News | April 27, 2008

Intraoperative Angiography During Intracranial Aneurysm Surgery Results in Better Care

April 28, 2008 - Doctors at The National Brain Aneurysm Center in St. Paul, MN, use intraoperative angiography (IA) now in all of their surgical procedures as re-examination of the vascular anatomy may disclose a fundamental misinterpretation of the local anatomy on the part of the surgeon, which might lead to an error without the use of IA.

Increases in the number of magnetic resonance images being performed in the state of Minnesota have caused an increase in the number of discovered brain aneurysms in the last 10 years. Many of the unruptured aneurysms were of the severe and complex variety treated via intracranial aneurysm surgery rather than with less invasive coiling procedures.

To ensure best possible results for patients undergoing microsurgery for intracranial aneurysms, the medical team at The National Brain Aneurysm Center performed intraoperative angiography (IA) in each case over a 10-year period.

The results of the study, 'IA During Intracranial Aneurysm Surgery, Experience with 1,025 Cases,' will be presented by Eric Nussbaum, M.D., chair of the National Brain Aneurysm Center on Tuesday, April 29, from 3:09-3:16 p.m. during the American Association of Neurological Surgeons annual meeting. Co-authors are Michael Madison, M.D., Michael Myers, M.D., and James Goddard, M.D.

The primary team of neurovascular surgeons led by Dr. Nussbaum and interventional neuroradiologist Dr. Madison focused the findings on cases in which IA altered surgical treatment. They began using IA as a means to ensure the titanium clip used to treat the aneurysm was correctly positioned and did not affect any other vessels, nerves or arteries during the procedure. Dr. Madison performs IA during every intracranial procedure by Dr. Nussbaum.

In 1997, IA added a mean 28.5 minutes to the surgical procedure; by 2006, this was reduced to 10.5 minutes. There were no major complications from any of the IA procedures.

Overall, IA resulted in clip repositioning or the placement of additional clips in 96 cases. Intraoperative angiography demonstrated unexpected aneurysm obliteration in 42 cases when the surgeon suspected additional clip placement would be needed. Those cases most impacted by IA included large/giant aneurysms, lesions with very wide necks necessitating multiclip reconstruction and those cases in which confirmation of a patient bypass represented a necessary precursor to vascular sacrifice.

Drs. Nussbaum and Madison also found that in a small subset of 30 patients, IA demonstrated completely unexpected residual aneurysm or vascular stenosis. Careful re-examination of the vascular anatomy by Dr. Nussbaum disclosed a fundamental misinterpretation of the local anatomy on the part of the surgeon that would have led to an error without the use of IA.

"The use of IA in all of our intracranial aneurysm surgeries gives us a deeper sense of assurance that we have completely corrected the problem, and that we have taken every step possible to ensure our patients' safety," Dr. Nussbaum said.

"We will continue to use intraoperative angiography in all of our surgical procedures because we cannot predict when it will affect the outcome or alter the surgical procedure," explained Dr. Madison.

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