Microsurgery for Intracranial Aneurysms: A Qualitative Survey on Technical Challenges and Technological Solutions

Overview

Journal Front Surg

Specialty General Surgery

Date 2022 Aug 22

PMID 35990100

Authors

W R Muirhead

H Layard Horsfall

D Z Khan

C Koh

P J Grover

A K Toma

P Castanho

D Stoyanov

H J Marcus

M Murphy

Affiliations

Soon will be listed here.

Abstract

Introduction: Microsurgery for the clipping of intracranial aneurysms remains a technically challenging and high-risk area of neurosurgery. We aimed to describe the technical challenges of aneurysm surgery, and the scope for technological innovations to overcome these barriers from the perspective of practising neurovascular surgeons.

Materials And Methods: Consultant neurovascular surgeons and members of the British Neurovascular Group (BNVG) were electronically invited to participate in an online survey regarding surgery for both ruptured and unruptured aneurysms. The free text survey asked three questions: what do they consider to be the principal technical barriers to aneurysm clipping? What technological advances have previously contributed to improving the safety and efficacy of aneurysm clipping? What technological advances do they anticipate improving the safety and efficacy of aneurysm clipping in the future? A qualitative synthesis of responses was performed using multi-rater emergent thematic analysis.

Results: The most significant reported historical advances in aneurysm surgery fell into five themes: (1) optimising clip placement, (2) minimising brain retraction, (3) tissue handling, (4) visualisation and orientation, and (5) management of intraoperative rupture. The most frequently reported innovation by far was indocyanine green angiography (84% of respondents). The three most commonly cited future advances were hybrid surgical and endovascular techniques, advances in intraoperative imaging, and patient-specific simulation and planning.

Conclusions: While some surgeons perceive that the rate of innovation in aneurysm clipping has been dwarfed in recent years by endovascular techniques, surgeons surveyed highlighted a broad range of future technologies that have the potential to continue to improve the safety of aneurysm surgery in the future.

Citing Articles

Single-Stage Microsurgical Clipping of Multiple Intracranial Aneurysms in a Patient with Cerebral Atherosclerosis: A Case Report and Review of Surgical Management.

Toader C, Serban M, Covache-Busuioc R, Radoi M, Aljboor G, Costin H J Clin Med. 2025; 14(1.

PMID: 39797351 PMC: 11722517. DOI: 10.3390/jcm14010269.

References

Ogilvy C, Jordan N, Ascanio L, Enriquez-Marulanda A, Salem M, Moore J . Surgical and Endovascular Comprehensive Treatment Outcomes of Unruptured Intracranial Aneurysms: Reduction of Treatment Bias. World Neurosurg. 2019; 126:e878-e887. DOI: 10.1016/j.wneu.2019.03.005. View

Anderson I, Kailaya-Vasan A, Nelson R, Tolias C . Clipping aneurysms improves outcomes for patients undergoing coiling. J Neurosurg. 2018; 130(5):1491-1497. DOI: 10.3171/2017.12.JNS172759. View

Benvenuti L, Chibbaro S, Carnesecchi S, Pulera F, Gagliardi R . Automated three-dimensional volume rendering of helical computed tomographic angiography for aneurysms: an advanced application of neuronavigation technology. Neurosurgery. 2005; 57(1 Suppl):69-77. DOI: 10.1227/01.neu.0000163485.56639.7e. View

Graziano F, Ganau M, Russo V, Iacopino D, Ulm 3rd A . Vertebrobasilar junction giant aneurysm: Lessons learned from a neurosurgical audit and anatomical investigation. Br J Neurosurg. 2015; 29(5):718-22. DOI: 10.3109/02688697.2015.1023778. View

Langer D, Vajkoczy P . ELANA: Excimer Laser-Assisted Nonocclusive Anastomosis for extracranial-to-intracranial and intracranial-to-intracranial bypass: a review. Skull Base. 2005; 15(3):191-205. PMC: 1214705. DOI: 10.1055/s-2005-872048. View

Spetzler R, McDougall C, Zabramski J, Albuquerque F, Hills N, Nakaji P . Ten-year analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial. J Neurosurg. 2019; 132(3):771-776. DOI: 10.3171/2018.8.JNS181846. View

Peerless S, Hernesniemi J, Gutman F, Drake C . Early surgery for ruptured vertebrobasilar aneurysms. J Neurosurg. 1994; 80(4):643-9. DOI: 10.3171/jns.1994.80.4.0643. View

Raabe A, Beck J, Gerlach R, Zimmermann M, Seifert V . Near-infrared indocyanine green video angiography: a new method for intraoperative assessment of vascular flow. Neurosurgery. 2002; 52(1):132-9; discussion 139. DOI: 10.1097/00006123-200301000-00017. View

Krisht A . Transcavernous approach to diseases of the anterior upper third of the posterior fossa. Neurosurg Focus. 2005; 19(2):E2. View

10.

Lai L, ONeill A . History, Evolution, and Continuing Innovations of Intracranial Aneurysm Surgery. World Neurosurg. 2017; 102:673-681. DOI: 10.1016/j.wneu.2017.02.006. View

11.

Heros R . Training in aneurysm surgery. Acta Neurochir (Wien). 2009; 151(9):1025-6. DOI: 10.1007/s00701-009-0451-x. View

12.

Polevaya N, Kalani M, Steinberg G, Tse V . The transition from hunterian ligation to intracranial aneurysm clips: a historical perspective. Neurosurg Focus. 2006; 20(6):E3. DOI: 10.3171/foc.2006.20.6.3. View

13.

Signorelli F, Pop R, Ganau M, Cebula H, Scibilia A, Gallinaro P . Endovascular versus surgical treatment for improvement of oculomotor nerve palsy caused by unruptured posterior communicating artery aneurysms. J Neurointerv Surg. 2020; 12(10):964-967. DOI: 10.1136/neurintsurg-2020-015802. View

14.

Fridriksson S, Saveland H, Jakobsson K, Edner G, Zygmunt S, Brandt L . Intraoperative complications in aneurysm surgery: a prospective national study. J Neurosurg. 2002; 96(3):515-22. DOI: 10.3171/jns.2002.96.3.0515. View

15.

Tan T, Black P . Sir Victor Horsley (1857-1916): pioneer of neurological surgery. Neurosurgery. 2002; 50(3):607-11; discussion 611-2. DOI: 10.1097/00006123-200203000-00032. View

16.

Krisht A, Krayenbuhl N, Sercl D, Bikmaz K, Kadri P . Results of microsurgical clipping of 50 high complexity basilar apex aneurysms. Neurosurgery. 2007; 60(2):242-50. DOI: 10.1227/01.NEU.0000249265.88203.DF. View

17.

Srinivasan V, Griessenauer C, Rodriguez-Hernandez A, Duckworth E, Thines L, Hecht N . A Survey of Microsurgical Technique for Extracranial-to-Intracranial Bypass. World Neurosurg. 2020; 141:e743-e751. DOI: 10.1016/j.wneu.2020.06.025. View

18.

Marchese E, Albanese A, Denaro L, Vignati A, Fernandez E, Maira G . Intraoperative microvascular Doppler in intracranial aneurysm surgery. Surg Neurol. 2005; 63(4):336-42. DOI: 10.1016/j.surneu.2004.05.031. View

19.

Lawton M, Abla A, Rutledge W, Benet A, Zador Z, Rayz V . Bypass Surgery for the Treatment of Dolichoectatic Basilar Trunk Aneurysms: A Work in Progress. Neurosurgery. 2015; 79(1):83-99. PMC: 4956413. DOI: 10.1227/NEU.0000000000001175. View

20.

Wolfe S, Baskaya M, Heros R, Tummala R . Cerebral aneurysms: learning from the past and looking toward the future. Clin Neurosurg. 2007; 53:157-78. View