Treatment of intracranial aneurysms within the concept of a hybrid operation room: role of intraoperative DSA

Aim: Intraoperative digital subtraction angiography (iDSA) is a rarely applied tool in cerebrovascular surgery, limited to the existence of a Hybrid Operation Room. It prevents unnecessary surgical manipulations after occlusion of aneurysms and accurately demonstrates occlusion rates. Primarily endovascular approaches even in crucial cases can be done with an option on immediate neurosurgical intervention. The preliminary experience is presented using iDSA within the concept of a hybrid operation room for interdisciplinary treatment of aneurysmal SAH. Methods and Results: Since its introduction of iDSA in our center in August 2006, a total of 99 patients underwent iDSA. Indications included intraoperative evaluation of clipped aneurysms (n = 30), chemical angioplasty (n = 4), balloon angioplasty (n = 2) and primarily endovascular coiling with option on neurosurgical intervention (n = 4). In two patients a reposition of the clip was needed due to neck remnant and perfusion of the aneurysm sack after clipping. In one case the clip was repositioned due to occlusion of a vicinity vessel. In one case a suboptimal occlusion of an aneurysm could be documented. Reposition of the clip was unsuccessful in reaching a total occlusion, and conventional angiogram and coiling of the remnant aneurysm was performed uneventfully. All endovascular aneurysm embolizations were successful; in one case the coiling was followed by craniotomy to evacuate an intracerebral hematoma. 5 cases underwent combined microsurgical and endovascular treatment of ruptured aneurysms and AVMs. Conclusions: The concept of a hybrid operation room should be considered in the planning of operation rooms dedicated to cerebrovascular surgery. Hybrid procedures combining endovascular with microsurgical strategies within the same surgical session are feasible and safe. iDSA within the hybrid OR enhances the quality especially in identifying cases of vessel occlusion or aneurysm remnant after clipping and facilitates the definitive treatment of cerebrovascular pathologies. These procedures are associated with cost-benefit advantages.