Optimale Gefäßrekonstruktion durch maßgeschneiderte Clipauswahl bei der chirurgischen Versorgung intrakranieller Aneurysmen

Vascular reconstruction (VR) is a fundamental objective in the surgical management of intracranial aneurysms, aiming to exclude the aneurysm from vascular circulation while maintaining physiological flow in the feeding vessel (FV). The efficacy of different clip designs (straight, bent, lateral and fenestrated) depends on the anatomy of the FV and the surgical approach employed. Optimized clip selection may therefore enhance clinical outcome by improving VR and minimizing residual perfusion (RP).

In a retrospective analysis (2020-2024) we examined 198 surgically clipped aneurysms. The study focused on the correlation between the FV, the clip design used, the quality of VR achieved and the presence of RP. FV were classified into 4 groups: A. cerebri media (MCA), A. communicans anterior (ACOM), A. carotis interna (ACI) and aneurysms of the posterior circulation (post). Additional parameters included occurrence of postoperative vasospasms (postV), temporary clipping (tC), intraoperative complications (iopC) and the modified Rankin Scale (mRS). The evaluation was based on the angiographic data (CT-A, DSA) and independently assessed by a neuroradiologist and two neurosurgeons. To detect statistically significant differences Pearson's Chi-Squared test was applied.

Among 198 aneurysms, the FV distribution was as follows: 112 MCA, 50 ACOM, 32 ACI and 4 post. Overall, VR was achieved in 52% of cases, with 17% demonstrating RP. Patients who did not achieve VR had an 8% higher incidence of postV. Overall, patients who achieved VR showed a better clinical outcome as measured by the mRS. There appears to be no significant correlation between tC or iopC and the mRS. Regarding the VR, a clear advantage was observed in the ACOM group for fenestrated (fen.) clips. VR was achieved in 86% of ACOM aneurysms treated with fen. clips (p<0.001), compared to 74% across all clip types. Furthermore, RP occurred in only 15% of ACOM aneurysms treated with fen. clips, in contrast to 26% for all clip types in this group.

Tailored clip selection significantly improves VR and reduces RP rates, particularly for ACOM aneurysms treated with fen. clips. To validate the observed trends and mitigate potential bias favoring fen. clips, a multicenter study with a broader patient population is planned.