Monitoring of brain tissue oxygenation in surgery of middle cerebral artery incidental aneurysms

摘要

Introduction: The management of incidental unruptured aneurysms remains a matter of controversy; middle-sized or large anterior circulation incidental aneurysms, in young or middle age patients, should be considered for treatment. Surgical clipping is an accepted treatment for middle cerebral artery unruptured aneurysms. Ischemic events can occur even in cases of incidental aneurysm surgery. Since regional cerebral blood flow can be compromised due to temporary arterial clipping or to incorrect placement of defi nitive clip, we performed intra-operative monitoring of brain tissue oxygen concentration (PtiO₂), to detect changes in brain oxygenation due to reduced blood fl ow, eventually leading to ischemia, during surgery of middle cerebral artery incidental aneurysms. Methods: PtiO₂ monitoring was performed during surgery of eight patients harboring incidental MCA aneurysms, using a polarographic microcatheter (Licox, GMS – Kiel, Germany), placed in the temporal lobe on the side of the lesion, from dural opening to dural closure. Results: Basal values varied between 2.3 and 27.3 mmHg; these values are lower than those previously described in the literature as “normal” for uninjured brain or in cases of subarachnoid hemorrhage. In all patients, a significant decrease in PtiO2 was found in every period of temporary clipping of MCA. Post-operative infarction in the territory of middle cerebral artery occurred in one patient and, in that case, there was a persistent minimum value of 0.6 mmHg, without recovery after the placement of the definitive clip. In another patient, an incorrect placement of the definitive clip could be predicted by a decrease in PtiO₂ value. Conclusions: PtiO₂ monitoring during aneurysm surgery shows brain tissue perfusion in real time and there is a correlation between any episode of reduced blood flow to the affected vascular territory during surgery and a decrease of PtiO2 values. Unexpected low basal values were obtained in “uninjured” brain, with no influence from subarachnoid hemorrhage. The values of risk for brain infarction during temporary arterial occlusion still need further studies, but an incomplete recovery or a persistent fall in PtiO₂ values after definitive clipping should be considered as an indication for verification of the position of the clip.