Why Should Temporary Arterial Clipping Be Used for Occlusion during Anterior Cerebral Artery Aneurysm Repair? Evaluation of Prospective Factors

Introduction: This study was undertaken to determine variables that could predict, in the perioperative period of anterior communicating artery (ACom) aneurysms surgeries, the likelihood of postoperative sequelae and complications, after temporary arterial occlusion.

Results: In a universe of 92 patients submitted to ACom aneurysm clipping between 2000 and 2013, a total of 32 patients were operated in the last 7 years. Among these patients, 21 needed temporary arterial occlusion during surgical aneurysm repair, and had their data examined retrospectively. Aneurysms larger than 7 mm were more likely to be treated with longer temporary clipping time than small aneurysms, <7 mm (11.3 ± 4.1 vs. 22 ± 5.7, t-test, p < 0.0001). There was no statistical correlation between time of occlusion and outcome (r = 0.92, Pearson, p > 0.08). Age, Glasgow Coma Scale (GCS) at initial evaluation, and Fisher scale at 1st CT scanning were independent factors of unfavorable outcome (Glasgow Outcome Scale ≤ 3) (cox-regression, p < 0.001). Among variable factors, being older than 50 years, an initial GCS under 13, and a Fisher grade III or IV resulted in worse outcome. Meanwhile gender, tobacco or alcohol addiction, obesity, arterial hypertension, dyslipidemia, location of temporary occlusion (A1 or A2), intraoperative rupture and the aneurysm size were not identified as independent prognostic factors. During follow-up period, two-thirds of the patients had a favorable outcome (GOS ≥ 4), accomplishing normal daily life activities without major complications. Fifty-two percent of patients evolved with hydrocephalus, despite of routinely fenestration of the lamina terminalis, performed in 71.4% of procedures. Most patients also developed clinical vasospasm (66.6%), with 19% of the patients harboring a severe disease. Delayed ischemic neurological deficit was observed in 28.5%, secondary to severe vasospasm, and without any statistical correlation to time of temporary occlusion or intraoperative aneurysm rupture.

Conclusion: Temporary clipping during ACom aneurysm repair does not seem to add more morbidities to the procedure, and is not an independent prognostic factor. However, age, initial GCS and Fisher grade are associated to unfavorable outcome.