Risk Factors and the Role of Intraoperative Hypotension in Cerebral Infarction After Microsurgical Clipping of Intracranial Aneurysms: A Retrospective Case-Control Study

Abstract Background Blood pressure control during microsurgical clipping of intracranial aneurysms is challenging, as high blood pressure increases the risk of rupture, while hypotension may impair cerebral perfusion. The impact of intraoperative hypotension on postoperative cerebral infarction remains unclear. This study aims to identify independent risk factors and quantify the association between intraoperative hypotension and postoperative cerebral infarction. Methods We conducted a retrospective case-control study of patients undergoing intracranial aneurysm clipping. The primary outcome was postoperative cerebral infarction, identified using routine computed tomography scans. Multivariate logistic regression analysis was performed to determine independent risk factors and assess the relationship between intraoperative hypotension parameters and postoperative cerebral infarction. Restricted cubic spline (RCS) models were used to quantify the relationship between intraoperative blood pressure and postoperative cerebral infarction. Results Among 689 patients, 83 (12.05%) experienced postoperative cerebral infarction. Multivariate regression analysis identified aneurysm size (odds ratio [OR] = 2.353, 95%CI: 1.327–4.173, P = 0.003), duration of intraoperative hypotension (OR = 1.021, 95%CI: 1.001–1.042, P = 0.045), and maximum diastolic blood pressure (OR = 0.717, 95%CI: 0.525–0.981, P = 0.038) as significant risk factors for postoperative cerebral infarction. RCS plots demonstrated an increased risk of postoperative cerebral infarction with prolonged hypotension durations and greater cumulative exposure to hypotension. Conclusion The high incidence of cerebral infarction following intracranial aneurysm clipping underscores the need for careful perioperative management. Aneurysm size and intraoperative hypotension burden are independent risk factors for cerebral infarction. Strategies to minimize intraoperative hypotension during microsurgical clipping may help reduce postoperative infarction rates and improve patient outcomes. Clinical trial number: Not applicable