Safety and efficacy of intraoperative angiography in craniotomies for cerebral aneurysms and arteriovenous malformations: a review of 1093 consecutive cases

Neurosurgery. 2012 Dec;71(6):1162-9. doi: 10.1227/NEU.0b013e318271ebfc.


Background: In an era of indocyanine angiography, the routine use of intraoperative angiography (IOA) in the surgical treatment of aneurysms and vascular malformations is controversial.

Objective: To retrospectively assess the safety and efficacy of IOA and to determine predictors of surgical revision.

Methods: Between 2003 and 2011, IOA was performed during surgical treatment of 976 aneurysms, 101 arteriovenous malformations (AVMs), and 16 arteriovenous fistulas.

Results: In 80 of 976 aneurysms (8.2%), IOA prompted clip repositioning. The reason for readjustment was residual aneurysm in 54.7%, parent vessel occlusion in 42.9%, and both in 2.4% of cases. In multivariate analysis, increasing aneurysm size (P, .001), ruptured aneurysm (P, .001), and increasing number of vessels injected (P, .001) were strong predictors of clip readjustment. There was a strong trend for posterior circulation aneurysm location to predict clip repositioning (P = .06). IOA revealed residual nidus/ fistula requiring further intervention in 9 of 101 AVMs (8.9%) and 3 of 16 arteriovenous fistulas (18.8%). Of 9 AVMs requiring a surgical revision, 2 (22.2%) were Spetzler-Martin grade II, 5 (55.6%) were grade III, and 2 (22.2%) were grade IV. Mean Spetzler-Martin grade was 3.0 in AVMs requiring surgical revision compared with 2.3 in those not requiring revision (P = .05). IOA-related complications were all transient or minor and occurred in 0.99% of patients; none resulted in permanent morbidity.

Conclusion: IOA remains a valuable tool in the surgical treatment of brain vascular abnormalities, guiding surgical re-exploration in .8% of cases. Easy access to an angiographer and routine use of IOA are important factors contributing to procedural safety and efficacy.

MeSH terms

  • Angiography / adverse effects*
  • Arteriovenous Malformations / surgery*
  • Craniotomy / methods*
  • Female
  • Humans
  • Intracranial Aneurysm / surgery*
  • Intraoperative Complications / etiology*
  • Male
  • Middle Aged
  • Multivariate Analysis
  • Retrospective Studies