J Neurol Surg A Cent Eur Neurosurg 2021; 82(05): 410-416
DOI: 10.1055/s-0040-1721004
Original Article

Predictors of Intraoperative Aneurysm Rupture, Aneurysm Remnant, and Brain Ischemia following Microsurgical Clipping of Intracranial Aneurysms: Single-Center, Retrospective Cohort Study

1   Maria Sklodowska-Curie Hospital, Neurosurgery Zgierz, Lodz, Poland
Jarosław Szymański
2   University of Lodz Faculty of Economics and Sociology, Economic and Social Statistics, Lodz, Poland
Anna Szymańska
2   University of Lodz Faculty of Economics and Sociology, Economic and Social Statistics, Lodz, Poland
Piotr Komuński
1   Maria Sklodowska-Curie Hospital, Neurosurgery Zgierz, Lodz, Poland
› Author Affiliations


Background and Study Aims Complete microsurgical clip occlusion of an aneurysm is one of the most important challenges in cerebrovascular surgery. Incorrect position of clip blades as well as intraoperative aneurysm rupture can expose the patient to serious complications such as rebleeding in case of aneurysm remnant and cerebral ischemia in case of occlusion of branching arteries or perforators. The aim of this study was to identify independent predictors of surgery-derived complications (aneurysm remnant and brain ischemia) as well as intraoperative aneurysm rupture in an institutional series of patients.

Material and Methods This is a single-institution, retrospective cohort study including 147 patients with 162 aneurysms that were selected for microsurgical clipping due to intracranial aneurysm in a 5-year period. Bivariate and multivariate analyses were performed to identify independent predictors among demographic, clinical, and radiographic factors.

Results Increasing aneurysm size with a cutoff value at 9 mm (p = 0.009; odds ratio [OR]: 0.644) and irregular dome shape (p = 0.003; OR: 4.242) were independently associated with brain ischemia and aneurysm remnants that occurred in 13.6 and 17.3% of patients in our group, respectively. Intraoperative rupture was encountered in 27% of patients and its predictors were patient's age (p = 0.002; OR: 1.073) and increasing aneurysm size with a cutoff value at 7 mm (p = 0.003; OR: 1.205).

Conclusion Aneurysm size, patient's age, and irregular dome shape were the most important risk factors of aneurysm remnant, brain ischemia, and intraoperative aneurysm rupture in our series of patients. We were not able to define a cutoff value for patient's age, but our results showed that with increasing age the risk of intraoperative aneurysm rupture increased.

Ethical Statement

This study was approved by the Medical Center Institutional Review Board for human research.

Informed consent was obtained from all individual participants in the study.

Publication History

Received: 21 December 2019

Accepted: 12 May 2020

Article published online:
14 February 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

  • References

  • 1 David CA, Vishteh AG, Spetzler RF, Lemole M, Lawton MT, Partovi S. Late angiographic follow-up review of surgically treated aneurysms. J Neurosurg 1999; 91 (03) 396-401
  • 2 Friedman JA, Pichelmann MA, Piepgras DG. et al. Ischemic complications of surgery for anterior choroidal artery aneurysms. J Neurosurg 2001; 94 (04) 565-572
  • 3 Macdonald RL, Wallace MC, Kestle JR. Role of angiography following aneurysm surgery. J Neurosurg 1993; 79 (06) 826-832
  • 4 Origitano TC, Schwartz K, Anderson D, Azar-Kia B, Reichman OH. Optimal clip application and intraoperative angiography for intracranial aneurysms. Surg Neurol 1999; 51 (02) 117-124 , discussion 124–128
  • 5 Zaidat OO, Castonguay AC, Teleb MS. et al. Middle cerebral artery aneurysm endovascular and surgical therapies: comprehensive literature review and local experience. Neurosurg Clin N Am 2014; 25 (03) 455-469
  • 6 Byoun HS, Bang JS, Oh CW. et al. The incidence of and risk factors for ischemic complications after microsurgical clipping of unruptured middle cerebral artery aneurysms and the efficacy of intraoperative monitoring of somatosensory evoked potentials: a retrospective study. Clin Neurol Neurosurg 2016; 151: 128-135
  • 7 Tanabe J, Ishikawa T, Moroi J, Sakata Y, Hadeishi H. Impact of right-sided aneurysm, rupture status, and size of aneurysm on perforator infarction following microsurgical clipping of posterior communicating artery aneurysms with a distal transsylvian approach. World Neurosurg 2018; 111: e905-e911
  • 8 Abboud T, Rustom J, Bester M. et al. Morphology of ruptured and unruptured intracranial aneurysms. World Neurosurg 2017; 99: 610-617
  • 9 Beck J, Rohde S, el Beltagy M. et al. Difference in configuration of ruptured and unruptured intracranial aneurysms determined by biplanar digital subtraction angiography. Acta Neurochir (Wien) 2003; 145 (10) 861-865 , discussion 865
  • 10 Lall RR, Eddleman CS, Bendok BR, Batjer HH. Unruptured intracranial aneurysms and the assessment of rupture risk based on anatomical and morphological factors: sifting through the sands of data. Neurosurg Focus 2009; 26 (05) E2
  • 11 Oh SY, Kim MJ, Kim BM, Lee KS, Kim BS, Shin YS. Angiographic characteristics of ruptured paraclinoid aneurysms: risk factors for rupture. Acta Neurochir (Wien) 2013; 155 (08) 1493-1499
  • 12 Goertz L, Kasuya H, Hamisch C. et al. Impact of aneurysm shape on morbidity after clipping of unruptured intracranial aneurysms. Acta Neurochir (Wien) 2018; 160 (11) 2169-2176
  • 13 Forbes G, Fox AJ, Huston III J, Wiebers DO, Torner J. Interobserver variability in angiographic measurement and morphologic characterization of intracranial aneurysms: a report from the International Study of Unruptured Intracranial Aneurysms. AJNR Am J Neuroradiol 1996; 17 (08) 1407-1415
  • 14 Ferch R, Pasqualin A, Pinna G, Chioffi F, Bricolo A. Temporary arterial occlusion in the repair of ruptured intracranial aneurysms: an analysis of risk factors for stroke. J Neurosurg 2002; 97 (04) 836-842
  • 15 Dhandapani S, Pal SS, Gupta SK, Mohindra S, Chhabra R, Malhotra SK. Does the impact of elective temporary clipping on intraoperative rupture really influence neurological outcome after surgery for ruptured anterior circulation aneurysms?: a prospective multivariate study. Acta Neurochir (Wien) 2013; 155 (02) 237-246
  • 16 Jabbarli R, Pierscianek D, Wrede K. et al. Aneurysm remnant after clipping: the risks and consequences. J Neurosurg 2016; 125 (05) 1249-1255
  • 17 Li H, Pan R, Wang H. et al. Clipping versus coiling for ruptured intracranial aneurysms: a systematic review and meta-analysis. Stroke 2013; 44 (01) 29-37
  • 18 Ahn SS, Kim YD. Three-dimensional digital subtraction angiographic evaluation of aneurysm remnants after clip placement. J Korean Neurosurg Soc 2010; 47 (03) 185-190
  • 19 Ihm EH, Hong CK, Shim YS, Jung JY, Joo JY, Park SW. Characteristics and management of residual or slowly recurred intracranial aneurysms. J Korean Neurosurg Soc 2010; 48 (04) 330-334
  • 20 Sindou M, Acevedo JC, Turjman F. Aneurysmal remnants after microsurgical clipping: classification and results from a prospective angiographic study (in a consecutive series of 305 operated intracranial aneurysms). Acta Neurochir (Wien) 1998; 140 (11) 1153-1159
  • 21 Thornton J, Bashir Q, Aletich VA, Debrun GM, Ausman JI, Charbel FT. What percentage of surgically clipped intracranial aneurysms have residual necks?. Neurosurgery 2000; 46 (06) 1294-1298 , discussion 1298–1300
  • 22 Kivisaari RP, Porras M, Ohman J, Siironen J, Ishii K, Hernesniemi J. Routine cerebral angiography after surgery for saccular aneurysms: is it worth it?. Neurosurgery 2004; 55 (05) 1015-1024
  • 23 Nakase H, Kamada Y, Aoki H, Goda K, Morimoto T, Sakaki T. Clinical study on recurrent intracranial aneurysms. Cerebrovasc Dis 2000; 10 (04) 255-260
  • 24 Le Roux PD, Elliott JP, Eskridge JM, Cohen W, Winn HR. Risks and benefits of diagnostic angiography after aneurysm surgery: a retrospective analysis of 597 studies. Neurosurgery 1998; 42 (06) 1248-1254 , discussion 1254–1255
  • 25 Burkhardt JK, Neidert MC, Mohme M, Seifert B, Regli L, Bozinov O. Initial clinical status and spot sign are associated with intraoperative aneurysm rupture in patients undergoing surgical clipping for aneurysmal subarachnoid hemorrhage. J Neurol Surg A Cent Eur Neurosurg 2016; 77 (02) 130-138
  • 26 Houkin K, Kuroda S, Takahashi A. et al. Intra-operative premature rupture of the cerebral aneurysms. Analysis of the causes and management. Acta Neurochir (Wien) 1999; 141 (12) 1255-1263
  • 27 Leipzig TJ, Morgan J, Horner TG, Payner T, Redelman K, Johnson CS. Analysis of intraoperative rupture in the surgical treatment of 1694 saccular aneurysms. Neurosurgery 2005; 56 (03) 455-468 , discussion 455–468
  • 28 van Lindert EJ, Böcher-Schwarz HG, Perneczky A. The influence of surgical experience on the rate of intraoperative aneurysm rupture and its impact on aneurysm treatment outcome. Surg Neurol 2001; 56 (03) 151-156 , discussion 156–158
  • 29 Hsu CE, Lin TK, Lee MH. et al. The impact of surgical experience on major intraoperative aneurysm rupture and their consequences on outcome: a multivariate analysis of 538 microsurgical clipping cases. PLoS One 2016; 11 (03) e0151805
  • 30 Lawton MT, Du R. Effect of the neurosurgeon's surgical experience on outcomes from intraoperative aneurysmal rupture. Neurosurgery 2005; 57 (01) 9-15 , discussion 9–15
  • 31 Oppong MD, Pierscianek D, Ahmadipour Y. et al. Intraoperative aneurysm rupture during microsurgical clipping: risk re-evaluation in the post-International Subarachnoid Aneurysm Trial era. World Neurosurg 2018; 119: e349-e356