz Brian T, Gardner Paul, Friedlander Robert M, Chang Yue-Fang, Crammond Donald J, Balzer Jeffrey R, Thirumala Parthasarathy D
Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; Department of Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
World Neurosurg. 2017 Aug;104:442-451. doi: 10.1016/j.wneu.2017.05.036. Epub 2017 May 17.
Temporary arterial occlusion (TAO) is valuable for minimizing intraoperative rupture risk during intracranial aneurysm microsurgery; however, it may be associated with ischemic injury. This study aims to identify surgical and intraoperative neurophysiologic monitoring factors that predict perioperative stroke risk after TAO.
We performed a retrospective chart review of 177 intracranial aneurysm surgeries at our institution in which TAO was performed before placement of a permanent clip under monitoring with somatosensory evoked potentials (SSEPs) and electroencephalography. Perioperative stroke was defined as a new-onset neurologic deficit that developed within 24 hours postoperatively that was correlated with hypodensity on postoperative computed tomography.
Ten (6%) patients developed perioperative stroke in the vascular territory of TAO. SSEP changes were observed in 50% (5/10) of patients with perioperative stroke and in 14% (24/167) of patients without stroke (P = 0.003). Mean maximum single-episode TAO duration for patients who developed perioperative stroke was 12.6 minutes (95% confidence interval 8.1-17.1) and TAO duration for patients without stroke was 8.0 minutes (95% confidence interval 7.3-8.7; P = 0.026). In patients with SSEP changes, risk of stroke was particularly elevated with unruptured aneurysms (P = 0.013) compared with patients with ruptured aneurysms. Temporary clip location, number of occlusive episodes, onset and duration of intraoperative neurophysiologic monitoring changes, and rupture status were not predictive of perioperative stroke.
SSEP changes and increased single-episode TAO duration are independently associated with increased perioperative stroke risk. SSEP changes are most predictive for perioperative stroke in unruptured cases.
临时动脉阻断（TAO）对于降低颅内动脉瘤显微手术中术中破裂风险具有重要价值；然而，它可能与缺血性损伤相关。本研究旨在确定预测TAO后围手术期卒中风险的手术及术中神经生理监测因素。
我们对本机构177例颅内动脉瘤手术进行了回顾性病历审查，这些手术在体感诱发电位（SSEP）和脑电图监测下于放置永久性夹闭前进行了TAO。围手术期卒中定义为术后24小时内出现的与术后计算机断层扫描低密度相关的新发神经功能缺损。
10例（6%）患者在TAO血管区域发生围手术期卒中。围手术期卒中患者中有50%（5/10）观察到SSEP变化，无卒中患者中有14%（24/167）观察到SSEP变化（P = 0.003）。发生围手术期卒中的患者平均单次TAO最长持续时间为12.6分钟（95%置信区间8.1 - 17.1），无卒中患者的TAO持续时间为8.0分钟（95%置信区间7.3 - 8.7；P = 0.026）。在有SSEP变化的患者中，与破裂动脉瘤患者相比，未破裂动脉瘤患者的卒中风险尤其升高（P = 0.013）。临时夹闭位置、阻断次数、术中神经生理监测变化的起始和持续时间以及破裂状态均不能预测围手术期卒中。
SSEP变化和单次TAO持续时间增加与围手术期卒中风险增加独立相关。SSEP变化在未破裂病例中对围手术期卒中的预测性最强。
