Abstract
Premature rupture of a cerebral aneurysm during operation is a serious hazard. Temporary clipping of intracranial arteries has emerged as a valuable technical adjunct in the management of intracranial aneurysms. During a 4-year and 3 month period, 89 patients (35 ICA aneurysms, 23 MCA aneurysms, and 31 ACA territory aneurysms) who underwent elective temporary occlusion under normothermia and normotension were evaluated with regard to the appearance of clinical and radiological evidence of cerebral infarction in the early postoperative period. 73 of 89 patients were consequetively monitored with SEP during operation. Median nerve SEPs were used in 29 ICA and 19 MCA aneurysm operations, while posterior tibial nerve SEPs were used in 25 ACA aneurysm operations. Temporary clipping was used once in 62 cases, twice in 18 cases, three times in 7 cases and 4 times in 2 cases. Application form of temporary clipping was proximal clipping in 47 cases and trapping in 42 cases. Temporary clipping time was as follows: ICA aneurysms; 14.0±11.8 minutes, MCA aneurysms; 12.6±7.4 minutes, ACA aneurysms; 19.3±16.4 minutes. Ischemic group representing positive neurological deficits or asymptomatic perforating artery territory infarction showed longer temporary clipping time than that of non-ischemic group. Neurological deficits occurred in 6 cases (6.7%). Permanent left hemiplegia with a right hemispheric infarction developed in a ICA aneurysm case following trapping of ICA for 60 minutes. Transient neurological deficits included one ICA aneurysm with right hemiparesis, two MCA aneurysm cases with motor aphasia and sensory aphasia, and two ACA aneurysm cases with left hemiparesis. All but one positive neurological deficits cases underwent trapping as temporary clipping for somewhat longer period. Both the Acorn A aneurysm case with transient left hemiparesis and the MCA aneurysm case with transient sensory aphasia were considered as SEP false negative cases. 15 cases (16.9%) had asymptomatic perforating artery territory infarction, which included 4 cases in putamen and 4 cases in caudate with ICA aneurysm case, one case in globus pallidus with MCA aneurysm case, and 5 cases in caudate and one case in putamen with ACA aneurysm. 12 of 15 cases with asymptomatic peforating artery territory infarction underwent trapping as temporary clipping. Perforating artery territory was demonstrated to be weak in cerebral ischemia following temporary clipping of main trunk of cerebral artery in aneurysm surgery as expected in the mechanism of cerebral infarction for major trunk occlusion such as ICA occlusion.
