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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]

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.

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.

Temporary clips are invaluable safety tools during the clipping of an aneurysm. Controversies regarding maximum permissible duration and safety, however, remain unanswered. This descriptive narrative attempts to review the literature to provide valuable insights on controversies clouding the use of temporary clips among neurosurgeons. Popular databases, including Pub Med, Medline/Medscape, Scopus, Cochrane, Embase, Google Scholar, were searched to find available literature on temporary clips. The searched MeSH terms were "Temporary Clip," "Temporary Clipping," "Cerebral Aneurysm," and "Aneurysm." Temporary clips have been in use since 1928 and have undergone considerable structural and technical modifications. A temporary clip's optimal safety limit is not yet defined with literature evidence ranging from immediate to 93 min. It is not yet definite whether temporary clips application aggravates vasospasm, but emergency temporary clips application, especially in poor-grade aneurysmal subarachnoid hemorrhage patients, is associated with poor outcomes. A temporary clip needs to be applied with caution in patients treated earlier by endovascular technique and having indwelling stents. Nitinol Stent is feasible, while a Cobalt-Chromium alloy stent does not get occluded and gets deformed under the closing pressure of a temporary clip. Although a temporary clip application is a fundamental strategy during the clipping of an aneurysm; the exact safe duration remains to be decided in randomized control trials. Their utility for the shorter duration is beneficial under un-conclusive evidence of neuroprotective agents and intraoperative monitoring. Neurosurgeons need to consider all aspects of their pros and cons for optimal use. [ABSTRACT FROM AUTHOR]

The profound deepening of medicamentous sleep down to the burst-suppression electroencephalography pattern is used to provide medication-based protection of brain during preventive temporary clipping of the major arteries when performing surgery due to cerebral aneurysms. There is no consensus about the effect of profound suppression of electrobiological activity on the development of post-operative cognitive dysfunction. The goal: to evaluate the impact of anesthesia with the burst-suppression electroencephalography pattern on the post-operative cognitive status of the patients with no cerebral disorders. Subjects and methods. 30 patients were enrolled into the prospective randomized study, they all had surgeries due to degenerative spinal diseases. All patients were divided into two groups. Anesthesia in the main group (Group 1) differed from the one in the control group (Group 2); it included administration of propofol till achieving suppression of the electrobiological activity of burst-suppression electroencephalography pattern during 15 minutes. Prior to the surgery and in 4 days after it, all patients had neuro-psychological tests using Montreal Cognitive Assessment (MoCA), Frontal Assessment Battery (FAB) and numbers memorization techniques (NMT). Results. When testing in 4 days after surgery, results in the patients from Group 1 did not differ from pre-operative results of MoCA (Mebefore = 28, Meafter= 28, Z = 0.714, p = 0.476), FAB (Mebefore = 18, Meafter = 18, Z = 0.592, p = 0.554), memorization of numbers in the direct order (Mebefore = 18, Meafter = 18, Z = 0.178, p = 0.859) and in the reverse order (Mebefore = 18, Meafter = 18, Z = 0.548, p = 0.583). The results of the post-operative testing in Group 2 were compatible with pre-operative results of (Mebefore = 18, Meafter = 18, Z = 0.459, p = 0.646), FAB (Mebefore = 18, Meafter = 18, Z = 1.348, p = 0.178), memorization of numbers in the direct order (Mebefore = 18, Meafter = 18, Z = 0.21, p = 0.843) and in the reverse order (Mebefore = 18, Meafter = 18, Z = 0.809, p = 0.418). None of the tests detected significant differences between the Groups (U = 88, p = 0.319, Z = 0.995 for MoCA; U = 102.5, p = 0.644, Z = 0.394 for FAB; U = 92.0, p = 0.407, Z = -0.829 for memorization of numbers in the direct order, and U = 33.5, p = 0.62, Z = 0.572 for memorization of numbers in the reverse order). Conclusion. Anesthesia with burst-suppression electroencephalography pattern as a model of medication-based cerebral protection during temporary clipping of the major arteries does not cause the deterioration of cognitive status in the patients who had no cerebral pathology initially.

Context: The incidence of anterior communicating artery (Acomm) aneurysm is high and it is associated with high risk of rupture. Aims: The aim is to evaluate various factors (size, wall morphology, and fundus direction) associated with intraoperative rupture (IOR) of Acomm aneurysm. Settings and Design: Retrospective cohort study. Subjects and Methods: Our study includes 25 operated patients diagnosed to have ruptured Acomm aneurysm in the Department of Neurosurgery of Institute of Medical Sciences, Banaras Hindu University, Varanasi, India, between January 2016 and July 2020. Our study included all patients with ruptured Acomm aneurysm who received clipping as method of treatment. Statistical Analysis: Chi‑square test was used for analysis. Values with P < 0.05 were considered statistically significant. Statistical tests were done using GraphPad Prism version 8.3.0 software. Results: None of the patients with <4 mm, 6 patients of >4–10 mm, and 2 patients of >10 mm aneurysm size experienced IOR. IOR was seen in 2 patients with smooth wall and 6 in irregular aneurysm wall. All patients with posterior, 1 patient with inferior, 2 patients with anterior, and 1 patient with superior directing aneurysm experienced IOR. Patients with bilaterally clipped A1 experienced no IOR, while in unilaterally clipped aneurysm only 2 patients experienced IOR. Glasgow outcome score was better in patients with no IOR. Conclusion: The factors associated with high risk of IOR are: Aneurysm size >4 mm, multilobulated or irregular aneurysm wall, posteriorly and inferiorly directed aneurysms. Patients in whom Both A1 was temporarily clipped, experienced no IOR and better outcome. [ABSTRACT FROM AUTHOR]

Introduction Scalp AVM (SAVM) is a rare condition. Although surgical excision is considered as definitive treatment for these lesions, troublesome intraoperative bleeding may pose a challenge. Embolization as an alternative modality is gaining popularity. Proximal feeding artery temporary clipping has been utilized by the authors in this series to address troublesome intraoperative bleeding. Presentation of cases The authors present their experience in the surgical management of 3 cases with SAVMs using proximal feeding artery temporary occlusion followed by total surgical excision. The clinical presentations and radiological features of these cases are discussed in the article. Intraoperative blood loss was less than 150 ml in all patients. Postoperative period was uneventful with no morbidity or mortality. Discussion Intraoperative bleeding during surgical excision of scalp AVMs can be troublesome and challenging. To combat this, the authors advocate proximal feeding artery temporary clipping prior to surgical excision of the lesion. The external carotid artery was temporarily clipped in one case and superficial temporal artery in two patients. Conclusion Although most SAVMs can be operated by traditional method of excision, use of temporary clipping of feeding arteries (like Superficial temporal artery[STA], External carotid artery[ECA]) enables total excision of giant SAVMs with minimal blood loss for a definitive cure. This novel technique obviates the need for preoperative embolization. [ABSTRACT FROM AUTHOR]

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.)

Objective : To propose a new measure for effective monitoring of intraoperative somatosensory evoked potentials (SEP) and to validate the feasibility of this measure for evoked potentials (EP) and single trials with a retrospective data analysis study. Methods : The proposed new measure (hereafter, a slope-measure) was defined as the relative slope of the amplitude and latency at each EP peak compared to the baseline value, which is sensitive to the change in the amplitude and latency simultaneously. We used the slope-measure for EP and single trials and compared the significant change detection time with that of the conventional peak-to-peak method. When applied to single trials, each single trial signal was processed with optimal filters before using the slope-measure. In this retrospective data analysis, 7 patients who underwent cerebral aneurysm clipping surgery for unruptured aneurysm middle cerebral artery (MCA) bifurcation were included. Results : We found that this simple slope-measure has a detection time that is as early or earlier than that of the conventional method; furthermore, using the slope-measure in optimally filtered single trials provides warning signs earlier than that of the conventional method during MCA clipping surgery. Conclusion : Our results have confirmed the feasibility of the slope-measure for intraoperative SEP monitoring. This is a novel study that provides a useful measure for either EP or single trials in intraoperative SEP monitoring. [ABSTRACT FROM AUTHOR]

Objective: To propose a new measure for effective monitoring of intraoperative somatosensory evoked potentials (SEP) and to validate the feasibility of this measure for evoked potentials (EP) and single trials with a retrospective data analysis study., Methods: The proposed new measure (hereafter, a slope-measure) was defined as the relative slope of the amplitude and latency at each EP peak compared to the baseline value, which is sensitive to the change in the amplitude and latency simultaneously. We used the slope-measure for EP and single trials and compared the significant change detection time with that of the conventional peak-to-peak method. When applied to single trials, each single trial signal was processed with optimal filters before using the slope-measure. In this retrospective data analysis, 7 patients who underwent cerebral aneurysm clipping surgery for unruptured aneurysm middle cerebral artery (MCA) bifurcation were included., Results: We found that this simple slope-measure has a detection time that is as early or earlier than that of the conventional method; furthermore, using the slope-measure in optimally filtered single trials provides warning signs earlier than that of the conventional method during MCA clipping surgery., Conclusion: Our results have confirmed the feasibility of the slope-measure for intraoperative SEP monitoring. This is a novel study that provides a useful measure for either EP or single trials in intraoperative SEP monitoring.

Objective: Delayed ischemic deficit or cerebral infarction is the leading cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH). The purpose of this study is to reassess the prognostic impact of intraoperative elements, including factors related to surgery and anesthesia, on the development of cerebral infarction in patients with ruptured cerebral aneurysms., Methods: Variables related to surgery and anesthesia as well as predetermined factors were all evaluated via a retrospective study on 398 consecutive patients who underwent early microsurgery for ruptured cerebral aneurysms in the last 7 years. Patients were dichotomized as following; good clinical grade (Hunt-Hess grade I to III) and poor clinical grade (IV and V). The end-point events were cerebral infarctions and the clinical outcomes were measured at postoperative 6 months., Results: The occurrence of cerebral infarction was eminent when there was an intraoperative rupture, prolonged temporary clipping and retraction time, intraoperative hypotension, or decreased O(2) saturation, but there was no statistical significance between the two different clinical groups. Besides the Fisher Grade, multiple logistic regression analyses showed that temporary clipping time, hypotension, and low O(2) saturation had odds ratios of 1.574, 3.016, and 1.528, respectively. Cerebral infarction and outcome had a meaningful correlation (gamma=0.147, p=0.038)., Conclusion: This study results indicate that early surgery for poor grade SAH patients carries a significant risk of ongoing ischemic complication due to the brain's vulnerability or accompanying cardio-pulmonary dysfunction. Thus, these patients should be approached very cautiously to overcome any anticipated intraoperative threat by concerted efforts with neuro-anesthesiologist in point to point manner.