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Background Microvascular Doppler (MVD) has been widely used for the detection of arterial blood flow in the brain, especially during aneurysm clipping, vascular malformation resection, or bypass surgeries. However, the benefits obtained from early identification of intracranial sinuses and deep draining veins during tumor resection has not been reported. Methods We reviewed the clinical data and imaging from our cases and conducted a systemic review of the medical literature using PubMed and keywords. Bibliographies of each result were evaluated to determine if additional reports describing the use of MVD during tumor resection could be found. Results No reports were found in the literature where MVD was specifically used for venous identification during the resection of deep-seated brain tumors. In our patient cohort, MVD was used successfully to detect and ultimately allow immediate protection of large dural venous sinuses as well as smaller deep cerebral veins during tumor resection. Each patient developed no new venous infarcts and made a satisfactory recovery with no new postoperative neurological deficits. Conclusion MVD is a reliable tool for the intraoperative detection of intracranial venous blood flow to allow for quick identification and protection of venous structures. MVD is an additional safety measure for the patient as its accuracy in detecting venous structures is less susceptible to many of the inherent weaknesses of stereotactic neuro-navigation including the accompanying brain shift or anatomical distortion produced by long duration deep seated brain tumor resection.

Background Anatomy of anterior communicating vascular complex is variable and sometimes causes troublesome situations during microsurgical clipping of ruptured anterior communicating (Acom) aneurysms. Preoperative understanding of anatomy, expecting the presence of normal variations, knowing the exact aneurysm morphometrics and understanding flow dynamic patterns, help to reach an appropriate surgical outcome. Methods We analyzed the preoperative angiographic anatomical findings in computed tomography angiography and compared them to the intraoperative microscopic anatomical finding in 52 patients who underwent microsurgical clipping of ruptured Acom aneurysms, to reach angiographic prognostic factors in ruptured Acom aneurysm surgery. Results There is statistically significant relation between intraoperative anatomical factors and preoperative CTA findings (closed A2 aneurysm angle, neck extending to A2, anatomical variation, hypoplastic A1, and posterior projection). Conclusion CTA is a reliable method to predict the intraoperative anatomy in Acom aneurysm clipping. Poor outcome was more common among cases with posterior projection, closed A2-aneurysm angle, aneurysm neck extension to A2, and hypoplastic A1.

Pericallosal artery aneurysms differ from other cerebral aneurysms for the difficulty in establishing proximal vascular control during surgical clipping. A frontomedial craniotomy with combined pterional and interhemispheric approach allows obtaining a better proximal control. We present our surgical technique to achieve a proximal vessel control in pericallosal artery aneurysm clipping using a combined pterional and interhemispheric approach through frontomedial craniotomy. This surgical technique is illustrated by an intraoperative video. Proximal control for pericallosal artery aneurysm clipping can be challenging. In selected cases, a single craniotomy allows performing two approaches and obtaining a safer proximal control for surgical clipping.

In our institution, standard pterional craniotomy (PC) with an extended Sylvian fissure opening (ESFO) represented the standard approach for unruptured middle cerebral artery (MCA) aneurysm clipping until 2014, when we progressively started to prefer minipterional craniotomy (MPC) associated with a focused Sylvian fissure opening (FSFO). In the present study, we compared our results in terms of the efficacy of clipping and the rate of complications with these 2 different techniques.We included patients with small- and medium-size unruptured MCA aneurysms from January 2008 to December 2018 with follow-up of12 months. The clinical and radiologic data were reviewed from the medical records. The outcomes were measured in terms of efficacy (aneurysmal exclusion rate) and safety (intracranial complication rate).Overall, 134 patients who had presented with unruptured MCA aneurysms1.5 cm were treated at our institution from January 2007 to December 2018: PC and ESFO were used in 73 patients and MPC and FSFO in 61. The demographics and angioarchitectural features were comparable between the 2 groups, except for age, which was older in the FSFO group. The aneurysm exclusion rate was not different between the 2 groups. The intracranial complication rate was, overall, significantly lower in the FSFO group (P0.001), especially for the rate of postoperative seizures. Finally, the FSFO group had had shorter postoperative hospitalization and better short- and long-term clinical outcomes.The association between MPC and FSFO should represent the standard of treatment of unruptured MCA aneurysms in all referral cerebrovascular centers, allowing for the achievement of the same efficacy of standard PC with ESFO and minimizing the complications.

It is important to assess the cerebral arteries near the clip after cerebral aneurysm clipping. Contrast-enhanced computed tomography angiography has side effects of contrast medium and radiation exposure. Time-of-flight magnetic resonance angiography (TOF-MRA) is a fast and non-invasive method, but clip-induced artifact limits the assessment around the clip. Recently, 3 tesla MRA with ultrashort echo time called SILENT MRA (GE Healthcare Life Sciences, UK) has been reported to have the potential to overcome these disadvantages. We herein present consecutive 19 cerebral aneurysm patients treated by clipping and evaluated using SILENT MRA. The 19 patients (15 women and 4 men) underwent TOF-MRA and SILENT MRA during the same scan session. Two neurosurgeons independently assessed the visibility of the mother vessel at the clipping site in TOF-MRA and SILENT MRA. We also investigated the factors related to visibility in SILENT MRA. All patients' mother vessels were not described in TOF-MRA, and that of 16 patients (84%) were described in SILENT MRA. Overall agreement was 100% in the two neurosurgeons, and the fixed marginal kappa = 1.00 (95% CI: 0.36-1.00). Univariate analysis revealed that larger aneurysm dome and long clip blade length contributed to the visibility of the mother vessel in SILENT MRA. (p = 0.023, 0.007, each). In conclusion, SILENT MRA can be applied for the assessment of the arteries and aneurysm neck remnants near the clip. Using clips with long blade and ligation with its tip would be related to the visibility of the mother vessels in SILENT MRA.

Objective ‒ to analyze the effectiveness of intraoperative contact Doppler, repositioning the clip on the aneurysm and pilot clipping of the cervical aneurysm as the main methods of prevention of inadequate clipping of the cervical aneurysm in patients with intraoperative rupture of aneurysms. Materials and methods. Due to the use of intraoperative contact ultrasound Doppler control it was possible to avoid inadequate clipping of cerebral aneurysms in 16 cases, of which in 12 (75.00 %) cases ‒ incomplete clipping of cerebral aneurysms, in 3 (18.75 %) cases ‒ compression of the aneurysm’s artery-carrier, in 1 (6.25 %) case ‒ slipping of the clip with cerebral aneurysm. Perioperative examination of patients, in addition to intraoperative contact ultrasound Doppler control of radical clipping cerebral aneurysms, included clinical and neurological examination, computed tomography of the brain, cerebral angiography, ultrasound duplex scanning of the main vessels of the head and neck. In the analysis of observations of inadequate clipping of cerebral aneurysms (according to contact intraoperative Doppler), the following parameters were considered: size, location of cerebral aneurysm, timing of surgery after subarachnoid hemorrhage, anatomical forms of intracranial hemorrhage. Results. The purpose of the operations was to devascularize saccular aneurysm to prevent its re-rupture, to reduce the mass effect caused by intracerebral hematoma; reduction of intracranial pressure, rehabilitation of basal cisterns of the brain., But in the postoperative period there was a tendency to worsen the results of treatment, the appearance of focal neurological symptoms on the background of cerebral vasospasm with subsequent development of ischemic complications in patients with III‒V degree according to the Hunt‒Hess Scale on admission, in patients with prolonged temporary clipping of the cerebral aneurysm-artery and prolonged mechanical manipulation of the cerebral arteries and cerebral aneurysm. It should be noted that all patients in our sample, with complicated clipping of cerebral saccular aneurysms, had an intraoperative rupture of the MA, which complicated the process of clipping the saccular aneurysm and prolonged the time of surgery and was one of the inducers of postoperative aggravating consequences. There was a tendency to worsen the results of treatment in patients with III–IV degree according to the Hunt‒Hess Scale. Thus, patients with 1 point according to the Glasgow Outcome Scale, there were 2 patients who had II and III degrees according to Hunt–Hess Scale at hospitalization; among discharged patients with 3 point according to Glasgow Outcome Scale was dominated by patients from the second century according to Hunt‒Hess Scale at hospitalization, among patients with 5 point according to Glasgow Outcome Scale dominated patients who had I degree according to the Hunt‒Hess Scale at hospitalization. Conclusions. Inadequate clipping of the cervix cerebral aneurysm is the main type of non-hemorrhagic complications in the surgery of cerebral aneurysms. The Inadequate clipping of the cervix of the cerebral aneurysm includes the presence of residual blood flow in the cerebral aneurysm after its clipping, stenosis/compression of the main and perforating cerebral arteries with a clip, slipping of the clip from the aneurysm. Among the factors influencing the radical and adequate clipping of the cervix cerebral aneurysm are the size, location of the aneurysm, atherosclerotic lesions of the walls of the arteries and neck of the aneurysm and transferred subarachnoid hemorrhage. Reliable methods of prevention of inadequate clipping of saccular aneurysm are the use of intraoperative Doppler blood flow control, pilot clipping of complex aneurysms, optimization and individualization of surgical access. Aggravating factors that lead to unsatisfactory results of treatment of patients and negative clinical dynamics after the operation of clipping cerebral saccular aneurysm are: severe condition of the patient before surgery (III‒V gr. according to the Hunt‒Hess Scale), severe cerebral edema, intraoperative rupture of saccular aneurysm, long-term mechanical manipulations on cerebral arteries (long-term temporary clipping of saccular aneurysm, isolation of saccular aneurysm and «neighboring» cerebral arteries from arachnoid adhesions, frequent repositioning of the clip).

Objective Aneurysm residuals after clipping are a well-known problem, but the course of aneurysm remnants in follow-up is not well studied. No standards or follow-up guidelines exist for treatment of aneurysm remnants. The aim of this study was to evaluate the risk factors for postoperative aneurysm remnants and their changes during follow-up. Methods We performed a retrospective analysis of 666 aneurysms treated via clipping in our hospital from 2006 to 2016. Postoperative and follow-up angiographic data were analyzed for aneurysm remnants and regrowth. Clinical parameters and aneurysm-specific characteristics were correlated with radiological results. Results The frequency of aneurysm residuals was 12% (78/666). Aneurysms located in the middle cerebral artery (p = 0.02) showed a significantly lower risk for incomplete aneurysm occlusion. Larger aneurysms with a diameter of 11–25 mm (p = 0.005) showed a significantly higher risk for incomplete aneurysm occlusion. Five patients underwent re-clipping during the same hospital stay. Remnants were stratified based on morphological characteristics into “dog ears” (n = 60) and “broad based” (n = 13). The majority of the “dog ears” stayed stable, decreased in size, or vanished during follow-up. Broad-based remnants showed a higher risk of regrowth. Conclusions A middle cerebral artery location seems to lower the risk for the incomplete clip occlusion of an aneurysm. Greater aneurysm size (11–25 mm) is associated with a postoperative aneurysm remnant. The majority of “dog-ear” remnants appear to remain stable during follow-up. In these cases, unnecessarily frequent angiographic checks could be avoided. By contrast, broad-based residuals show a higher risk of regrowth that requires close imaging controls if retreatment cannot be performed immediately.

The Liliequist membrane is a critical membrane located at the base of the brain separating the supratentorial from the infratentorial cisterns. The advantages of Liliequist membrane fenestration as a critical part of the pterional trans-Sylvian approach for ruptured anterior circulation aneurysm clipping is not well established. We demonstrated that the fundamental role of Liliequist membrane fenestration is brain relaxation through the egress of CSF that is not usually gained from other modalities (e.g., placement of a lumbar drain, fenestration of lamina terminalis) in this specific setting.

Past studies revealed the prognosis differed between aneurysmal subarachnoid hemorrhage (aSAH) patients with surgical clipping and endovascular coiling. We retrospectively reviewed aSAH patients in our institution to investigate the effectiveness of grading scores between two groups. In the surgical clipping group (n = 349), VASOGRADE had a favorable performance for predicting delayed cerebral ischemia (DCI) (area under curve (AUC) > 0.750), and had better results than clinical (World Federation of Neurosurgical Societies (WFNS), Hunt & Hess (HH) and radiological scores (modified Fisher Scale (mFS), Subarachnoid Hemorrhage Early Brain Edema Score) (P 0.750), and had better results than radiological scores (P 0.700, with better performance than mFS (P 0.750), and were better than the radiological scores (P

Compared with endovascular techniques, clipping of ruptured cerebral aneurysms has been shown to associate with increased morbidity in several studies. Despite this, clipping remains the preferred option for many aneurysms. The objective of this study is to describe the reported adverse events of open repair of ruptured cerebral aneurysms and their impact on patient outcome. The PubMed, Embase and Cochrane databases were searched between June 1999 and June 2019 to identify original studies of at least 100 patients undergoing surgical repair of ruptured cerebral aneurysms and in which adverse event rates were reported. Thirty-six studies reporting adverse events in a total of 12,410 operations for repair of ruptured cerebral aneurysms were included. Surgical adverse events were common with 36 event types reported including intraoperative rupture (median rate of 16.6%), arterial injury (median rate of 3.8%) and brain swelling (median rate 5.6%). Only 6 surgical events were statistically shown to associate with poor outcomes by any author and for intraoperative rupture (the most frequently analysed), there was an even split between authors finding a statistical association with poor outcome and those finding no association. Even with modern surgical techniques, the technical demands of surgical aneurysm repair continue to lead to a high rate of intraoperative adverse events. Despite this, it is not known which of these intraoperative events are the most important contributors to the poor outcomes often seen in these patients. More research directed towards identifying the events that most drive operative morbidity has the potential to improve outcomes for these patients. Electronic supplementary material The online version of this article (10.1007/s10143-020-01312-4) contains supplementary material, which is available to authorized users.

Once considered far-fetched, endoscopic endonasal clipping (EEC) has been reported as a feasible alternative route for treating intracranial aneurysms located in the midline. Appropriately, debates regarding EEC applicability have arisen amongst the neurosurgical community. We aim to define the safety, effectiveness, and current state-of-art in the use of EEC for intracranial aneurysms. Two databases (PubMed, Cochrane) were queried for intracranial aneurysms that underwent EEC between inception and 2019. Literature review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Data regarding clinical presentation, radiological imaging, and outcome were extracted and analyzed from selected publications. Nine studies with 27 patients (8 males, 19 females), harboring 35 aneurysms (9 ruptured, 26 nonruptured), met the predetermined inclusion criteria. Patient age range is from 34 to 70 (median = 50) years old. Four aneurysms were considered not suitable for EEC during the procedure, and two aneurysms required additional treatment, leading to an overall treatment success (obliteration) rate of 86%. Complications occurred in 7 patients (26%), including CSF leakage in 5 patients (18%) and ischemic complications in 4 (15%). Among the cases reported, complications occurred more frequently in posterior circulation aneurysms in comparison with anterior circulation aneurysms (62.5 vs 10.5%). Ischemic complications occurred in 4 out of 8 posterior circulation aneurysms. Although feasible, EEC is associated with a significant risk of complications, with rates identified that are significantly higher than established open clipping or endovascular management. The current data suggest that transcranial clipping and endovascular occlusion are still the primary indication for treating intracranial aneurysms.

The authors reported 2 cases with proximal anterior cerebral artery (A1) aneurysms, and one was treated with aneurysm clipping, whereas another was treated with coil embolization. The authors suggest both endovascular surgery and aneurysm clipping are good options for A1 aneurysms.

Objective The aim of the study was to establish a predictive postoperative nomogram for acute kidney injury (AKI) after intracranial aneurysm clipping surgery, in order to early identify patients with high postoperative AKI risk. Methods This is a retrospective study, which included patients who underwent intracranial aneurysm clipping surgery. Multivariate logistic regression was employed to select confound factors that associated with AKI, then incorporated into the nomogram. The predictive accuracy of the model was assessed by concordance index (C-Index). Results A total of 365 patients after intracranial aneurysm clipping surgery were enrolled in the study eventually, of which 68 (18.63%) suffered postoperative AKI, and the incidence of stage 1, stage 2 and stage 3 were 92.65% (63/68), 5.88% (4/68), and 1.47% (1/68), respectively. Univariate logistic regression revealed that high density lipoprotein (HDL), prothrombin time (PT), estimated glomerular filtration rate (eGFR), size of aneurysm ≥10 mm, and aneurysm ruptured before surgery were associated with AKI after surgery, while multivariate logistic regression showed same results as the size of aneurysm ≥10 mm and aneurysm ruptured were independent AKI risk factors. In addition, the nomogram demonstrated a good accuracy in estimating intracranial aneurysm clipping associated AKI, as a C-Index and a bootstrap-corrected one of 0.772 and 0.737, respectively. Moreover, calibration plots showed consistency with the actual presence of AKI. Conclusion The novel nomogram model can serve as a promising predictive tool to improve the identification of AKI among those who underwent intracranial aneurysm clipping surgery.

Basilar apex aneurysms constitute 5%–8% of all intracranial aneurysms. Microsurgical clipping of basilar tip aneurysms is still advocated for as it is safe, especially for unruptured basilar tip aneurysms which have a low risk of postoperative mortality or morbidity. Careful patient preparation is needed preoperatively because the risk of intraoperative rupture is significant. Good surgical techniques should be applied. The skill will need to be preserved as endovascular surgery becomes more popular.This is a case of basilar tip aneurysm managed by clipping through the anterior temporal approach, followed by a review of the literature.

Introducción: los aneurismas cerebrales son dilataciones localizadas de la pared arterial, por lo general, se encuentran en puntos de bifurcación como las arterias grandes del po­lígono de Willis, las cuales tienen potencial de ruptura y traen consigo complicaciones serias, tales como el evento vascular cerebral (EVC) hemorrágico, en donde la mortalidad es del 66%. Debido al impacto que tiene dicha enfermedad, el profesional de enfermería requiere brindar cuidado integral a este grupo de pacientes, a través del uso del Proceso Cuidado Enfermero (PCE), el cual está dirigido hacia la planificación y el desarrollo de cuidados sistematizados, lógicos y racionales. Objetivo: desarrollar un plan de cuidado de enfermería mediante el uso de la taxonomía NANDA NIC NOC para un paciente posoperado de clipaje de aneurisma en base a la fisiopatología de la enfermedad y su intervención quirúrgica a partir de un caso clínico. Material y métodos: valoración por patrones funcionales de salud de un paciente poso­perado de clipaje de aneurisma, revisión bibliográfica y elaboración del proceso cuidado enfermero (PCE) individualizado con el uso de la taxonomía NNN. Conclusión: el paciente neuroquirúrgico, representa un gran reto en el área de salud, por lo que, el profesional de enfermería debe responder a las necesidades sociales y propias de la disciplina para desempeñar un papel eficiente en la ejecución de un plan de cuidado individualizado, que permita el logro de resultados establecidos por el equipo multidisci­plinario.

This article reports a patient with unruptured right vertebral artery aneurysm which deviates across the midline to the left side. The contralateral (left) transcondylar fossa approach with bilateral V3 exposure is used for aneurysm clipping. The literature related to this technique is also reviewed.

Background Thirty-day readmissions (30dRAs) and 90-day readmissions (90dRAs) are being increasingly scrutinized as quality metrics for hospital and provider performances. Little information regarding risk factors for 30dRA and 90dRA after elective cerebral aneurysm clipping (CAC) of unruptured cerebral aneurysms is available. We sought to characterize risk factors with a nationally representative administrative database. Methods The Nationwide Readmissions Database was used to identify patients who underwent elective CAC between 2010 and 2014. The outcomes of interest were unplanned readmissions occurring within 30 or 90 days of discharge. Binary logistic regression was used to identify variables related to patients' demographics, comorbidities, and index hospital admission that were associated with readmission. A Cochran-Mantel-Haenszel test was used to evaluate for changes in annual readmission rates. Results A total of 1123 patients met the inclusion criteria for 30dRA analysis and 946 patients were eligible for 90dRA analysis. The 5-year 30dRA and 90dRA readmission rates were 9.1% and 14.9%, respectively. The annual rate of readmission between 2010 and 2014 did not change. Greater Charlson Comorbidity Index (odds ratio [OR], 2.68; 95% confidence interval [CI], 1.14–6.28) and nonroutine discharge after the index admission (OR, 1.81; 95% CI, 1.04–3.14) were associated with greater odds of 30dRA. Charlson Comorbidity Index (OR, 3.45; 95% CI, 1.57–7.56) and treatment at a metropolitan teaching hospital (OR, 2.21; 95% CI, 1.06–4.60) were associated with increased odds of 90dRA. Wound infection was the most common reason for readmission. Conclusions Readmission rates after elective CAC remained unchanged between 2010 and 2014, suggesting that improved methods for reducing unplanned readmissions after CAC are needed.

Background Patients with acute aneurysmal subarachnoid hemorrhage (aSAH) experience excruciating headache that is difficult to manage in resource-constrained settings. Pregabalin’s (β-isobutyl-GABA) analgesic, antiepileptic, and antiemetic properties make it an attractive adjuvant in pain management for these patients. Methods We conducted a double-blind, placebo-controlled, randomized clinical trial on 40 aSAH patients undergoing aneurysmal clipping to assess the effect of perioperative pregabalin in decreasing perioperative headache, anesthetic, and opioid requirement. Patients received either pregabalin (75 mg) or placebo twice daily soon after admission till 24-hour postoperative, in addition to paracetamol 650 mg thrice daily. Headache assessed using a visual analog scale (VAS) at five time points was compared using a mixed effects regression model. Results Pain assessed by VAS declined significantly more from the baseline in pregabalin recipients compared with placebo at preinduction (–3.6 vs.–1.8; p = 0.004), 12-hour (4.3 vs. 2.8; p = 0.014), and 24-hour postsurgery (4.7 vs. 2.9; p = 0.007), but not at the 6-hour postoperation (4.9 vs. 3.8; p = 0.065). Pregabalin recipients required a lower minimum alveolar concentration of sevoflurane to maintain a prespecified bispectral index of 40 and 60 (0.8 vs. 0.9; p = 0.014) and required fewer rescue analgesic doses in the 24 hours following surgery (1.8 vs. 3.3; p = 0.005). The intraoperative fentanyl requirement was not significantly different between the groups (10 μg/kg vs. 11.4 μg/kg; p = 0.065). There was no significant difference in the sedation scores. Conclusions Pregabalin 75 mg administered twice daily, during the perioperative period, was an effective adjunct in the management of the severe headache experienced by patients with aSAH and decreased the opioid and anesthetic requirement without significantly increasing sedation.

Objective Recently, three-dimensional (3D) printed models of the intracranial vascular have served as useful tools in simulation and training for cerebral aneurysm clipping surgery. Precise and realistic 3D printed aneurysm models may improve patients' understanding of the 3D cerebral aneurysm structure. Therefore, we created patient-specific 3D printed aneurysm models as an educational and clinical tool for patients undergoing aneurysm clipping surgery. Herein, we describe how these 3D models can be created and the effects of applying them for patient education purpose. Methods Twenty patients with unruptured intracranial aneurysm were randomly divided into two groups. We explained and received informed consent from patients in whom 3D printed models-(group I) or computed tomography angiography-(group II) was used to explain aneurysm clipping surgery. The 3D printed intracranial aneurysm models were created based on time-offlight magnetic resonance angiography using a 3D printer with acrylonitrile-butadiene-styrene resin as the model material. After describing the model to the patients, they completed a questionnaire about their understanding and satisfaction with aneurysm clipping surgery. Results The 3D printed models were successfully made, and they precisely replicated the actual intracranial aneurysm structure of the corresponding patients. The use of the 3D model was associated with a higher understanding and satisfaction of preoperative patient education and consultation. On a 5-point Likert scale, the average level of understanding was scored as 4.7 (range, 3.0-5.0) in group I. In group II, the average response was 2.5 (range, 2.0-3.0). Conclusion The 3D printed models were accurate and useful for understanding the intracranial aneurysm structure. In this study, 3D printed intracranial aneurysm models were proven to be helpful in preoperative patient consultation.

Anterior communicating artery (ACoA) aneurysm, accounts for 30%-35% of all the aneurysm making it one of the most common intracranial aneurysms. Although the Pterional approach is considered as the safe and appropriate method in ACoA aneurysm surgery, temporalis atrophy and injury to a frontal branch of the facial nerve are few inexorable complications. With the advancement of minimally invasive surgery several modified approaches, such as the supraorbital eyebrow incision approach, the minipterional approach, the mini-supraorbital approach, and the lateral supraorbital approach has been recently introduced and has been used as an alternative.

Technical challenges in aneurysms can broadly be divided into general aneurysmal management challenges and aneurysm specific challenges. Specifically, we usually prefer to select the approach based on the presence or absence of temporal hematoma, and the length of the M1 segment. In the presence of temporal lobe hematoma it is wise to select the superior temporal gyrus approach, as hematoma evacuation is easy and we usually find the M3 segment to trace back to find the aneurysm. Other challenge lies while clipping the aneurysm. MCA bifurcation aneurysm seems to be the most notorious type, because of its varied morphology. We may find them a simple, multiple lobed, giant, fusiform, and occasionally its the M2 stuck to the neck of the aneurysm or arising from its dome. For multiple lobed MCA bifurcation aneurysm, the pearls of clipping is to think different lobes as a different aneurysms.

Objective: The effects of repeated lumbar puncture and continuous lumbar cistern drainage on the cognitive function of patients with aneurysmal subarachnoid hemorrhage were compared and analyzed. Methods: Retrospective analysis was performed on 59 patients with aneurysmal subarachnoid hemorrhage treated at our Neurosurgery Department between October 2017 and October 2018. According to the hemorrhagic cerebrospinal fluid drainage mode after aneurysm clipping, the patients were divided into the following two groups: the repeated lumbar puncture drainage (Group A, n = 28) and continuous lumbar cistern drainage (Group B, n = 31). Before and 1 month after surgery, the cognitive function of the patients was scored using the Montreal Cognitive Assessment Scale. Scores of 27~30 were defined as normal, and scores of < 27 as cognitive impairment. Results: The incidences of cognitive impairment were 46% (13/28) and 32% (10/31) for Groups A and B, respectively, before surgery, but the difference was not significant ( P > 0.05). The incidences of cognitive impairment were 35% (10/28) and 12% (4/31) for Groups A and B, respectively, at 1 month after surgery, with significant difference ( P < 0.05). Conclusion: Compared with repeated lumbar puncture, continuous lumbar cistern drainage for aneurysmal subarachnoid hemorrhage significantly reduced the incidence of cognitive impairment after aneurysm clipping.

Anterior communicating artery (ACOM) aneurysm clipping with intraoperative measures to ensure total occlusion and avoid ischemic complications is standard in countries such as the United States. However, alternatives need to be considered in resource-limited settings. The clipping of an unruptured, superiorly projecting ACOM aneurysm in a resource-limited setting is presented and special nuances that optimize safety are described. Careful surgical technique, meticulous identification of relevant anatomy, post-ligation inspection of the aneurysm and adjacent vessels, and possibly needle puncture of the aneurysm dome are critical to achieve favorable results.

Simple Summary Motor evoked potential (MEP) alarm criteria may have an important impact on the preservation of motor function in supratentorial neurosurgical procedures. However, no consensus exists regarding the optimal cut-off values and interpretation of MEP signal changes. In addition, their performance as diagnostic and surrogate biomarkers has not been adequately investigated. The existing clinical studies that utilized alarm criteria are heterogeneous, rendering quantitative evidence synthesis problematic. In this study, we sought to summarize the pertinent literature using an emerging synthesis methodology, namely a scoping review. The objective was to assess the extent and range of available evidence, identifying research gaps, clarifying concepts, and providing insights for further research. Due to the heterogeneity of studies, we applied a descriptive approach, in particular by visualizing instead of pooling the data. A comprehensive overview of MEP warning criteria has not been provided yet, and therefore, our study should pave the way for future research. Abstract During intraoperative monitoring of motor evoked potentials (MEP), heterogeneity across studies in terms of study populations, intraoperative settings, applied warning criteria, and outcome reporting exists. A scoping review of MEP warning criteria in supratentorial surgery was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Sixty-eight studies fulfilled the eligibility criteria. The most commonly used alarm criteria were MEP signal loss, which was always a major warning sign, followed by amplitude reduction and threshold elevation. Irreversible MEP alterations were associated with a higher number of transient and persisting motor deficits compared with the reversible changes. In almost all studies, specificity and Negative Predictive Value (NPV) were high, while in most of them, sensitivity and Positive Predictive Value (PPV) were rather low or modest. Thus, the absence of an irreversible alteration may reassure the neurosurgeon that the patient will not suffer a motor deficit in the short-term and long-term follow-up. Further, MEPs perform well as surrogate markers, and reversible MEP deteriorations after successful intervention indicate motor function preservation postoperatively. However, in future studies, a consensus regarding the definitions of MEP alteration, critical duration of alterations, and outcome reporting should be determined.

Objective. To analyze the different effects of Continuous Lumbar Drainage of fluid and lumbar puncture drainage for aneurysmal subarachnoid hemorrhage (SAH) after intracranial aneurysm clipping. Method. Seventy-five patients with aneurysmal SAH who underwent aneurysm clipping were retrospectively analyzed and were divided into two groups according to the different postoperative drainage methods. The lumbar spine group received lumbar puncture drainage, and the lumbar cistern group received lumbar pool continuous drainage to compare the efficacy. Result. The time to normalize intracranial pressure and headache relief after drainage treatment in the lumbar cistern group was shorter than that in the lumbar spine group. The GOS score was higher than that in the lumbar spine group, and the cerebral artery flow velocity and NIHSS score were significantly lower than those in the lumbar spine group ( P < 0.05 ). The total effective rate of drainage treatment was 76.32% in the lumbar cistern group, which was higher than that in the lumbar spine group (54.05%) ( P < 0.05 ). The total complication rate was 18.42% in the lumbar cistern group, which was lower than that in the lumbar spine group (40.54%) ( P < 0.05 ). Conclusion. Continuous Lumbar Drainage of fluid after intracranial aneurysm clipping for aneurysmal SAH can control symptoms more rapidly, reduce neurological deficits, and improve prognosis than lumbar puncture. Also, the drainage is safer and more widely used.