Albert J Schuette1, Daniel L Barrow1, Aaron A Cohen-Gadol2. 1. Department of Neurosurgery, Emory University, Atlanta, Georgia, USA. 2. Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University, Indianapolis, Indiana, USA. Electronic address: acohenmd@gmail.com.
Abstract
BACKGROUND: The occurrence of intraoperative rupture (IOR) of an aneurysm is one of the most precarious moments in microsurgery, and the management of IOR profoundly affects operative outcomes. METHODS: The authors describe their personal experiences during the past decade with managing intraoperative aneurysm rupture for microsurgical treatment of complex cerebral aneurysm procedures. RESULTS: Steps to avoid and manage IOR depend on the stage of the operation or phase of dissection and on aneurysm location and configuration. The point at which IOR occurs dictates the management options available. The rupture of the aneurysm itself usually does not cause death or disability, but the subsequent actions performed by the surgeon can make the difference between a good and poor outcome. Major complications are caused by the surgeon's premature reaction placing a permanent clip in the face of torrential bleeding without adequate visualization, leading to vascular and cranial nerve injuries. Short videos are provided to illustrate the technical nuances to minimize complications. CONCLUSIONS: Accurate knowledge of the anatomy of the aneurysm and surrounding vasculature is the keystone to prevention and treatment of IOR. Most importantly, the surgeon must not rush prematurely to apply a permanent clip blindly in an effort to stop the hemorrhage.
BACKGROUND: The occurrence of intraoperative rupture (IOR) of an aneurysm is one of the most precarious moments in microsurgery, and the management of IOR profoundly affects operative outcomes. METHODS: The authors describe their personal experiences during the past decade with managing intraoperative aneurysm rupture for microsurgical treatment of complex cerebral aneurysm procedures. RESULTS: Steps to avoid and manage IOR depend on the stage of the operation or phase of dissection and on aneurysm location and configuration. The point at which IOR occurs dictates the management options available. The rupture of the aneurysm itself usually does not cause death or disability, but the subsequent actions performed by the surgeon can make the difference between a good and poor outcome. Major complications are caused by the surgeon's premature reaction placing a permanent clip in the face of torrential bleeding without adequate visualization, leading to vascular and cranial nerve injuries. Short videos are provided to illustrate the technical nuances to minimize complications. CONCLUSIONS: Accurate knowledge of the anatomy of the aneurysm and surrounding vasculature is the keystone to prevention and treatment of IOR. Most importantly, the surgeon must not rush prematurely to apply a permanent clip blindly in an effort to stop the hemorrhage.