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PubMed2006

Effect of clot removal and the different incidence of vasospasm between clipping and GDC.

The removal of subarachnoid clot has been thought to be effective for prevention of cerebral vasospasm. However, it is suggested that the incidence of cerebral vasospasm is not high in the cases where ruptured cerebral aneurysms are obliterated using Guglielmi detachable coils (GDC) without clot removal. The effect of subarachnoid clot removal on the occurrence of cerebral vasospasm and the different incidence of cerebral vasospasm between clipping cases and in GDC cases are reviewed.Surgical clot removal in experimental model indicated marked preventive effect on cerebral vasospasm. However, the clinical trials of clot removal during early aneurysm surgery had failed to show satisfactory preventive effect for vasospasm, and the cumulative incidence of symptomatic vasospasm in these trials was 29%. As fibrinolytic drug, intrathecal administration of tissue plasminogen activator showed sufficient elimination of subarachnoid clot and prevention of cerebral vasospasm in the experimental studies and in the clinical case trials and nonrandomized case-control trials. However, the multi-center, randomized case-control trial showed no statistically significant effect on symptomatic cerebral vasospasm. On the other hand, the cumulative incidence of cerebral vasospasm in GDC cases was 20%. The comparative studies of the incidence of vasospasm between GDC cases and in clipping cases also showed less incidence of symptomatic vasospasm and a more favorable outcome in GDC cases. From the results of studies reviewed, the incidence of cerebral vasospasm seems less in GDC cases than in clipping cases. It should be clarified why clipping could not be dominant in the prevention of cerebral vasospasm compared to GDC.

Animals↗
PubMed2006

Protocol design and current status of CLIVIT: a randomized controlled multicenter relevance trial comparing clips versus ligatures in thyroid surgery.

BACKGROUND: Annually, more than 90000 surgical procedures of the thyroid gland are performed in Germany. Strategies aimed at reducing the duration of the surgical procedure are relevant to patients and the health care system especially in the context of reducing costs. However, new techniques for quick and safe hemostasis have to be tested in clinically relevance randomized controlled trials before a general recommendation can be given. The current standard for occlusion of blood vessels in thyroid surgery is ligatures. Vascular clips may be a safe alternative but have not been investigated in a large RCT. METHODS/DESIGN: CLIVIT (Clips versus Ligatures in Thyroid Surgery) is an investigator initiated, multicenter, patient-blinded, two-group parallel relevance randomized controlled trial designed by the Study Center of the German Surgical Society. Patients scheduled for elective resection of at least two third of the gland for benign thyroid disease are eligible for participation. After surgical exploration patients are randomized intraoperatively into either the conventional ligature group, or into the clip group. The primary objective is to test for a relevant reduction in operating time (at least 15 min) when using the clip technique. Since April 2004, 121 of the totally required 420 patients were randomized in five centers. DISCUSSION: As in all trials the different forms of bias have to be considered, and as in this case, a surgical trial, the role of surgical expertise plays a key role, and will be documented and analyzed separately. This is the first randomized controlled multicenter relevance trial to compare different vessel occlusion techniques in thyroid surgery with adequate power and other detailed information about the design as well as framework. If significant, the results might be generalized and may change the current surgical practice.

Journal Article↗
PubMed1982

Recurrence of cerebral aneurysm after initial neck clipping.

Neck clipping has generally been believed to be among the most reliable of the operative modalities for cerebral aneurysm. However, recurrences with catastrophic outcome have been known to occur. We recently treated two patients who each had a new aneurysm at the site of the initial clipping. In both cases, the recurrence was found several years after the aneurysm neck had been closed successfully with a silver clip, which had been confirmed by intraoperative inspection and by postoperative angiographic studies demonstrating disappearance of the aneurysm. Histological examination of the recurrent aneurysm showed that the arterial wall had apparently been damaged by the clip edge, which resulted in thinning and disruption of both the muscle layer and the internal elastic lamina. Therefore, local fragility of the arterial wall adjacent to the aneurysm seems to have been the cause of the formation of a new aneurysm. The need to reinforce the thin-walled parent artery and the usefulness of high resolution computed tomography for the early detection of recurrent aneurysms are emphasized.

Cerebral Angiography↗
PubMed1983

Temporary clipping during early operation for ruptured aneurysm: preliminary report.

Temporary arterial occlusion was performed in 16 patients undergoing early aneurysm operation. Ten patients had a ruptured middle cerebral artery (MCA) aneurysm, and 6 had a ruptured anterior communicating artery aneurysm. Premature aneurysm rupture during operation necessitated temporary arterial occlusion in 10 patients. In 5 patients, temporary arterial occlusion was performed to facilitate dissection of the aneurysm. In 1 patient with a large MCA aneurysm, temporary occlusion was performed to provoke collapse of the completely exposed aneurysm sac, thus making clipping of the base possible. The results do not indicate that temporary occlusion by the standard aneurysm clips now in general use leads to angiographically detectable arterial wall changes or increased thromboembolic complications. Temporary clipping of the MCA proximal to the perforating arteries may be well tolerated for up to 20 minutes during early aneurysm operation. Temporary occlusion of one or both anterior cerebral arteries or temporary pericallosal clipping need not unconditionally lead to disastrous consequences if rendered necessary during aneurysm operations performed in the acute stage.

Adult↗
PubMed1983

Angiographic demonstration of postoperative cortical artery stenosis induced by Biemer temporary clips.

Five patients underwent cerebral revascularization operations during which Biemer clips were used to occlude temporarily a branch of the middle cerebral artery. Postoperative angiograms revealed stenoses at the sites where the clips were applied. Excessive clip closing forces may have caused significant endothelial injury, which then produced the stenoses. Clips that exert a minimal occlusive force would avoid this response and are recommended for temporary occlusion of cortical arteries.

Adult↗
PubMed2005

Intraoperative awakening for vision examination during ophthalmic artery aneurysm clipping: technical case report.

OBJECTIVE AND IMPORTANCE: We present a case of a patient with an ophthalmic artery aneurysm in which the ophthalmic artery originated from the body of the aneurysm, requiring sacrifice of the ophthalmic artery to achieve complete aneurysm obliteration. We awakened the patient intraoperatively to assess optic nerve function after clipping and were able to confirm optic nerve function. Controlled intraoperative awakening proved a valuable adjunct to intraoperative angiography in determining the immediate consequences of sacrifice of the ophthalmic artery. CLINICAL PRESENTATION: The patient was a 55-year-old right-handed woman with a 3-month history of episodic blurriness in her left eye; imaging demonstrated an unruptured 5-mm left ophthalmic artery aneurysm in which the ophthalmic artery originated from the body of the aneurysm. INTERVENTION: Complete obliteration of the aneurysm required clip placement across the neck of the aneurysm, incorporating not only the aneurysm but also the ophthalmic artery. Aware that sacrifice of the ophthalmic artery was likely, we awakened the patient after clipping and before dural closure to evaluate her optic nerve function. Once fully awake, the patient was able to execute simple commands and conclusively confirm light perception in both of her eyes. She was then reanesthetized, and intraoperative angiography showed successful aneurysm obliteration and parent artery patency. CONCLUSION: The ophthalmic artery can be sacrificed during aneurysm clipping without loss of vision in many cases, most likely because of adequate collateral filling from the external carotid artery. Certainty about the visual consequences of sacrifice of the ophthalmic artery, however, is difficult to obtain preoperatively or intraoperatively. Intraoperative awakening for evaluation of optic nerve function served as a useful technique to assess the acute results of interruption of ophthalmic artery flow in this case.

Aneurysm↗
PubMed2006

Outcome of oculomotor nerve palsy from posterior communicating artery aneurysms: comparison of clipping and coiling.

OBJECTIVE: Recovery of posterior communicating artery aneurysm-induced oculomotor nerve palsy (ONP) after aneurysm coiling has been reported. However, the coil mass may compromise recovery of the nerve. Therefore, we compared the outcome of coiling and clipping for this indication. METHODS: We retrospectively compared the outcomes of ONP in 13 patients, six of whom underwent endovascular coiling and seven of whom underwent surgical clipping. RESULTS: Six of the seven surgical patients with ONP recovered completely, compared with two of the six patients in the endovascular group. Of the patients with more than 1 year of follow-up, all six surgical patients recovered completely, compared with two of four endovascular patients (P = 0.05). In addition, preoperative complete or partial ONP also was associated with degree of resolution by survival analysis (P = 0.03). All patients with partial ONP in the surgical group and two of three patients in the endovascular group recovered without residual deficits, whereas three of the four patients with complete ONP in the clipping group and none in the coiling group recovered completely. Regardless of the treatment method, time to complete resolution of ONP was 6 months in both groups. CONCLUSION: Clipping posterior communicating artery aneurysms was associated with a higher probability of complete recovery from ONP than coiling. Degree of preoperative ONP also affected recovery. If patients can tolerate surgery, it should be considered the treatment of choice.

Adult↗
PubMed1999

Colocalization of cytoplasmic dynein with dynactin and CLIP-170 at microtubule distal ends.

Cytoplasmic dynein is a minus end-directed microtubule motor responsible for centripetal organelle movement and several aspects of chromosome segregation. Our search for cytoplasmic dynein-interacting proteins has implicated the dynactin complex as the cytoplasmic dynein 'receptor' on organelles and kinetochores. Immunofluorescence microscopy using a total of six antibodies generated against the p150Glued, Arp1 and dynamitin subunits of dynactin revealed a novel fraction of dynactin-positive structures aligned in linear arrays along the distal segments of interphase microtubules. Dynactin staining revealed that these structures colocalized extensively with CLIP-170. Cytoplasmic dynein staining was undetectable, but extensive colocalization with dynactin became evident upon transfer to a lower temperature. Overexpression of the dynamitin subunit of dynactin removed Arp1 from microtubules but did not affect microtubule-associated p150Glued or CLIP-170 staining. Brief acetate treatment, which has been shown to affect lysosomal and endosomal traffic, also dispersed the Golgi apparatus and eliminated the microtubule-associated staining pattern. The effect on dynactin was rapidly reversible and, following acetate washout, punctate dynactin was detected at microtubule ends within 3 minutes. Together, these findings identify a region along the distal segments of microtubules where dynactin and CLIP-170 colocalize. Because CLIP-170 has been reported to mark growing microtubule ends, our results indicate a similar relationship for dynactin. The functional interaction between dynactin and cytoplasmic dynein further suggests that this these regions represent accumulations of cytoplasmic dynein cargo-loading sites involved in the early stages of minus end-directed organelle transport.

Animals↗
PubMed2005

Effect of spirometric maneuver, nasal clip, and submaximal inspiratory effort on measurement of exhaled nitric oxide levels in asthmatic patients.

STUDY OBJECTIVES: The measurement of exhaled nitric oxide (eNO) in asthmatic patients is increasingly being used to aid diagnosis and management. To standardize the measurement techniques, the American Thoracic Society and European Respiratory Society guidelines were published, but these were based mainly on expert opinions without strong clinical evidence on many aspects. We investigated the effect of three different factors on the on-line measurement of eNO. In a clinical setting, we evaluated the effect of prior spirometry, the use of nasal clips, and the influence of submaximal inspiratory effort on on-line eNO readings. Recommended guidelines on these factors have been published but have been supported by scanty research data. METHODS: Three groups of stable asthmatic patients (30 patients in each group) had eNO measurements made on-line (NIOX; Aerocrine AB; Solna, Sweden) before and 5 min after performing spirometric maneuvers, without and with a nasal clip, or with maximal and then submaximal inspiratory efforts. RESULTS: There were no significant differences in mean eNO levels among all three groups, before and after spirometry (68.2 vs 66.0 parts per billion [ppb], respectively; mean difference, 2.2 ppb; 95% confidence interval [CI], -0.4 to 4.9; p = 0.090), without use of a nasal clip compared with its use (46.7 vs 45.6 ppb, respectively; mean difference, 1.1 ppb; 95% CI, -0.7 to 2.8; p = 0.234), and maximal or submaximal inspiratory effort (52.6 vs 51.2 ppb, respectively; mean difference, 1.4 ppb; 95% CI, -0.3 to 3.0; p = 0.096). CONCLUSION: We conclude that on-line eNO measurements in clinical practice are not significantly affected by prior spirometry maneuver, use of a nasal clip, or submaximal inspiratory effort.

Adolescent↗
PubMed1984

Vasovasostomy in rabbits after vasectomy or vas occlusion by tantalum clip.

Vasovasostomy was performed in rabbits that had been vasectomized or had the vas occluded by a tantalum clip for 6 or 15 months. Vasovasostomy restored fertility to 40-50% in vasectomized rabbits and 60-70% in the tantalum clip-occluded animals. Any changes that occurred due to vasectomy and tantalum clip occlusion (e.g. testicular weight, enzyme concentrations in the testis) returned to normal within 3-6 months of vasovasostomy. We suggest that vas occlusion with tantalum clips is a good method of surgical male sterilization and has a high success rate for restoration of fertility.

Alkaline Phosphatase↗
PubMed1987

Characterization of neurohormonal changes following the production of the benign and malignant phases of two-kidney, two-clip Goldblatt hypertension.

The neurohormonal contribution to high blood pressure was investigated in 9 conscious two-kidney, two-clip Goldblatt (2K2C) hypertensive dogs during evolution of the benign and malignant phases after application of bilateral renal clips (BRC). Serial measurements were taken of the plasma renin activity (PRA), plasma angiotensin I-immunoreactivity (Ang I-ir), plasma angiotensin II-ir (Ang II-ir), renin substrate (RS) catecholamines [epinephrine (Epi) and norepinephrine (NE)] and vasopressin (AVP). Immediately after BRC, the elevation of the blood pressure (86 +/- 3 to 110 +/- 3 mmHg, p less than 0.01) was associated with an increase in heart rate (93 +/- 3 to 114 +/- 9 beats/min, p less than 0.01). These hemodynamic changes were accompanied by increases in PRA, Ang I-ir, Ang II-ir, Epi, NE and AVP. The renin angiotensin system was activated throughout the 3 week period following BRC, as indicated by increases in PRA, Ang I-ir and Ang II-ir. Catecholamines were elevated immediately after BRC, followed by a return toward the control values. AVP underwent a slight but not significant elevation after BRC, which was sustained during the 3 weeks. Production of malignant hypertension was affected by occlusion of one of the adjustable renal clips 3 weeks after BRC. A marked elevation of the blood pressure was associated with significant increases in PRA, Ang I-ir, Ang II-ir, Epi, NE and AVP, compared with the pre-occlusion values. In addition, pharmacologic experiments were performed in 6 of 9 dogs. Administration of angiotensin I converting enzyme inhibitor (SQ 14225) reduced the blood pressure both in the benign and malignant phases of 2K2C renovascular hypertension, and a ganglionic blocking agent (hexamethonium) also decreased the blood pressure. However, a specific, vascular acting AVP antagonist failed to reduce the blood pressure significantly. From this study, it seems likely that severe renal ischemia caused by renal clipping caused the activation of the renin-angiotensin and the sympathetic nervous system and elevation of serum vasopressin. However, there are no apparent differences between the benign and malignant phases of renovascular hypertension, except for the marked elevation of neurohormone levels in malignant hypertension.

Angiotensin I↗
PubMed2005

Clip readjustment in aneurysm surgery after flow evaluation using the ultrasonic perivascular probe: case report.

Occlusion or stenosis of a parent vessel or its distal branches is a major cause of poor patient outcome after cerebral aneurysm surgery. Despite great attempts to preserve patency at the time of clip application, intraoperative visual observation may not reveal arterial compromise or occlusion. Quantitative measurement of blood flow in cerebral vessels during aneurysm surgery can help prevent ischaemia and improve patient outcome. We report a case of a large complex middle cerebral artery (MCA) aneurysm in which perivascular microflow probes were used to measure blood flow quantitatively in MCA and its branches before and after aneurysm clipping. Following aneurysm clipping, blood flow in the MCA branches were significantly reduced to less than its initial baseline value with occlusion of the inferior M2 segment. Prompt detection of compromised blood flow gave the surgeon the opportunity to adjust the clip. This adjustment was performed several times until restore MCA flow to its preclipping values. Intraoperative quantitative vessel-flow measurements were safe and may have prevented cerebral ischaemia and neurological deficit to this patient.

Adult↗
PubMed1997

Clinical analysis of recurrent subarachnoid hemorrhage after neck clipping surgery.

The clinical features of recurrent subarachnoid hemorrhage (SAH) after neck clipping surgery were investigated in a series of 1,436 consecutive patients treated between 1980 and 1994, and seven patients treated prior to 1980. Recurrent SAH occurred within 1 month in seven patients and between 1.5 and 20 years in 20 patients (mean interval 9.2 years) from the first surgery. The patients were aged from 31 to 76 years (mean 49.8 years) at the first SAH. There were 19 females and eight males. Recurrent SAH occurred at the same site as the prior aneurysms in 12 cases, at an infundibular dilatation in three cases, de novo aneurysms in nine cases, untreated multiple aneurysms in two cases, and unknown in one case. The main causes for early recurrent SAH were incomplete clipping or untreated multiple aneurysms, whereas late recurrent SAH was due to de novo aneurysms, untreated multiple aneurysms, or regrowth aneurysm at the prior site. The outcomes of late recurrent SAH were good in eight cases, moderate disability in two, severe disability in three, and dead in seven, whereas most cases of early recurrent SAH resulted in poor outcome. Immediate postoperative angiography is desirable in cases with incomplete clipping, because early recurrent SAH resulted in poor outcomes. De novo or regrowth aneurysms caused late recurrent SAH, so follow-up angiography is strongly recommended for young patients, even if complete clipping was achieved.

Adult↗
PubMed2001

Acute subdural hematoma in patients who underwent aneurysm clipping--four case reports.

Four patients presented with intracranial hemorrhage mainly consisting of acute subdural hematoma (ASDH), who had all undergone aneurysm clipping 2-20 years earlier. Whether the clips had slipped or new trauma had caused the bleeding was difficult to determine, since the initial computed tomography showed that the subarachnoid hemorrhage or the intracerebral hematoma developed near the clips. Angiography in three patients showed that the clips had not slipped off. Three of four ASDHs appeared in the same side as the craniotomy used for the previous aneurysm surgery. Anti-platelet agents and ventriculoperitoneal shunting had been previously used in two patients with no causal signs of trauma. The outcomes were poor in three patients and one patient died. Weakening of the extra- or intracranial structure after aneurysm surgery might have been involved together with the postoperative anti-platelet agent and shunt treatment in the etiology of the present ASDH.

Aged↗
PubMed2006

Preparation of digital movie clips for online journal publication.

OBJECTIVE: This article presents general guidelines for preparing movie clips for online journal publication. CONCLUSION: As more and more radiology journals establish an online presence, radiologists wishing to submit journal articles with movie clips need to understand the electronic submission process. Viewing a movie clip via an online journal is different from viewing one with PowerPoint using a local desktop computer because the movie file must first be downloaded onto the client computer before it can be displayed. Users thus should be cautious in selecting movie format and compression when creating movie clips for online journals. This article provides step-by-step demonstrations and general guidelines for movie format and compression selections.

Internet↗
PubMed2003

Use of animation-enhanced video clips for teaching abnormal breathing patterns.

The ability to characterize disease of the respiratory tract accurately based on breathing pattern is helpful for the development of differential diagnoses and an efficient diagnostic plan and critical for the stabilization of patients in respiratory distress. Veterinary students do not have sufficient clinical experience to observe personally all types of respiratory diseases and their resultant abnormal breathing patterns. We developed a teaching tool, the animated breathing pattern videotape (ABV), to fill this gap. The ABV is a collection of video clips of small animal patients with normal and abnormal breathing patterns on a conventional videotape of approximately 20 minutes duration. Each video clip is shown for 20 to 40 seconds, followed by the same clip with superimposed animation of rib and diaphragm motion, followed by the initial clip again, without overlying animation. The ABV has since been used in teaching third-year veterinary students, interns, residents, practicing veterinarians, and veterinary technicians. Student evaluations and responses to questionnaires by interns, residents, practicing veterinarians, veterinary technicians, and peer reviewers have been uniformly positive.

Animals↗
PubMed1991

Movement of hemostatic clips from the ventricles through the aqueduct to the lumbar spinal canal. Case report.

The authors report a patient in whom rebleeding after operation for a left temporal arteriovenous malformation resulted in the dislocation of multiple hemostatic clips. Several clips, including a Yasargil aneurysm clip, were detected incidentally in the lumbar spinal canal. No clinical signs or symptoms were noted. Retrospectively, passage of the aneurysm clip through the aqueduct could be detected on computerized tomography scans performed to evaluate a series of epileptic seizures.

Cerebral Angiography↗
PubMed1991

Giant carotid-ophthalmic artery aneurysms: direct clipping utilizing the "trapping-evacuation" technique.

The authors have devised a "trapping-evacuation" technique to facilitate direct clipping of giant aneurysms in the paraophthalmic region of the internal carotid artery (ICA). The giant aneurysm is collapsed by first trapping the aneurysm by temporary occlusion of the cervical common carotid and external carotid arteries, along with temporary clipping of the intracranial ICA distal to the aneurysm. Thereafter, intra-aneurysmal blood is simultaneously aspirated through a catheter placed in the cervical ICA. Exposure of the proximal end of the aneurysm neck is mandatory for successful clipping. This is accomplished by extensive unroofing of the optic canal, removal of the anterior clinoid process, opening of the anterior part of the cavernous sinus, and exposure of the most proximal intradural (C2) and genu (C3) portions of the ICA. Four cases of giant aneurysms of the paraophthalmic ICA were successfully treated by this technique and the postoperative outcome was good in all cases. Preoperative magnetic resonance imaging for evaluation of the anatomical details, balloon occlusion test of the ICA, and intraoperative measurement of cortical blood flow were important to the success of the operation. Intraoperative digital subtraction angiography via the catheter placed in the cervical ICA was useful in confirming successful clipping.

Aged↗