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Mechanical stimulation of the trigeminal nerve during craniofacial, skull base, or dental surgeries may cause bradycardia, hypotension, or cardiac arrest. This phenomenon is called trigeminal cardiac reflex (TCR). We encountered a rare case of a patient who experienced sinus arrest due to temporary clipping of the intracranial carotid artery during the clipping of a ruptured aneurysm. We discuss possible reasons for the occurrence of TCR in this case. A man in his 30s with no medical history presented with a sudden-onset headache. Computed tomography revealed a subarachnoid hemorrhage in the basal cistern and left Sylvian fissure. Angiography revealed a saccular aneurysm of the left internal carotid-anterior choroidal artery. A left frontotemporal craniotomy and dural incision were performed, followed by a trans-Sylvian approach. Cardiac arrest occurred twice during the temporary clipping of the intracranial carotid artery. After surgery, we performed a cardiac ultrasound echo and a 1-week Holter electrocardiogram. Neither showed abnormalities. No arrhythmia or cardiac events were observed over a one and half-year follow-up period. The cardiac arrest might have been triggered by the stimulation of the trigeminal nerve in the internal carotid artery. The repeated and anatomical features of this case suggest that TCR triggered cardiac arrest. The high probability that cardiac arrest was induced by trigeminal nerve stimulation should be considered during the temporary clipping of the internal carotid artery. However, the predisposing factors and exact underlying mechanisms for these arrhythmias remain unknown and require further investigation. [ABSTRACT FROM AUTHOR]

Background: Neurosurgery's challenging area involves addressing intracranial aneurysms, given the high morbidity and mortality rates associated with them. Safe clipping, a technique that involves the intraoperative temporary occlusion of the arterial supply, is generally used. However, a focused review on the evolution of temporary clipping in intracranial aneurysms hasn't been previously carried out. Methods: We performed a comprehensive literature search on PubMed Medline and Google Scholar, using the combination of terms: [Temporary clip* AND (Cerebral OR Intracranial) Aneurysm]. Results: From an initial pool of 579 results, we excluded unrelated papers, narrowing it down to 25 relevant studies. These ranged from retrospective and prospective studies on the outcome favorability or radiological evidence, to analyses on potential independent prognostic factors, and articles related to the history and evolution of temporary clipping. Conclusion: Temporary arterial occlusion in aneurysm surgery has evolved significantly since its inception in the early 20th century, marked by innovations in instruments and temporary clips. Despite these advancements, the utility and safety of temporary clips continue to be topics of discussion, particularly due to concerns regarding possible complications and their influence on long-term results. [ABSTRACT FROM AUTHOR]

It is necessary to secure both the proximal and distal sides of the parent artery to prevent premature rupture when clipping cerebral aneurysms. Herein, we describe four cases in which the proximal internal carotid artery (ICA), affected by a paraclinoid aneurysm, was secured using an endoscopic endonasal approach. We used various tools, including a surgical video, cadaver dissection picture, artist's illustration, and intraoperative photographs, to elucidate the process. No patient experienced postoperative complications at our institution. Compared to the cervical or cavernous ICA, the ICA adjacent to the clivus (paraclival ICA) can be anatomically safely and easily exposed using an endoscopic endonasal approach because there is no need to consider cerebrospinal fluid leakage or hemorrhage from the cavernous sinus. Securing the proximal side of the parent artery using an endoscopic endonasal approach may be a viable method for clipping selected ICA aneurysms, such as paraclinoid aneurysms especially for upward or outward aneurysms of the C2 portion. [ABSTRACT FROM AUTHOR]

Background: Neurosurgery's challenging area involves addressing intracranial aneurysms, given the high morbidity and mortality rates associated with them. Safe clipping, a technique that involves the intraoperative temporary occlusion of the arterial supply, is generally used. However, a focused review on the evolution of temporary clipping in intracranial aneurysms hasn't been previously carried out. Methods: We performed a comprehensive literature search on PubMed Medline and Google Scholar, using the combination of terms: [Temporary clip* AND (Cerebral OR Intracranial) Aneurysm]. Results: From an initial pool of 579 results, we excluded unrelated papers, narrowing it down to 25 relevant studies. These ranged from retrospective and prospective studies on the outcome favorability or radiological evidence, to analyses on potential independent prognostic factors, and articles related to the history and evolution of temporary clipping. Conclusion: Temporary arterial occlusion in aneurysm surgery has evolved significantly since its inception in the early 20th century, marked by innovations in instruments and temporary clips. Despite these advancements, the utility and safety of temporary clips continue to be topics of discussion, particularly due to concerns regarding possible complications and their influence on long-term results.

Intraoperative neurophysiological monitoring (IONM) represents one of the available technologies able to assess ischemia and aimed to improve surgical outcome reducing the treatment related morbidity in surgery for intracranial aneurysms. Many studies analyzing the impact of IONM are poised by the heterogeneity bias affecting the cohorts. We report our experience with IONM for surgery of unruptured middle cerebral artery (MCA) aneurysm in order to highlight its influence on functional and radiological outcome and surgical strategy. We retrospectively reviewed all MCA unruptured aneurysms treated between January 2013 and June 2021 by our institutional neurovascular team. Patients were divided into 2 groups according to the use of IONM. A total of 153 patients were included in the study, 52 operated on without IONM and 101 with IONM. The groups did not differ preoperatively regarding clinical status and aneurysm characteristics. Patients operated with IONM had better functional outcomes at discharge as well as at follow-up (p= 0.048, p=0.041) due to lower symptomatic ischemia and better radiological outcome due to lower rate of unexpected aneurysmal remnants (p= 0.0173). The introduction of IONM changed the use of temporary clipping (TeC), increasing its average duration (p= 0.01) improving the safety of dissecting and clipping the aneurysm. IONM in surgery for unruptured MCA aneurysm could improve the efficacy and safety of clipping strategy in the way it showed a role in changing the use of TeC and was associated to the reduction of unexpected aneurysmal remnants' rate and improvement in both short- and long-term patient's outcome. [ABSTRACT FROM AUTHOR]

ObjectiveThis study aimed to evaluate the diagnostic effect of intraoperative neurophysiological monitoring in identifying intraoperative ischemic events and predicting postoperative neurological dysfunction during PCoA aneurysm clipping, as well as to explore the safe duration of intraoperative temporary clipping of the parent artery.MethodsAll 71 patients with PCoA aneurysm underwent craniotomy and aneurysm clipping. MEP and SSEP were used for monitoring during operation to evaluate the influence of MEP/SSEP changes on postoperative neurological function. Receiver operating characteristic (ROC) curve analysis was used to calculate optimal duration of intraoperative temporary clipping.ResultsPatients with intraoperative MEP/SSEP changes were more likely to develop short-term and long-term neurological deficits than those without MEP/SSEP changes (P 4.5 min was significantly higher than that in patients with temporary clipping ≤4.5 min (P = 0.015, P = 0.018).ConclusionIntraoperative MEP/SSEP changes are significantly associated with postoperative neurological dysfunction in patients with PCoA aneurysms. The optimal duration of temporary clipping of the parent artery during posterior communicating aneurysm clipping was 4.5 min under neurophysiological monitoring.

Objective: This study aimed to evaluate the diagnostic effect of intraoperative neurophysiological monitoring in identifying intraoperative ischemic events and predicting postoperative neurological dysfunction during PCoA aneurysm clipping, as well as to explore the safe duration of intraoperative temporary clipping of the parent artery., Methods: All 71 patients with PCoA aneurysm underwent craniotomy and aneurysm clipping. MEP and SSEP were used for monitoring during operation to evaluate the influence of MEP/SSEP changes on postoperative neurological function. Receiver operating characteristic (ROC) curve analysis was used to calculate optimal duration of intraoperative temporary clipping., Results: Patients with intraoperative MEP/SSEP changes were more likely to develop short-term and long-term neurological deficits than those without MEP/SSEP changes ( P  < 0.05). From the ROC curve analysis, the safe time from the initiation of temporary clipping during the operation to the early warning of neurophysiological monitoring was 4.5 min (AUC = 0.735, 95%CI 0.5558-0.912). Taking 4.5 min as the dividing line, the incidence of short-term and long-term neurological dysfunction in patients with temporary clipping >4.5 min was significantly higher than that in patients with temporary clipping ≤4.5 min ( P  = 0.015, P  = 0.018)., Conclusion: Intraoperative MEP/SSEP changes are significantly associated with postoperative neurological dysfunction in patients with PCoA aneurysms. The optimal duration of temporary clipping of the parent artery during posterior communicating aneurysm clipping was 4.5 min under neurophysiological monitoring., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Tang, Li, Wang, Tang and Feng.)

Cerebral aneurysm thrombosis is one of the factors increasing the risk of microsurgical treatment. Thrombi and calcifications within the aneurysm neck prevent adequate clipping and should be removed before the procedure. At the same time, the process of thrombectomy is difficult and time consuming that increases duration of temporary arterial clipping and risk of cerebral ischemia., Objective: To evaluate the results of thrombectomy without temporary arterial clipping for giant aneurysms of anterior brain circulation., Material and Methods: Four patients with giant partially thrombosed saccular aneurysms underwent thrombectomy without temporary clipping followed by neck clipping. In all cases, the aneurysm was thrombosed by more than 80-90% of its baseline volume, and aneurysm neck contained parietal thrombi from all sides. Mean duration of thrombectomy from aneurysm opening to bleeding and temporary clipping of the parent artery was 82 minutes, time of temporary clipping was about 12 minutes., Results: Favorable clinical and radiological postoperative results were obtained in all patients. The authors present a scheme of surgical stages and video presentation involving the main surgical aspects of this procedure., Conclusion: Thrombectomy without temporary clipping of the parent artery is an effective technique for microsurgical treatment of giant partially thrombosed saccular intracranial aneurysms. Since most thrombi are removed without bleeding, duration of temporary blood flow discontinuation in the parent artery is significantly reduced. Therefore, we decrease the risk of cerebral ischemia. This technique can be useful in microsurgical treatment of complex aneurysms of the middle cerebral and internal carotid arteries, as well as other aneurysms.