Surgery of brain aneurysm in a BrainSuite® theater. A review of 105 cases

Introduction The BrainSuite® is a highly integrated operating theater designed mainly for brain tumor surgery. The issues concerning its routine use in vascular neurosurgery have not been discussed in literature to date. We report our experience of surgical treatment of cerebral aneurysms in the BrainSuite®, with a view to evaluating safety, feasibility, advantages, disadvantages, and contraindications. Material and methods Retrospectively, we reviewed all the patients affected by ruptured and unruptured aneurysms that underwent craniotomy with clipping between January 2007 and May 2013 and a subsequent minimum 12-month follow up. Intraoperative DWI, MRA, and volumetric MRI were always performed in order to evaluate vessel patency and early ischemic lesions. The usefulness of navigation was also evaluated in terms of loss/gain of time and its effectiveness as a surgical aid to both the localization of small distal aneurysms and the preoperative planning of the clipping strategies to adopt. Results A total of 105 patients were included in this report. Of these, 39 and 66 were affected, respectively, by ruptured and unruptured aneurysms. The mean age was 56.1 and the male-to-female ratio was 1:2.9. The aneurysms affected, with progressively descending incidence, the MCA, ACoA, ICA bifurcation, PComA, A2, A1-A2, and C6 segment of the ICA in 40 (38.1%), 23 (22%), 15 (14.3%), 7 (6.6%), 7 (6.6%), 7 (6.6%), and 6 (5.8%) cases, respectively. The aneurysms were clipped and completely excluded from blood circulation in all cases and no difficulty was encountered in positioning and fixing the patients' heads, despite the particular head holder of the BrainSuite®. MRI created no interference or problems in cases of carotid exposure at the neck, while harvesting of the lower-limb saphenous vein was not feasible due to the vicinity of the operating field to the magnet. Intraoperative angiography was never performed since an angiogram is not compatible with the BrainSuite. Intraoperative DWI, MRA, and volumetric MRI proved to be effective tools for post-clipping evaluation of the patency of the parent vessels and their collateral branches as well as of aneurismal occlusion. This was also checked doubly by availing also of intraoperative micro Doppler ultrasonography. Intraoperative DWI also permitted us to evaluate the presence of initial ischemic lesions as possible consequences of both direct arterial occlusion and early vasospasm related to surgical manipulation. Intraoperative navigation of brain aneurysm with 3D-model reconstructions may be of some use to younger surgeons when planning the clipping strategies and localizing the aneurysm particularly in cases, respectively, of large-complex aneurysms where the sac involves collateral branches and small aneurisms affecting both distal ACA and MCA aneurysms. The outcomes for patients, evaluated according to the GOS (Glasgow outcome score), associated significantly with the preoperative HH (Hunt and Hess) scale grading. Patients with high HH scores (IV and V) in particular showed the highest incidence of unfavorable outcome (GOS = 1 or 2) Conclusions The BrainSuite® theater is completely suited to brain aneurysm surgery but only in cases where a combined endovascular approach may be required. It provides some advantages and few limitations compared to a normally-equipped neurosurgical operating theater; our experience shows that the technological advances of this complex operating room are useful though not essential in aneurysm surgery.