Monitoring of brain oxygenation in surgery of ruptured middle cerebral artery aneurysms

BACKGROUND: The occurrence of brain ischemic lesions, due to temporary arterial occlusion or incorrect placement of the definitive clip, is a major complication of aneurysm surgery. Temporary clipping is a current technique during surgery and there is no reliable method of predicting the possibility of ischemia due to extended regional circulatory interruption. Even with careful inspection, misplacement of the definitive clip can be difficult to detect. Brain tissue oxygen concentration (PtiO(2)) was monitored during surgery of middle cerebral artery (MCA) aneurysm presenting with subarachnoid hemorrhage (SAH), for detection of changes in brain oxygenation due to reduced blood flow, as a predictor of ischemic events, during temporary clipping and after definitive clipping. METHODS: PtiO(2) was monitored during surgery of 13 patients harboring MCA aneurysms presenting with SAH, using a polarographic microcatheter (Licox, GMS, Kiel, Germany) placed in the territory of MCA. RESULTS: A decrease in PtiO(2) values was verified in every period of temporary clipping. Brain infarction occurred in 2 patients; in both cases, there was a decrease in PtiO(2) greater than 80% from basal value, a minimum value of less than 2 mmHg persisting for 2 or more minutes during temporary clipping, and an incomplete recovery of PtiO(2) after definitive clipping. In 2 patients, incomplete recovery of values after definitive clipping led to verification of inappropriate placement and repositioning of the clip. CONCLUSION: The results suggest that intraoperative monitoring of PtiO(2) may be a useful method of detection of changes in brain tissue oxygenation during MCA aneurysm surgery. Postoperative infarction in the territory of MCA developed in cases with an abrupt decrease of PtiO(2) and a very low and persistent minimum value, during temporary clipping, and an incomplete recovery after definitive clipping. Verification of clip position should be considered when there is an incomplete recovery or a persistent fall in PtiO(2) after definitive clipping.