Frameless neuronavigation in surgery of distal cerebral aneurysms

Aim. To compare results of surgical treatment of patients with distal aneurysms of the middle cerebral and pericallosal arteries who underwent surgery with frameless neuronavigation and without it.

Materials and methods. The study was performed at the N. V. Sklifosovsky Research Institute for Emergency Medicine, Russian Сenter of Neurology and Neurosciences, Moscow City Hospital named after S. S. Yudin between January 1st 2009 and December 31st 2023. Analysis included 45 patients with distal aneurysms of the pericallosal and middle cerebral arteries. Taking into account surgical technique, the patients were divided into 2 groups: the 1st group (n = 21) included patients who underwent surgery with frameless neuronavigation; among them 10 (47.6 %) patients had distal aneurysms of the middle cerebral artery, 11 (52.4 %) patients had distal aneurysms of the pericallosal artery. The 2nd group (n = 24) included patients who underwent surgery without frameless neuronavigation; among them 10 (41.7 %) patients had distal aneurysms of the middle cerebral artery, 14 (58.3 %) patients had distal aneurysms of the pericallosal artery.

Results. The use of frameless neuronavigation helps in the search for distal aneurysms during the main stage of the surgery, decreases time between dissection and clipping of a distal aneurysm (p = 0.0001), decreases operative time (р = 0.0001) but requires more time for access planning (p = 0.008). Frameless neuronavigation helps to determine optimal size and location of craniotomy for the most direct and safe trajectory to the distal aneurysm (p = 0.008), decreases the risk of intraoperative injury of the frontal sinus (p = 0.025). Patients, in whom distal aneurysm clipping was performed using frameless navigation, had lower rate of neurologic deficit (p = 0.0001), postoperative (p = 0.025) and systemic (p = 0.005) complications, repeat surgeries (p = 0.002).

Conclusion. The use of frameless neuronavigation decreases search time for distal aneurysms and operative time, allows to decrease craniotomy area and prevent intraoperative injury of the frontal sinus, statistically significantly decreases the risk of postoperative neurologic deficit, and improves clinical outcomes.

1. Крылов В.В. Хирургия аневризм головного мозга. Т. 2. М.: Новое время, 2011. С. 516.

2. Krylov V.V. Surgery of cerebral aneurysms. V. 2. Moscow: Novoe Vremya, 2011. P. 516. (In Russ.).

3. Nussbaum E., Madison M., Goddard J. et al. Peripheral intracranial aneurysms: management challenges in 60 consecutive cases. J Neurosurg 2009;110(1):7–13. DOI: 10.3171/2008.6.JNS0814

4. Rodriguez-Hernandez A., Zador Z., Rodriguez-Mena R., Lawton M. Distal aneurysms of intracranial arteries: application of numerical nomenclature, predilection for cerebellar arteries, and results of surgical management. World Neurosurg 2013; 80(1–2):103–12. DOI: 10.1016/j.wneu.2012.09.010

5. Hernesniemi J., Tapaninaho A., Vapalahti M. et al. Saccular aneurysms of the distal anterior cerebral artery and its branches. Neurosurgery 1992;31(6):994–9. DOI: 10.1227/00006123-199212000-00002

6. Wu C., Sun Z., Wang F. et al. Surgical managements of peripheral intracranial aneurysms. Zhonghua Yi Xue Za Zhi 2014;94(9): 698–700. (In Chinese).

7. Senko I.V., Krylov V.V. Microsurgical treatment of distal cerebral aneurysms. Neyrokhirurgiya = Russian Journal of Neurosurgery 2016;1:98–103. (In Russ.).

8. Albert F.K., Wirtz C.R., Forsting M. et al. Image guided excision of a ruptured feeding artery “pedicle aneurysm” associated with an a rteriovenous malformation in a child: case report. Comput Aided Surg 1997;2(1):5–10. DOI: 10.1002/(SICI)1097- 0150(1997)2:1<5::AID-IGS3>3.0.CO;2-3

9. Melgar M.A., Zamorano L., Jiang Z., Guthikonda M. Three-dimensional magnetic resonance angiography in the planning of aneurysm surgery. Comput Aided Surg 1997;2(1):11–23. DOI: 10.1002/(sici)1097-0150(1997)2:1<11::aid-igs4>3.0.co;2-q

10. Raabe A., Beck J., Rohde S., Berkefeld J. Three-dimensional rotational angiography guidance for aneurysm surgery. J Neurosurg 2006;105(3):406–11. DOI: 10.3171/jns.2006.105.3.406

11. Kim T., Joo S., Lee J. et al. Neuronavigation-assisted surgery for distal anterior cerebral artery aneurysm. Minim Invasive Neurosurg 2007;50(3):140–4. DOI: 10.1055/s-2007-985151

12. Lee S.H., Bang J.S. Distal middle cerebral artery M4 aneurysm surgery using navigation-CT angiography. J Korean Neurosurg Soc 2007;46(6):478–80. DOI: 10.3340/jkns.2007.42.6.478

13. Kil J.S., Kim D.W., Kang S.D. Navigation-guided keyhole approach for unruptured intracranial aneurysms. Korean J Cerebrovasc Surg 2011;13(3):244–8.

14. Hermann E.J., Petrakakis I., Götz F. et al. Surgical treatment of distal anterior cerebral artery aneurysms aided by electromagnetic navigation CT angiography. Neurosurg Rev 2015;38(3):523–30. DOI: 10.1007/s10143-015-0611-9

15. Toyooka T., Otani N., Wada K. et al. Head-up display may facilitate safe keyhole surgery for cerebral aneurysm clipping. J Neurosurg 2017;129(4):883–9. DOI: 10.3171/2017.5.jns162692

16. Dai W., Ling H., Sun Y. et al. The comparison of neuronavigation combined with CT three-dimensional angiography vs. CT angiography in the guidance of clipping treatment in distal intracranial aneurysm surgery: a retrospective clinical study. Ann Transl Med 2022;10(10):572. DOI: 10.21037/atm-22-1749

17. Han S., Qin X., Zhang W. et al. Advantages of computed tomography-based navigation in clipping distal anterior cerebral artery aneurysms: a retrospective cohort study. Quant Imaging Med Surg 2023;13(12):8326–35. DOI: 10.21037/qims-23-671