Intraoperative angiography ‘valuable’ in vascular brain surgery

By Eleanor McDermid, Senior medwireNews Reporter

Use of intraoperative angiography (IOA) often leads to surgical revision during treatment of brain vascular abnormalities, say researchers.

"Despite the ever-changing pattern of brain vascular abnormalities referred for surgical treatment, IOA is still a powerful and valuable tool in the armamentarium of the neurovascular surgeon," say Stavropoula Tjoumakaris (Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA) and colleagues.

IOA also had a good safety profile, with just 0.09% of patients experiencing complications related to the technique. These included a visual transient ischemic attack, retroperitoneal hematoma, and minor groin hematoma. All complications were mild or transient and none caused permanent disability.

However, the researchers "acknowledge that in smaller centers where IOA is performed only on a selective basis, the morbidity rate can be higher."

There were over 1000 patients in the retrospective study, most (976) of whom had aneurysms. IOA findings prompted clip repositioning for 8.2% of aneurysms. This rate is lower than those reported in some previous studies, but Tjoumakaris et al observe that aneurysms that frequently require readjustment, such as vertebrobasilar and paraclinoid aneurysms, were rare in their study because these are now managed by endovascular coiling.

But they say that, despite such large changes in practice, "we believe that IOA is still a powerful tool guiding surgical clipping in a substantial number of patients."

They note: "Importantly, middle cerebral artery and anterior communicating artery aneurysms, which constitute the bulk of aneurysms referred for surgical clipping, were found to benefit from IOA in over 8% of cases in this series."

Tjoumakaris and team recommend routine use of IOA for aneurysms, as it can be hard to predict which patients will benefit from the technique, although they say that this could be difficult if logistic support and neuroradiology staff are limited. "In this case, patients with large and ruptured aneurysms would benefit the most from IOA."

The researchers also advise routine use for patients with arteriovenous fistulas, because IOA findings led to further surgical intervention in 19% of the 16 patients included in their study.

There were also 101 patients with arteriovenous malformations (AVMs). Twenty patients had Spetzler-Martin Grade I lesions and none of these required reintervention, whereas IOA findings led to reintervention for 22% of 33 Grade II lesions, 56% of 32 Grade III lesions, and 22% of 16 Grade IV lesions.

"The routine use of IOA during surgical treatment of AVM may be justified, except perhaps for Grade I lesions, per the surgeon's discretion," conclude the researchers in Neurosurgery.

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