Clot-Vessel Interface-Oriented Microsurgical Strategy for Aneurysmal Subarachnoid Hemorrhage.

Abstract

Cerebral vasospasm remains a major determinant of outcome after aneurysmal subarachnoid hemorrhage (aSAH). Conventional surgical strategies primarily focus on aneurysm occlusion, whereas the pathological significance of the clot-vessel interface has not been fully integrated into surgical decision-making. We describe an interface-oriented microsurgical strategy for clot removal in aSAH. The technique is based on selective control of the clot-vessel interface using irrigation-assisted loosening and non-contact suction (double suction method). This approach was applied during microsurgical clipping combined with aggressive cisternal clot removal (ACCR). In a consecutive series of 65 patients treated with this strategy, symptomatic cerebral vasospasm was rarely observed, and favorable functional outcomes were achieved in the majority of cases. The clot-vessel interface represents a rational surgical target in aSAH. An interface-oriented framework provides a reproducible strategy for clot management and may contribute to reducing vasospasm. This concept shifts the focus of surgery from vessel-oriented manipulation to interface-oriented control.