51
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Pierot L. In Reply: Aneurysm Treatment With Woven EndoBridge in the Cumulative Population of 3 Prospective, Multicenter Series: 2-Year Follow-up. Neurosurgery 2020; 87:E78-E79. [DOI: 10.1093/neuros/nyaa089] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Laurent Pierot
- Department of Neuroradiology Hôpital Maison-Blanche Université Reims-Champagne-Ardenne Reims, France
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52
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Goertz L, Krischek B, Reiner M, Goldbrunner R, Brinker G. Penumbral Salvage by Delayed Clip Reposition 19 Hours After Cerebral Aneurysm Clipping-Induced Ischemia Results in Neurologic Restitution-Correlation with Indocyanine Green Videoangiography and FLOW 800 Measurements. World Neurosurg 2020; 138:61-67. [PMID: 32142943 DOI: 10.1016/j.wneu.2020.02.122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Cerebral infarction because of parent artery stenosis represents a potential complication of microsurgical aneurysm clipping. CASE DESCRIPTION We report a case of a 60-year-old woman that developed left-sided hemiparesis and aphasia 9 hours after clipping of an unruptured middle cerebral artery aneurysm with heavy calcification of the aneurysm neck. Angiographic workup revealed a marked parent artery stenosis, which occurred presumably because of thrombus generation at the reconstructed aneurysm neck. Revision surgery with relocation of the aneurysm clip was ultimately performed 19 hours after symptom onset. Although follow-up computed tomography scan showed a small cerebral infarction, the patient recovered fully from surgery. CONCLUSIONS This case shows that relocation of the aneurysm clip in case of vessel stenosis can lead to penumbral salvage, even when performed more than 6 hours after symptom onset.
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Affiliation(s)
- Lukas Goertz
- University of Cologne, Faculty of Medicine and University Hospital, Center for Neurosurgery, Department of General Neurosurgery, Cologne, Germany.
| | - Boris Krischek
- University of Cologne, Faculty of Medicine and University Hospital, Center for Neurosurgery, Department of General Neurosurgery, Cologne, Germany
| | - Michael Reiner
- University of Cologne, Faculty of Medicine and University Hospital, Center for Neurosurgery, Department of General Neurosurgery, Cologne, Germany
| | - Roland Goldbrunner
- University of Cologne, Faculty of Medicine and University Hospital, Center for Neurosurgery, Department of General Neurosurgery, Cologne, Germany
| | - Gerrit Brinker
- University of Cologne, Faculty of Medicine and University Hospital, Center for Neurosurgery, Department of General Neurosurgery, Cologne, Germany
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53
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Srivatsan A, Kan P. Commentary: Expanding Indications for Flow Diverters: Distal Aneurysms, Bifurcation Aneurysms, Small Aneurysms, Previously Coiled Aneurysms and Clipped Aneurysms, Carotid Cavernous Fistulas. Neurosurgery 2020; 86:E227-E228. [PMID: 31844902 DOI: 10.1093/neuros/nyz450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 08/23/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Aditya Srivatsan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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Randhawa HS, Pearce G, Hepton R, Wong J, Zidane IF, Ma X. An investigation into the design of a device to treat haemorrhagic stroke. Proc Inst Mech Eng H 2019; 234:323-336. [PMID: 31774350 PMCID: PMC7132436 DOI: 10.1177/0954411919890698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In this study, we present the design considerations of a device to assist in the
potential treatment of hemorrhagic stroke with the aim of stopping blood from
flowing out into brain tissue. We present and model three designs for the
clinical scenarios when saccular aneurysms rupture in the middle cerebral artery
in the brain. We evaluate and model these three designs using computer aided
design software, SolidWorks, which allows the devices to be tested using finite
element analysis and also enables us to justify that the materials chosen were
suitable for potential use. Computational fluid dynamics modelling were used to
demonstrate and analyse the flow of blood through the artery under conditions of
normal and ruptured states. We conclude that our device could potentially be
useful in the treatment of hemorrhagic stroke, and the modelling process is
useful in assisting in determining the performance of our devices.
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Affiliation(s)
| | - Gillian Pearce
- School of Engineering and Applied Science, Aston University, Birmingham, UK
| | - Rachel Hepton
- The School of Life & Health Sciences, Aston University, Birmingham, UK
| | - Julian Wong
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore
| | - Iham F Zidane
- Mechanical Engineering Department, College of Engineering and Technology, Arab Academy for Science, Technology and Maritime Transport (AASTMT), Alexandria, Egypt
| | - Xianghong Ma
- School of Engineering and Applied Science, Aston University, Birmingham, UK
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55
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Lv Z, Zhu Y, Wang W, Wu Q, Li W, Li Q, Xu L. Comparison of Two Endovascular Interventions with Low-Profile Visualized Intraluminal Support or Pipeline Embolization Device in Middle Cerebral Arterial Aneurysms Patients. J INVEST SURG 2019; 34:590-594. [PMID: 31769307 DOI: 10.1080/08941939.2019.1670883] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Zhonghua Lv
- Department of Neurosurgery, The Second Hospital Changxing Branch Affiliated to Zhejiang University, Hangzhou Shi, Zhejiang Sheng, China
| | - Yong Zhu
- Department of Neurosurgery, The Second Hospital Changxing Branch Affiliated to Zhejiang University, Hangzhou Shi, Zhejiang Sheng, China
| | - Wei Wang
- Department of Neurosurgery, The Second Hospital Changxing Branch Affiliated to Zhejiang University, Hangzhou Shi, Zhejiang Sheng, China
| | - Qiangjun Wu
- Department of Neurosurgery, Lishui Central Hospital, Lishui Shi, Zhejiang Sheng, China
| | - Wen Li
- Department of Neurosurgery, The First Hospital Affiliated to Soochow University, Suzhou Shi, Jiangsu Sheng, China
| | - Qiang Li
- Department of Neurosurgery, Shanghai Changhai Hospital, Yangpu Qu, Shanghai Shi, China
| | - Liang Xu
- Department of Neurosurgery, The Second Hospital Affiliated to Zhejiang University, Hangzhou Shi, Zhejiang Sheng, China
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56
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Maldaner N, Steinsiepe VK, Goldberg J, Fung C, Bervini D, May A, Bijlenga P, Schaller K, Roethlisberger M, Zumofen DW, D'Alonzo D, Marbacher S, Fandino J, Maduri R, Daniel RT, Burkhardt JK, Chiappini A, Robert T, Schatlo B, Seule MA, Weyerbrock A, Regli L, Stienen MN. Patterns of care for ruptured aneurysms of the middle cerebral artery: analysis of a Swiss national database (Swiss SOS). J Neurosurg 2019; 133:1811-1820. [PMID: 31731273 DOI: 10.3171/2019.9.jns192055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 09/11/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to determine patterns of care and outcomes in ruptured intracranial aneurysms (IAs) of the middle cerebral artery (MCA) in a contemporary national cohort. METHODS The authors conducted a retrospective analysis of prospective data from a nationwide multicenter registry of all aneurysmal subarachnoid hemorrhage (aSAH) cases admitted to a tertiary care neurosurgical department in Switzerland in the years 2009-2015 (Swiss Study on Aneurysmal Subarachnoid Hemorrhage [Swiss SOS]). Patterns of care and outcomes at discharge and the 1-year follow-up in MCA aneurysm (MCAA) patients were analyzed and compared with those in a control group of patients with IAs in locations other than the MCA (non-MCAA patients). Independent predictors of a favorable outcome (modified Rankin Scale score ≤ 3) were identified, and their effect size was determined. RESULTS Among 1866 consecutive aSAH patients, 413 (22.1%) harbored an MCAA. These MCAA patients presented with higher World Federation of Neurosurgical Societies grades (p = 0.007), showed a higher rate of concomitant intracerebral hemorrhage (ICH; 41.9% vs 16.7%, p < 0.001), and experienced delayed cerebral ischemia (DCI) more frequently (38.9% vs 29.4%, p = 0.001) than non-MCAA patients. After adjustment for confounders, patients with MCAA were as likely as non-MCAA patients to experience DCI (aOR 1.04, 95% CI 0.74-1.45, p = 0.830). Surgical treatment was the dominant treatment modality in MCAA patients and at a significantly higher rate than in non-MCAA patients (81.7% vs 36.7%, p < 0.001). An MCAA location was a strong independent predictor of surgical treatment (aOR 8.49, 95% CI 5.89-12.25, p < 0.001), despite statistical adjustment for variables traditionally associated with surgical treatment, such as (space-occupying) ICH (aOR 1.73, 95% CI 1.23-2.45, p = 0.002). Even though MCAA patients were less likely to die during the acute hospitalization (aOR 0.52, 0.30-0.91, p = 0.022), their rate of a favorable outcome was lower at discharge than that in non-MCAA patients (55.7% vs 63.7%, p = 0.003). At the 1-year follow-up, 68.5% and 69.6% of MCAA and non-MCAA patients, respectively, had a favorable outcome (p = 0.676). CONCLUSIONS Microsurgical occlusion remains the predominant treatment choice for about 80% of ruptured MCAAs in a European industrialized country. Although patients with MCAAs presented with worse admission grades and greater rates of concomitant ICH, in-hospital mortality was lower and long-term disability was comparable to those in patients with non-MCAA.
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Affiliation(s)
| | | | | | - Christian Fung
- 2Department of Neurosurgery, University Hospital Bern
- 13Department of Neurosurgery, University Hospital Freiburg, University of Freiburg, Germany
| | - David Bervini
- 2Department of Neurosurgery, University Hospital Bern
| | - Adrien May
- 3Department of Neurosurgery, University Clinic Geneva
| | | | - Karl Schaller
- 3Department of Neurosurgery, University Clinic Geneva
| | | | | | - Donato D'Alonzo
- 5Section for Diagnostic and Interventional Neuroradiology, Department of Radiology, Basel University Hospital, Basel
- 6Department of Neurosurgery, Kantonsspital Aarau
| | - Serge Marbacher
- 5Section for Diagnostic and Interventional Neuroradiology, Department of Radiology, Basel University Hospital, Basel
- 6Department of Neurosurgery, Kantonsspital Aarau
| | - Javier Fandino
- 5Section for Diagnostic and Interventional Neuroradiology, Department of Radiology, Basel University Hospital, Basel
- 6Department of Neurosurgery, Kantonsspital Aarau
| | - Rodolfo Maduri
- 7Department of Clinical Neurosciences, Service of Neurosurgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Roy Thomas Daniel
- 7Department of Clinical Neurosciences, Service of Neurosurgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | | | - Alessio Chiappini
- 8Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Thomas Robert
- 9Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland
| | - Bawarjan Schatlo
- 10Department of Neurosurgery, University Hospital Göttingen, Germany
| | | | | | - Luca Regli
- 11Department of Neurosurgery, University Hospital Zurich
- 12Clinical Neuroscience Center, University of Zurich, Switzerland; and
| | - Martin Nikolaus Stienen
- 11Department of Neurosurgery, University Hospital Zurich
- 12Clinical Neuroscience Center, University of Zurich, Switzerland; and
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Ravina K, Rennert RC, Kim PE, Strickland BA, Chun A, Russin JJ. Orphaned Middle Cerebral Artery Side-to-Side In Situ Bypass as a Favorable Alternative Approach for Complex Middle Cerebral Artery Aneurysm Treatment: A Case Series. World Neurosurg 2019; 130:e971-e987. [DOI: 10.1016/j.wneu.2019.07.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 07/03/2019] [Accepted: 07/04/2019] [Indexed: 10/26/2022]
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Scullen T, Mathkour M, Nerva JD, Dumont AS, Amenta PS. Editorial. Clipping versus coiling for the treatment of middle cerebral artery aneurysms: which modality should be considered first? J Neurosurg 2019; 133:1120-1123. [PMID: 31597118 DOI: 10.3171/2019.5.jns191280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Tyler Scullen
- 1Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine; and
- 2Department of Neurosurgery, Ochsner Clinic Foundation, New Orleans, Louisiana
| | - Mansour Mathkour
- 1Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine; and
- 2Department of Neurosurgery, Ochsner Clinic Foundation, New Orleans, Louisiana
| | - John D Nerva
- 1Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine; and
| | - Aaron S Dumont
- 1Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine; and
| | - Peter S Amenta
- 1Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine; and
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Zhou Y, Duan G, Zhang X, Yang PF, Fang YB, Li Q, Zhao R, Xu Y, Hong B, Huang QH, Liu JM. Outcome and Prognostic Factors of Ruptured Middle Cerebral Artery Aneurysms Treated via Endovascular Approach: A Single-Center 11-Year Experience. World Neurosurg 2019; 133:e187-e196. [PMID: 31493611 DOI: 10.1016/j.wneu.2019.08.189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 08/23/2019] [Accepted: 08/24/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate outcomes and prognostic factors of ruptured middle cerebral artery (MCA) aneurysms, treated via endovascular approach, with improving treatment materials and techniques. PATIENTS AND METHODS A total of 185 consecutive patients, admitted with acutely ruptured MCA aneurysms and treated by endovascular methods between 2006 and 2016, were retrospectively reviewed. Their baseline characteristics, procedure-related complications, and angiographic and clinical outcomes were collected. Univariate analysis and logistic regression analysis were completed to identify any association between procedure-related complications or clinical outcomes and potential risk factors. RESULTS Procedure-related complications occurred in 28 patients (15.1%), including aneurysm rebleeding in 7 (3.8%), hematoma expansion in 10 (5.4%), and ischemia in 13 (7.0%) (concurrent hemorrhage and ischemia in 2 patients), which resulted in morbidity/mortality of 7% and 1.4%. Final evaluations indicated that 153 patients (82.7%, 153/185) had a good outcome (modified Rankin Scale score 0-2). Among 120 (69.4%) who underwent angiographic follow-up, 89 (74.2%) were completely occluded and 20/120 (16.7%) were recanalized. Multivariate analysis of clinical outcome indicated that a high preoperative Hunt and Hess grade (IV-V), intrasylvian/intracerebral hematoma, and early period treatment (2006-2013) were associated with unfavorable outcomes. CONCLUSIONS Endovascular treatment for patients with ruptured middle cerebral artery aneurysms may offer favorable clinical and angiographic outcomes. With the evolution of treatment materials and updated techniques, treatment complications have become less common than previously reported in literature, and clinical outcomes have been improved in recent years.
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Affiliation(s)
- Yu Zhou
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, P.R. China
| | - Guoli Duan
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, P.R. China
| | - Xiaoxi Zhang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, P.R. China
| | - Peng-Fei Yang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, P.R. China
| | - Yi-Bin Fang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, P.R. China
| | - Qiang Li
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, P.R. China
| | - Rui Zhao
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, P.R. China
| | - Yi Xu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, P.R. China
| | - Bo Hong
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, P.R. China
| | - Qing-Hai Huang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, P.R. China
| | - Jian-Min Liu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, P.R. China.
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Stent-Assisted Coil Embolization of MCA Bifurcation Aneurysms at a Hypoplastic M1 Branch by Use of Hook Technique. World Neurosurg 2019; 128:e615-e620. [PMID: 31054347 DOI: 10.1016/j.wneu.2019.04.219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 04/23/2019] [Accepted: 04/24/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND We describe the Hook technique enabling coil embolization in unfavorable M1 bifurcation aneurysms and analyze the morphologic variations in M1 bifurcation to evaluate how often such aneurysms can be seen. METHODS Among 42 MCA aneurysms treated by stent-assisted coil embolization, aneurysms arising at the acute-angled hypoplastic M1 branch (n = 14) were treated by the Hook technique, in which a short stent was deployed only to protect the aneurysm neck after microcatheter selection of the hypoplastic M2, followed by subsequent coiling of the aneurysm. Outcome was evaluated, including Raymond classification, coil packing density, final modified Rankin Scale (mRS), and recurrence. Separately, 100 middle cerebral artery (MCA) bifurcation aneurysms were analyzed to assess the proportion of such unfavorable aneurysms. RESULTS Procedural success of the Hook technique was obtained in 13 of 14 patients (93%). A mean packing density of 30% was achieved. Magnetic resonance angiographic follow-up at a median 4 months (range, 1-26 months) showed complete occlusion in 11 patients and residual neck filling in 3 patients. There was no clinical event (mRS = 0) over a median 17 months (range, 2-26 months) of clinical follow-up. One patient had a thrombotic occlusion during the procedure, which was resolved after tirofiban infusion, without evidence of an infarct or deficit. Of the 100 MCA bifurcation aneurysms, aneurysm arising in asymmetric hypoplastic M2 division was the most common type (48%). CONCLUSIONS The Hook technique enabled stent-assisted coiling of M1 bifurcation aneurysm with extension along the asymmetric hypoplastic M2 division and also securing the M2 branch.
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Endovascular treatment of small (< 5 mm) unruptured middle cerebral artery aneurysms. Pol J Radiol 2019; 84:e198-e204. [PMID: 31481991 PMCID: PMC6717937 DOI: 10.5114/pjr.2019.84829] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 02/18/2019] [Indexed: 01/09/2023] Open
Abstract
Purpose We report our experience with endovascular treatment of these lesions, with special consideration of angiographic and clinical outcomes and periprocedural complications. Material and methods The analysis included treatment results of 19 patients with 20 aneurysms. The aneurysm size ranged from 1.9 to 4.7 mm (mean 3.8, SD 0.7). Clinical examinations with the use of modified Rankin Score and angiographic outcomes were evaluated initially postembolisation and at a minimum follow-up of six months. Results Initial post-treatment complete and near-complete aneurysm occlusion was achieved in 19 (95%) cases and incomplete occlusion in one (5%) case. Imaging follow-up, performed in 17 (89.4%) patients, showed no change in the degree of occlusion in 16 (94.1%) patients and coil compaction in one (5.9%). There were no retreatment procedures. The procedure-related mortality rate was 5% (1/20) and was associated with intraprocedural aneurysm rupture. There was a case of a clinically silent coil prolapse into the parent artery. The clinical follow-up evaluation achieved in 17 (89.4%) patients showed no change in clinical status in all followed patients. Conclusions Endovascular treatment of small unruptured middle cerebral artery aneurysms is feasible and effective. The procedure-related complications are not negligible, especially in terms of the benign natural course of these lesions.
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Torné R, García S, Sanroman L, Rodríguez-Hernández A, Reyes L, Tercero J, Enseñat J. Safety and Feasibility Assessment of the O-Arm as an Intraoperative Angiography Device in Aneurysm Surgery. World Neurosurg 2019; 127:e1159-e1165. [PMID: 30995551 DOI: 10.1016/j.wneu.2019.04.076] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 04/07/2019] [Accepted: 04/08/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To describe the technique and initial experience of using a rotational 3-dimensional (3D) fluoroscopy system (O-arm; Medtronic) as intraoperative angiography (IA) in the surgery of cerebral aneurysms. METHODS The 3D IA with O-arm (IAWOA) was performed in a consecutive cohort of patients with unruptured intracranial aneurysms. Conventional microsurgical clipping was performed with the assistance of indocyanine green videoangiography. Then the O-arm chassis was brought in, the ipsilateral internal carotid artery was catheterized, and contrasted images were acquired. Resulting datasets were exported in Digital Imaging and Communications in Medicine and processed using the Osirix software in an accessory computer. The 3D image reconstruction was evaluated intraoperatively to confirm aneurysm occlusion and parent vessel patency. Afterward, agreement among IAWOA, indocyanine green videoangiography, and standard postoperative angiography was analyzed. RESULTS The initial pilot study was performed in 6 patients with 7 unruptured aneurysms. The aneurysm occlusion rate was 100%. The concordance of the IAWOA and the standard postoperative angiography was complete, both in terms of occlusion and parent vessel patency. No complications derived from the IAWOA were observed except in 1 patient, who presented a retroperitoneal hematoma without clinical consequences. CONCLUSIONS The 3D rotational fluoroscopy (O-arm) device could be safely and effectively used as an IA system in selected patients. To the best of our knowledge, this is the first study reporting its use as an IA device. This technique seems to offer excellent image quality that could be compared with that of the gold standard 3D digital subtraction angiography but with a lower cost and versatility of use for other subspecialties.
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Affiliation(s)
- Ramón Torné
- Department of Neurological Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain.
| | - Sergio García
- Department of Neurological Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Luís Sanroman
- Department of Radiology, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Ana Rodríguez-Hernández
- Department of Neurological Surgery, Germans Trias i Pujol University Hospital, Barcelona, Spain
| | - Luís Reyes
- Department of Neurological Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Javier Tercero
- Department of Anestiology, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Joaquim Enseñat
- Department of Neurological Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
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Winkler EA, Lu A, Burkhardt JK, Rutledge WC, Yue JK, Birk HS, Alotaibi N, Choudhri O, Lawton MT. Microsurgical Clipping of Anterior Choroidal Artery Aneurysms: A Systematic Approach to Reducing Ischemic Complications in an Experience with 146 Patients. Oper Neurosurg (Hagerstown) 2019; 17:413-423. [DOI: 10.1093/ons/opz007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 01/31/2019] [Indexed: 02/07/2023] Open
Abstract
Abstract
BACKGROUND
Aneurysms of the anterior choroidal artery (AChA) have been associated with high treatment-associated morbidity due to ischemic complications.
OBJECTIVE
To report a large clinical experience of microsurgically treated AChA aneurysms and describe a systematic approach to reduce ischemic complications.
METHODS
One hundred forty-six patients with AChA aneurysms were retrospectively reviewed from a prospectively maintained database. Clinical characteristics, surgical techniques, clinical outcomes, arterial infarction, and use of intraoperative adjuncts (ie, ultrasonography, indocyanine green videoangiography, and neuromonitoring) were analyzed.
RESULTS
In total, one hundred forty-three aneurysms (97.9%) were clipped. Temporary clipping was utilized in 47 cases (32.2%) with mean occlusion time of 5.6 min. Arterial infarction occurred in 12 patients (8.2%). In clipped aneurysms, 90.5% were completely obliterated, 8.8% had minimal residual (<5% of original), and 0.7% were incompletely occluded (>5% of original). Mortality (2.7%) was limited to patients with high-grade subarachnoid hemorrhage. Indocyanine green videoangiography and neuromonitoring altered operative technique in ∼20% of cases. Multivariate logistic regression identified intraoperative rupture as the sole predictor for arterial infarction.
CONCLUSION
Open microsurgical clipping remains a safe, effective treatment for AChA aneurysms. Microsurgical technique is paramount in preserving AChA patency and reducing ischemic complications. Despite increasing reliance on qualitative measures of AChA blood flow (videoangiography and ultrasonography) and neurophysiological monitoring, these technologies aid us infrequently. However, these adjuncts provide important safety checks for AChA patency. Temporary clipping must be used judiciously to lower the risk of intraoperative rupture while limiting possible ischemia in the AChA territory.
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Affiliation(s)
- Ethan A Winkler
- Department of Neurological Surgery, University of California - San Francisco, San Francisco, California
| | - Alex Lu
- Department of Neurological Surgery, University of California - San Francisco, San Francisco, California
| | - Jan-Karl Burkhardt
- Department of Neurological Surgery, University of California - San Francisco, San Francisco, California
- Department of Neurosurgery, Baylor College of Medicine Medical Center, Houston, Texas
| | - W Caleb Rutledge
- Department of Neurological Surgery, University of California - San Francisco, San Francisco, California
| | - John K Yue
- Department of Neurological Surgery, University of California - San Francisco, San Francisco, California
| | - Harjus S Birk
- Department of Neurological Surgery, University of California - San Francisco, San Francisco, California
| | - Naif Alotaibi
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Omar Choudhri
- Department of Neurological Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael T Lawton
- Department of Neurological Surgery, University of California - San Francisco, San Francisco, California
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
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Hagen F, Maurer CJ, Berlis A. Endovascular Treatment of Unruptured MCA Bifurcation Aneurysms Regardless of Aneurysm Morphology: Short- and Long-Term Follow-Up. AJNR Am J Neuroradiol 2019; 40:503-509. [PMID: 30765382 DOI: 10.3174/ajnr.a5977] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 01/04/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE The optimal treatment of unruptured middle cerebral aneurysms is still under debate. Although today almost any aneurysm can be treated endovascularly, there is a lack of data comparing endovascular and microsurgical repair of MCA aneurysms. The aim of our analysis is to provide data on the efficacy, clinical outcome, complications and re-treatment rates of endovascular treatment of this subtype of aneurysms. MATERIALS AND METHODS Between May 2008 and July 2017, endovascular treatment of 1184 aneurysms in 827 patients was performed in our department. Twenty-four percent of these aneurysms were located at the MCA, and 150 unruptured MCA bifurcation aneurysms treated with coiling, stent-assisted-coiling, or endovascular flow diverter (WEB device) were identified for this retrospective data analysis. Ninety-six percent of all aneurysms, ruptured and unruptured, were treated by an endovascular approach, which yields a low selection bias for aneurysms suitable for endovascular treatment. Follow-up examinations were performed after 12 and 36 months and then every 1-3 years after embolization. Procedures were analyzed for periprocedural complications, outcome, and retreatment rate of the WEB (n = 38) and coiling with (n = 45) or without stent assistance (n = 67). RESULTS The procedure-associated good clinical outcome (mRS ≦ 2) was 89.9%, and the mortality rate was 2.7%. Short-term follow-up good clinical outcome/mortality rates were 91.3%/0.7%. At discharge, 137 patients had an mRS of 0-2 (91.3%) and 13 had an mRS of 3-6 (8.7%). The retreatment rate was significantly higher in the WEB group (21.1%) compared with the coiling group with (5.9%) or without (2.2%) stent placement (P < .05). CONCLUSIONS Regardless of the architecture of MCA bifurcation aneurysms, the endovascular treatment can be performed with low morbidity/mortality rates. The higher retreatment rate in the WEB group correlates with the learning curve in choosing the right device size.
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Affiliation(s)
- F Hagen
- From the Department of Diagnostic and Interventional Neuroradiology, Klinikum Augsburg, Augsburg, Germany
| | - C J Maurer
- From the Department of Diagnostic and Interventional Neuroradiology, Klinikum Augsburg, Augsburg, Germany.
| | - A Berlis
- From the Department of Diagnostic and Interventional Neuroradiology, Klinikum Augsburg, Augsburg, Germany
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Martinez-Perez R, Rayo N, Montivero A, Mura JM. The "Brain Stress Timing" phenomenon and other misinterpretations of randomized clinical trial on aneurysmal subarachnoid hemorrhage. Neural Regen Res 2019; 14:1364-1366. [PMID: 30964054 PMCID: PMC6524510 DOI: 10.4103/1673-5374.253513] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Clipping and coiling are currently the two alternatives in treatment of ruptured cerebral aneurysms. In spite of some meritorious analysis, further discussion is helpful to understand the actual state of art. Retreatment and rebleeding rates clearly favors clipping, although short-term functional outcome seems to be beneficial for clipping, while this different is not such if we perform the comparison at a longer follow up. Long-term follow ups and cost analysis are mandatory to have a clear view of the current picture in treatment of subarachnoid hemorrhage. Treatment strategy should be made by a multi-disciplinary team in accredited centers with proficient experience in both techniques.
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Affiliation(s)
- Rafael Martinez-Perez
- Division of Neurosurgery, Institute of Clinical Neurosciences, Universidad Austral de Chile, Valdivia; Division of Cerebrovascular and Skull Base Neurosurgery, Institute of Neurosurgery Dr Asenjo, Santiago, Chile
| | | | - Agustín Montivero
- Division of Cerebrovascular and Skull Base Neurosurgery, Institute of Neurosurgery Dr Asenjo, Santiago, Chile
| | - Jorge Marcelo Mura
- Division of Cerebrovascular and Skull Base Neurosurgery, Institute of Neurosurgery Dr Asenjo, Santiago, Chile
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Xin WQ, Xin QQ, Yang XY. Meta-Analysis of Clipping versus Coiling for the Treatment of Unruptured Middle Cerebral Artery Aneurysms: Direct Comparison of Procedure-Related Complications. Neuropsychiatr Dis Treat 2019; 15:3387-3395. [PMID: 31824162 PMCID: PMC6901057 DOI: 10.2147/ndt.s226353] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 11/13/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Endovascular coiling and surgical clipping are routinely used to treat unruptured middle cerebral artery aneurysms (MCAAs). However, the optimal treatment for unruptured MCAAs is controversial. We aimed to systematically and comprehensively compare the clinical outcomes between endovascular coiling and surgical clipping for the treatment of MCAAs. METHOD This meta-analysis retrieved academic articles comparing the clinical outcomes between endovascular coiling and surgical clipping for unruptured MCAAs from the Cochrane Library, Medline, PubMed, and EMBASE databases. The reference articles of the identified studies were carefully reviewed to ensure that all available articles were represented in the study. The meta-analysis was conducted in accordance with the acknowledged the prioritized reported items for systematic review and meta-analysis (PRISMA) guidelines. RESULTS A total of 6 studies, which enrolled a total of 789 participants, were included in our analysis. Of these 789 patients with MCAAs, 144 were assigned to an endovascular coiling group, and 645 were assigned to a surgical clipping group. Our results demonstrated that endovascular coiling was associated with a higher rate of retreatment (OR = 104.926; 95% CI: 12.931 to 851.379; P<0.001) and postoperative complications (OR = 3.157; 95% CI: 1.239 to 8.048; P= 0.016) than surgical clipping, especially for postoperative thrombus without infarction (OR = 4.905, 95% CI: 1.097 to 21.933; P = 0.037). Furthermore, surgical clipping was related to a higher rate of complete occlusion (OR = 0.349, 95% CI: 0.140 to 0.872; P = 0.024) and Glasgow Outcome Scale (GOS) ≥4 (OR = 0.250; 95% CI: 0.072 to 0.867; P= 0.029) than endovascular coiling after the operation. However, there was no significant difference in the rate of death, the proportion of patients with modified Rankin Scale (mRS)>2, infarction, or bleeding. CONCLUSION Although this study has inherent limitations, surgical clipping of unruptured MCAAs resulted in significantly higher complete aneurysm occlusion and GOS≥4 rates and was associated with a lower incidence of retreatment and complication, especially for postoperative thrombus without infarction. Therefore, the effect induced by surgical clipping of unruptured MCAAs remains superior to that induced by endovascular coiling; surgical clipping should be regarded as the first choice of treatment for unruptured MCAAs.
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Affiliation(s)
- Wen-Qiang Xin
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, Peoples Republic of China
| | - Qi-Qiang Xin
- Department of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, Jiangxi 330000, Peoples Republic of China
| | - Xin-Yu Yang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, Peoples Republic of China
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Michelozzi C, Darcourt J, Guenego A, Januel AC, Tall P, Gawlitza M, Bonneville F, Cognard C. Flow diversion treatment of complex bifurcation aneurysms beyond the circle of Willis: complications, aneurysm sac occlusion, reabsorption, recurrence, and jailed branch modification at follow-up. J Neurosurg 2018; 131:1751-1762. [PMID: 30579280 DOI: 10.3171/2018.7.jns18654] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 07/19/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The purpose of this study is to present the authors' medium-term results, with special emphasis on complications, occlusion rate of the aneurysm sac (digital subtraction angiography [DSA] and MRI), and the fate of cortical branches and perforating arteries covered ("jailed") by the flow diverter (FD) stent. METHODS Between January 2010 and September 2017, 29 patients (14 female) with 30 aneurysms were treated with an FD stent. Twenty-one aneurysms were at the middle cerebral artery bifurcation, 8 were in the anterior communicating artery region, and 1 was a pericallosal artery bifurcation. Thirty-five cortical branches were covered. A single FD stent was used in all patients. Symptomatic and asymptomatic periprocedural and delayed complications were reported. DSA and MRI controls were analyzed to evaluate modification of the aneurysm sac and jailed branches. RESULTS Permanent morbidity was 3.4% (1/29), due to a jailed branch occlusion, with a modified Rankin Scale (mRS) score of 2 at the last follow-up. Mortality and permanent complication with poor prognosis (mRS score > 2) rates were 0%. The mean follow-up time for DSA and MRI (mean ± SD) was 21 ± 14.5 months (range 3-66 months) and 19 ± 16 months (range 3-41 months), respectively. The mean time to aneurysm sac occlusion (available for 24 patients), including stable remodeling, was 11.8 ± 6 months (median 13, range 3-27 months). The overall occlusion rate was 82.1% (23/28), and it was 91.7% (22/24) in the group of patients with at least 2 DSA control sequences. One recanalization occurred at 41 months posttreatment. At the time of publication, at the latest follow-up, 7 (20%) of 35 covered branches were occluded, 18 (51.4%) showed a decreased caliber, and the remaining 10 (28.5%) were unchanged. MRI T2-weighted sequences showed complete sac reabsorption in 7/29 aneurysms (24.1%), and the remaining lesions were either smaller (55.2%) or unchanged (17.2%). MRI revealed asymptomatic and symptomatic ischemic events in perforator territories in 7/28 (25%) and 4/28 (14.3%) patients, respectively, which were reversible within 24 hours. CONCLUSIONS Flow diversion of bifurcation aneurysms is feasible, with low rates of permanent morbidity and mortality and high occlusion rates; however, recurrence may occur. Caliber reduction and asymptomatic occlusion of covered cortical branches as well as silent perforator stroke are common. Ischemic complications may occur with no identified predictable factors. MRI controls should be required in all patients to evaluate silent ischemic lesions and aneurysm sac reabsorption over time.
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Affiliation(s)
- Caterina Michelozzi
- 1Service de Neuroradiologie, Hôpital Pierre-Paul Riquet, CHU de Toulouse; and
| | - Jean Darcourt
- 1Service de Neuroradiologie, Hôpital Pierre-Paul Riquet, CHU de Toulouse; and
| | - Adrien Guenego
- 1Service de Neuroradiologie, Hôpital Pierre-Paul Riquet, CHU de Toulouse; and
| | | | - Philippe Tall
- 1Service de Neuroradiologie, Hôpital Pierre-Paul Riquet, CHU de Toulouse; and
| | | | - Fabrice Bonneville
- 1Service de Neuroradiologie, Hôpital Pierre-Paul Riquet, CHU de Toulouse; and
| | - Christophe Cognard
- 1Service de Neuroradiologie, Hôpital Pierre-Paul Riquet, CHU de Toulouse; and
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Huang CQ, Kang DZ, Yu LH, Zheng SF, Yao PS, Lin YX, Lin ZY. The classification of intracranial aneurysm neck: a single center research experience. Chin Neurosurg J 2018; 4:39. [PMID: 32922899 PMCID: PMC7398182 DOI: 10.1186/s41016-018-0138-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 09/19/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND There is associating with incidence of unfavorable outcomes compared to microsurgical clippings. We are in order to investigate the outcomes of microsurgical clipping for intracranial aneurysms and determine the ideal clipping methods for different aneurysm subtypes. METHOD Retrospectively analyzed the clinical characteristics and follow-up data (completely recorded) of 123 patients with 128 aneurysms were treated. 20 cases were treated as control group from October 2013 to December 2013. Since January 2014, aneurysms were classified base on the 20 cases of aneurysm imaging data. 103 patients were treated as experimental group, the classification of aneurysms previously proposed was used to estimate the way of surgery, and the guiding value of the genotype was verified according to the intraoperative findings. The proposed aneurysm classification is based on the virtual surface of the aneurysm and the parent artery, the aneurysm neck was classified as follows: subtype I, the curved surface of the neck is a single curved surface; subtype II, the neck is hyperboloid; subtype III, neck is a three-curved surface. Aneurysms were divided into further subtypes according to the ratio of the width of the aneurysm neck surface and the length of the artery circumference: subtype A, the ratio of the aneurysm neck surface to the parent artery was not more than 0.5; subtype B, more than 0.5. There are some clamping methods include simple, sliding, interlocking and hybrid. RESULTS In the control group, patients did not undergo a suitable clipping scheme without classification of aneurysm neck (unclassed clipping). While causing the occurrence of occlusion adverse events, including neck residual, Tumor artery stenosis, electrophysiological changes, the lack of blood supply and so on. The experimental[page1image12073600]group was analyzed by using a predetermined clipping scheme (classed clipping), and the use of aneurysms clamps was approximately the same as expected. Compared the preoperative assessment with the actual situation, the consistency of the control group was 50% and the experimental group was 96%. Adverse events of classed clipping is 2%, another is 60%. There is a significant difference between the two groups (P < 0.05).Classed clipping of subject IA and IB are simple (mean 1.2 and 1.3 clips); classed clipping of subject IIA is simple and interlocking(mean 1.2 clips); classed clipping of subject IIB is sliding and hybrid(mean 2.05 clips); classed clipping of subject IIIA and IIIB are hybrid(mean 2.3 clips). CONCLUSION There is a higher consistency in surgery through the above classification of preoperative assessment of clipping. There was no adverse event of intracranial aneurysm clipping in the clipping mode selected by the above classification, and satisfactory surgical clipping rate was achieved and no recurrence was found.
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Affiliation(s)
- Cai-Qiang Huang
- Department of Neurosurgery, The First Affiliated Hospital, Fujian Medical University, No.20 Changzhou Road,Taijiang District, Fuzhou, 350004 Fujian Province China
| | - De-Zhi Kang
- Department of Neurosurgery, The First Affiliated Hospital, Fujian Medical University, No.20 Changzhou Road,Taijiang District, Fuzhou, 350004 Fujian Province China
| | - Liang-Hong Yu
- Department of Neurosurgery, The First Affiliated Hospital, Fujian Medical University, No.20 Changzhou Road,Taijiang District, Fuzhou, 350004 Fujian Province China
| | - Shu-Fa Zheng
- Department of Neurosurgery, The First Affiliated Hospital, Fujian Medical University, No.20 Changzhou Road,Taijiang District, Fuzhou, 350004 Fujian Province China
| | - Pei-Sen Yao
- Department of Neurosurgery, The First Affiliated Hospital, Fujian Medical University, No.20 Changzhou Road,Taijiang District, Fuzhou, 350004 Fujian Province China
| | - Yuan-Xiang Lin
- Department of Neurosurgery, The First Affiliated Hospital, Fujian Medical University, No.20 Changzhou Road,Taijiang District, Fuzhou, 350004 Fujian Province China
| | - Zhang-Ya Lin
- Department of Neurosurgery, The First Affiliated Hospital, Fujian Medical University, No.20 Changzhou Road,Taijiang District, Fuzhou, 350004 Fujian Province China
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Goertz L, Kabbasch C, Borggrefe J, Hamisch C, Telentschak S, von Spreckelsen N, Stavrinou P, Timmer M, Brinker G, Goldbrunner R, Krischek B. Preoperative Three-Dimensional Angiography May Reduce Ischemic Complications During Clipping of Ruptured Intracranial Aneurysms. World Neurosurg 2018; 120:e1163-e1170. [DOI: 10.1016/j.wneu.2018.09.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 09/02/2018] [Accepted: 09/04/2018] [Indexed: 12/12/2022]
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Dimitriadis S, Qeadan F, Taylor CL, Yonas H, Carlson AP. Middle Cerebral Artery Aneurysm "Neck Overhang": Decreased Postclipping Residual Using the Intersecting Clipping Technique. Oper Neurosurg (Hagerstown) 2018. [PMID: 29529311 DOI: 10.1093/ons/opx278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Middle cerebral artery (MCA) aneurysms continue to be viewed by many as primarily surgical entities. OBJECTIVE To introduce a new, easily measurable dimension termed "neck overhang," defined as the amount of the aneurysm that extends proximal to the 2 dimensionally defined "neck" and to evaluate the utility of the intersecting clipping technique (use of straight clip and intersecting fenestrated clip) to adapt to this overhanging segment's specific dimensions and achieve better obliteration of the MCA aneurysms. METHODS We reviewed retrospectively 100 MCA aneurysms treated surgically over the last 10 yr at our institution. We identified the clipping technique that was performed (intersecting vs "standard" technique) and we evaluated the presence of a postoperative remnant. We then correlated these with the aneurysm's overhanging neck length. RESULTS Forty-three aneurysms were treated with the intersecting clipping technique. The overall rate of remnant was 16%. In the standard group, the rate of remnant was 23%, whereas with intersecting clipping that was 7% (P = .029). Within the standard clipping group, we found that the optimum threshold for length of the neck overhang was ≥1.9 mm in order to predict the occurrence of residual. Applying this threshold to the intersecting clipping technique group resulted in a reduction in remnant from 35% in the standard group to 9%. CONCLUSION Neck overhang >1.9 mm is associated with a higher chance of postclipping residual aneurysm in MCA aneurysms. The intersecting clipping technique is a versatile technique that can conform to various aneurysms' geometry and can reduce the rate of post clipping residual for aneurysms with high neck overhang.
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Affiliation(s)
- Stavros Dimitriadis
- Department of Neurological Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Fares Qeadan
- Department of Internal Medicine, division of Epidemiology, Biostatistics and Preventive Medicine University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Christopher L Taylor
- Department of Neurological Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Howard Yonas
- Department of Neurological Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Andrew P Carlson
- Department of Neurological Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
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Kotowski M, Farzin B, Fahed R, Guilbert F, Chagnon M, Darsaut TE, Daniel RT, Raymond J. Residual Cerebral Aneurysms After Microsurgical Clipping: A New Scale, an Agreement Study, and a Systematic Review of the Literature. World Neurosurg 2018; 121:e302-e321. [PMID: 30261387 DOI: 10.1016/j.wneu.2018.09.100] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 09/10/2018] [Accepted: 09/12/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The surgical repair of a cerebral aneurysm does not always lead to complete occlusion. A standardized repeatable method of reporting results of surgical clipping is desirable. Our purpose was to systematically review methods of classifying aneurysm remnants, provide a new scale with precise definitions of categories, and perform an agreement study to assess the variability in adjudicating remnants after aneurysm clipping. METHODS A systematic review was performed to identify ways to report angiographic results of surgical clipping between 1963 and 2017. Postclipping angiographic results of 43 patients were also independently evaluated by 10 raters of various experience and backgrounds using a new 4-category scale. Agreement between responses were analyzed using κ statistics. RESULTS The systematic review yielded 63 articles with 37 different nomenclatures using 2-6 categories. The reliability of judging the presence of an aneurysm remnant on catheter angiography was studied only twice, with only 2 raters each time, with contradictory results. Interobserver agreement using the new 4-category scale was moderate (κ = 0.52; 95% confidence interval, 0.43-0.62) for all observers, but improved to substantial (κ = 0.62; 95% confidence interval, 0.47-0.76) when results were dichotomized (grade 0/1 vs. 2/3). CONCLUSIONS Various classification schemes to evaluate angiographic results after surgical clipping exist in the literature, but they lack standardization. Adjudication using fewer, better defined categories may yield more reliable agreement.
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Affiliation(s)
- Marc Kotowski
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada; Faculty of Biology and Medicine, Université de Lausanne, Lausanne, Switzerland
| | - Behzad Farzin
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Robert Fahed
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada; Interventional Neuroradiology Unit, Fondati Rothschild Hospital, Paris, France
| | - François Guilbert
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Miguel Chagnon
- Department of Mathematics and Statistics, Université de Montréal, Montreal, Quebec, Canada
| | - Tim E Darsaut
- University of Alberta Hospital, Mackenzie Health Sciences Centre, Division of Neurosurgery, Department of Surgery, Edmonton, Canada
| | - Roy T Daniel
- Faculty of Biology and Medicine, Université de Lausanne, Lausanne, Switzerland; Department of Clinical Neurosciences, Neurosurgery Unit, Centre hospitalier universitaire vaudois (CHUV), Lausanne, Switzerland
| | - Jean Raymond
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
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Nussbaum ES, Madison MT, Goddard JK, Lassig JP, Kallmes KM, Nussbaum LA. Microsurgical treatment of unruptured middle cerebral artery aneurysms: a large, contemporary experience. J Neurosurg 2018; 130:1498-1504. [PMID: 29932382 DOI: 10.3171/2018.1.jns172466] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 01/10/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Advances in endovascular therapy for the treatment of middle cerebral artery (MCA) aneurysms have led to scrutiny of its benefits compared with microsurgical repair. To provide information regarding complication rates and outcomes, the authors reviewed the results of a large series of unruptured MCA aneurysms treated with open microsurgery. METHODS The authors included all patients who underwent surgical repair of an unruptured MCA aneurysm between 1997 and 2015. All surgical procedures, including clipping, wrapping, bypass, and parent artery occlusion, were performed by a single neurosurgeon. Aneurysm occlusion was assessed using intraoperative digital subtraction angiography (DSA) or DSA and indocyanine green videoangiography in all cases. Postoperatively, all patients were monitored in a neurointensive care unit overnight. Clinical follow-up was scheduled for 2-4 weeks after surgery, and angiographic follow-up was performed in those patients with subtotally occluded aneurysms at 1, 2, and 5 years postoperation. RESULTS The authors treated 750 unruptured MCA aneurysms in 716 patients: 649 (86.5%) aneurysms were small, 75 (10.0%) were large, and 26 (3.5%) were giant. Most aneurysms (n = 677, 90%) were treated by primary clip reconstruction. The surgical morbidity rate was 2.8%, and the mortality rate was 0%. Complete angiographic aneurysm occlusion was achieved in 92.0% of aneurysms. At final follow-up, 713 patients had a modified Rankin Scale (mRS) score of 0, 2 patients had an mRS score of 2 or 3, and 1 had an mRS score of 4. CONCLUSIONS In high-volume centers, microsurgical management of MCA aneurysms can be performed with very low morbidity rates. Currently, microsurgical repair appears to be a highly effective method of treating MCA aneurysms.
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Affiliation(s)
- Eric S Nussbaum
- 1National Brain Aneurysm Center, Twin Cities, Minnesota; and
| | | | - James K Goddard
- 1National Brain Aneurysm Center, Twin Cities, Minnesota; and
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Pierot L, Moret J, Barreau X, Szikora I, Herbreteau D, Turjman F, Holtmannspötter M, Januel AC, Costalat V, Fiehler J, Klisch J, Gauvrit JY, Weber W, Desal H, Velasco S, Liebig T, Stockx L, Berkefeld J, Molyneux A, Byrne J, Spelle L. Safety and efficacy of aneurysm treatment with WEB in the cumulative population of three prospective, multicenter series. J Neurointerv Surg 2018; 10:553-559. [PMID: 28965106 PMCID: PMC5969386 DOI: 10.1136/neurintsurg-2017-013448] [Citation(s) in RCA: 147] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 09/14/2017] [Accepted: 09/15/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND Flow disruption with the WEB is an innovative endovascular approach for treatment of wide-neck bifurcation aneurysms. Initial studies have shown a low complication rate with good efficacy. PURPOSE To report clinical and anatomical results of the WEB treatment in the cumulative population of three Good Clinical Practice (GCP) studies: WEBCAST (WEB Clinical Assessment of Intrasaccular Aneurysm), French Observatory, and WEBCAST-2. METHODS WEBCAST, French Observatory, and WEBCAST-2 are single-arm, prospective, multicenter, GCP studies dedicated to the evaluation of WEB treatment. Clinical data were independently evaluated. Postoperative and 1-year aneurysm occlusion was independently evaluated using the 3-grade scale: complete occlusion, neck remnant, and aneurysm remnant. RESULTS The cumulative population comprised 168 patients with 169 aneurysms, including 112 female subjects (66.7%). The patients' ages ranged between 27 and 77 years (mean 55.5±10.2 years). Aneurysm locations were middle cerebral artery in 86/169 aneurysms (50.9%), anterior communicating artery in 36/169 (21.3%), basilar artery in 30/169 (17.8%), and internal carotid artery terminus in 17/169 (10.1%). The aneurysm was ruptured in 14/169 (8.3%). There was no mortality at 1 month and procedure/device-related morbidity was 1.2% (2/168). At 1 year, complete aneurysm occlusion was observed in 81/153 aneurysms (52.9%), neck remnant in 40/153 aneurysms (26.1%), and aneurysm remnant in 32/153 aneurysms (20.9%). Re-treatment was carried out in 6.9%. CONCLUSIONS This series is at the moment the largest prospective, multicenter, GCP series of patients with aneurysms treated with WEB. It shows the high safety and good mid-term efficacy of this treatment. CLINICAL TRIAL REGISTRATION French Observatory: Unique identifier (NCT18069); WEBCAST and WEBCAST-2: Unique identifier (NCT01778322).
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Affiliation(s)
- Laurent Pierot
- Hôpital Maison-Blanche, Université Reims-Champagne-Ardenne, Reims, France
| | - Jacques Moret
- Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Kremlin-Bicêtre, France
| | | | - Istvan Szikora
- National Institute of Clinical Neurosciences, Budapest, Hungary
| | | | | | | | | | | | - Jens Fiehler
- Departrment of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Werner Weber
- Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, Bochum, Germany
| | | | | | | | - Luc Stockx
- ZOL(Ziekenhuis Oost-Limburg) Genk, Genk, Belgium
| | - Joachim Berkefeld
- Institutfür Neuroradiologie, Klinikum der Johann Wolfgang Goethe-Universitaet, Frankfurt, Germany
| | - Andrew Molyneux
- Nuffield Department of Surgical Sciences, Oxford University, Oxford, UK
| | - James Byrne
- Nuffield Department of Surgical Sciences, Oxford University, Oxford, UK
| | - Laurent Spelle
- Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Kremlin-Bicêtre, France
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Mooney MA, Simon ED, Brigeman S, Nakaji P, Zabramski JM, Lawton MT, Spetzler RF. Long-term results of middle cerebral artery aneurysm clipping in the Barrow Ruptured Aneurysm Trial. J Neurosurg 2018; 130:895-901. [PMID: 29701554 DOI: 10.3171/2017.10.jns172183] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 10/20/2017] [Indexed: 12/19/2022]
Abstract
Objective A direct comparison of endovascular versus microsurgical treatment of ruptured middle cerebral artery (MCA) aneurysms in randomized trials is lacking. As endovascular treatment strategies continue to evolve, the number of reports of endovascular treatment of these lesions is increasing. Herein, the authors report a detailed post hoc analysis of ruptured MCA aneurysms treated by microsurgical clipping from the Barrow Ruptured Aneurysm Trial (BRAT). Methods The cases of patients enrolled in the BRAT who underwent microsurgical clipping for a ruptured MCA aneurysm were reviewed. Characteristics of patients and their clinical outcomes and long-term angiographic results were analyzed. Results Fifty patients underwent microsurgical clipping of a ruptured MCA aneurysm in the BRAT, including 21 who crossed over from the endovascular treatment arm. Four patients with nonsaccular (e.g., dissecting, fusiform, or blister) aneurysms were excluded, leaving 46 patients for analysis. Most (n = 32; 70%) patients presented with a Hunt and Hess grade II or III subarachnoid hemorrhage, with a high prevalence of intraparenchymal blood (n = 23; 50%), intraventricular blood (n = 21; 46%), or both. At the last follow-up (up to 6 years after treatment), clinical outcomes were good (modified Rankin Scale score 0–2) in 70% (n = 19) of 27 Hunt and Hess grades I–III patients and in 36% (n = 4) of 11 Hunt and Hess grade IV or V patients. There were no instances of rebleeding after the surgical clipping of aneurysms in this series at the time of last clinical follow-up. Conclusions Microsurgical clipping of ruptured MCA aneurysms has several advantages over endovascular treatment, including durability over time. The authors report detailed outcome data of patients with ruptured MCA aneurysms who underwent microsurgical clipping as part of a prospective, randomized trial. These results should be used for comparison with future endovascular and surgical series to ensure that the best results are being achieved for patients with ruptured MCA aneurysms.
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75
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Chong MY, Martin SC, Phang I, St George E, Suttner N, Teo MK. The Prevalence of Cerebrovascular Abnormalities Detected in Various Diagnostic Subgroups of Spontaneous Subarachnoid Hemorrhage in the Modern Era. World Neurosurg 2018; 111:e355-e361. [DOI: 10.1016/j.wneu.2017.12.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 12/10/2017] [Accepted: 12/11/2017] [Indexed: 11/24/2022]
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Alreshidi M, Cote DJ, Dasenbrock HH, Acosta M, Can A, Doucette J, Simjian T, Hulou MM, Wheeler LA, Huang K, Zaidi HA, Du R, Aziz-Sultan MA, Mekary RA, Smith TR. Coiling Versus Microsurgical Clipping in the Treatment of Unruptured Middle Cerebral Artery Aneurysms: A Meta-Analysis. Neurosurgery 2018; 83:879-889. [DOI: 10.1093/neuros/nyx623] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 12/12/2017] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Open microsurgical clipping of unruptured intracranial aneurysms has long been the gold standard, yet advancements in endovascular coiling techniques have begun to challenge the status quo.
OBJECTIVE
To compare endovascular coiling with microsurgical clipping among adults with unruptured middle cerebral artery aneurysms (MCAA) by conducting a meta-analysis.
METHODS
A systematic search was conducted from January 2011 to October 2015 to update a previous meta-analysis. All studies that reported unruptured MCAA in adults treated by microsurgical clipping or endovascular coiling were included and cumulatively analyzed.
RESULTS
Thirty-seven studies including 3352 patients were included. Using the random-effects model, pooled analysis of 11 studies of microsurgical clipping (626 aneurysms) revealed complete aneurysmal obliteration in 94.2% of cases (95% confidence interval [CI] 87.6%-97.4%). The analysis of 18 studies of endovascular coiling (759 aneurysms) revealed complete obliteration in 53.2% of cases (95% CI: 45.0%-61.1%). Among clipping studies, 22 assessed neurological outcomes (2404 aneurysms), with favorable outcomes in 97.9% (95% CI: 96.8%-98.6%). Among coiling studies, 22 examined neurological outcomes (826 aneurysms), with favorable outcomes in 95.1% (95% CI: 93.1%-96.5%). Results using the fixed-effect models were not materially different.
CONCLUSION
This updated meta-analysis demonstrates that surgical clipping for unruptured MCAA remains highly safe and efficacious. Endovascular treatment for unruptured MCAAs continues to improve in efficacy and safety; yet, it results in lower rates of occlusion.
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Affiliation(s)
- Meshal Alreshidi
- Massachusetts College of Pharmacy and Health Sciences (MCPHS), Boston, Massachusetts
| | - David J Cote
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hormuzdiyar H Dasenbrock
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael Acosta
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anil Can
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joanne Doucette
- Massachusetts College of Pharmacy and Health Sciences (MCPHS), Boston, Massachusetts
| | - Thomas Simjian
- Massachusetts College of Pharmacy and Health Sciences (MCPHS), Boston, Massachusetts
| | - M Maher Hulou
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lee A Wheeler
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kevin Huang
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hasan A Zaidi
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rose Du
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - M Ali Aziz-Sultan
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rania A Mekary
- Massachusetts College of Pharmacy and Health Sciences (MCPHS), Boston, Massachusetts
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy R Smith
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Ding D, Buell TJ, Raper DM, Chen CJ, Mastorakos P, Liu KC, Vollmer DG. Sylvian Arteriovenous Malformation Resection and Associated Middle Cerebral Artery Aneurysm Clipping: Technical Nuances of Concurrent Surgical Treatment. Cureus 2018; 10:e2166. [PMID: 29805922 PMCID: PMC5963952 DOI: 10.7759/cureus.2166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Approximately 10-30% of brain arteriovenous malformations (AVM) have associated arterial aneurysms (AAA), and the management of these lesions can be challenging. In this video technical note, we demonstrate the microsurgical treatment of an unruptured, Spetzler-Martin grade I AVM in the distal Sylvian fissure with two AAAs arising proximally from the inferior M2 trunk immediately distal to the middle cerebral artery (MCA) bifurcation. First, we resected the superficially located AVM to normalize the blood flow through the Sylvian vein. Next, we performed a Sylvian fissure dissection to access and clip the two MCA AAAs. We also discuss the technical nuances of tandem surgical intervention for AVMs with AAAs as it pertains to this case, particularly with respect to the order of lesion treatment, Sylvian fissure dissection, nidal resection, and aneurysm clipping.
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Affiliation(s)
- Dale Ding
- Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Thomas J Buell
- Department of Neurological Surgery, University of Virginia
| | - Daniel M Raper
- Department of Neurological Sugery, University of Virginia, Charlottesville, United States
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia
| | | | - Kenneth C Liu
- Department of Neurological Surgery, University of Virginia, Charlottesville, United States
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Maldaner N, Burkhardt JK, Stienen MN, Goldberg J, Bervini D, Bijlenga P, Croci D, Zumofen D, D’Alonzo D, Marbacher S, Maduri R, Daniel RT, Serra C, Esposito G, Neidert MC, Bozinov O, Regli L. Decision-making and neurosurgeons' agreement in the management of aneurysmal subarachnoid haemorrhage based on computed tomography angiography. Acta Neurochir (Wien) 2018; 160:253-260. [PMID: 29214402 DOI: 10.1007/s00701-017-3415-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 11/23/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND To determine the neurosurgeon's agreement in aneurysmal subarachnoid haemorrhage (aSAH) management with special emphasis on the rater's level of experience. A secondary aim was to analyse potential aneurysm variables associated with the therapeutic recommendation. METHOD Basic clinical information and admission computed tomography angiography (CTA) images of 30 consecutive aSAH patients were provided. Twelve neurosurgeons independently evaluated aneurysm characteristics and gave recommendations regarding the emergency management and aneurysm occlusion therapy. Inter-rater variability and predictors of treatment recommendation were evaluated. RESULTS There was an overall moderate agreement in treatment decision [κ = 0.43; 95% confidence interval ((CI), 0.387-0.474] with moderate agreement for surgical (κ = 0.43; 95% CI, 0.386-0.479) and endovascular treatment recommendation (κ = 0.45; 95% CI, 0.398-0.49). Agreement on detailed treatment recommendations including clip, coil, bypass, stent, flow diverter and ventriculostomy was low to moderate. Inter-rater agreement did not significantly differ between residents and consultants. Middle cerebral artery (MCA) aneurysm location was a positive predictor of surgical treatment [odds ratio (OR), 49.57; 95% CI, 10.416-235.865; p < 0.001], while patients aged >65 years (OR, 0.12; 95% CI, 0.03-0.0434; p = 0.001), fusiform aneurysm type (OR, 0.18; 95% CI, 0.044-0.747; p = 0.018) and intracerebral haematoma (ICA) aneurysm location (OR, 0.24; 95% CI, 0.088-0.643; p = 0.005) were associated with a recommendation for endovascular treatment. CONCLUSIONS Agreement on aSAH management varies considerably across neurosurgeons, while therapeutic decision-making is challenging on an individual patient level. However, patients aged >65 years, fusiform aneurysm shape and ICA location were associated with endovascular treatment recommendation, while MCA aneurysm location remains a surgical domain in the opinion of neurosurgeons without formal endovascular training.
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79
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Tayebi Meybodi A, Benet A, Lawton MT. In Reply to the Letter to the Editor “Feasibility of Using a Superficial Temporal Artery Graft in Internal Maxillary Artery Bypass”. World Neurosurg 2017; 108:973-974. [DOI: 10.1016/j.wneu.2017.08.135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 08/22/2017] [Indexed: 10/18/2022]
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Cagnazzo F, Mantilla D, Lefevre PH, Dargazanli C, Gascou G, Costalat V. Treatment of Middle Cerebral Artery Aneurysms with Flow-Diverter Stents: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol 2017; 38:2289-2294. [PMID: 28982785 DOI: 10.3174/ajnr.a5388] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 07/18/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND The safety and efficacy of flow-diversion treatment of MCA aneurysms have not been well-established. PURPOSE Our aim was to evaluate angiographic and clinical outcomes after flow diversions for MCA aneurysms. DATA SOURCES A systematic search of PubMed, MEDLINE, and Embase was performed for studies published from 2008 to May 2017. STUDY SELECTION According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we selected studies with >5 patients describing angiographic and clinical outcomes after flow-diversion treatment of MCA aneurysms. DATA ANALYSIS Random-effects meta-analysis was used to pool the following outcomes: aneurysm occlusion rate, procedure-related complications, rupture rate of treated aneurysms, and occlusion of the jailed branches. DATA SYNTHESIS Twelve studies evaluating 244 MCA aneurysms were included in this meta-analysis. Complete/near-complete occlusion was obtained in 78.7% (95% CI, 67.8%-89.7%) of aneurysms. The rupture rate of treated aneurysms during follow-up was 0.4% per aneurysm-year. The rate of treatment-related complications was 20.7% (95% CI, 14%-27.5%), and approximately 10% of complications were permanent. The mortality rate was close to 2%. Nearly 10% (95% CI, 4.7%-15.5%) of jailed arteries were occluded during follow-up, whereas 26% (95% CI, 14.4%-37.6%) had slow flow. Rates of symptoms related to occlusion and slow flow were close to 5%. LIMITATIONS Small and retrospective series could affect the strength of the reported results. CONCLUSIONS Given the not negligible rate of treatment-related complications, flow diversion for MCA aneurysms should be considered an alternative treatment when traditional treatment methods are not feasible. However, when performed in this select treatment group, high rates of aneurysm occlusion and protection against re-rupture can be achieved.
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Affiliation(s)
- F Cagnazzo
- From the Neuroradiology Department, University Hospital Güi-de-Chauliac, Centre Hospitalier Universitaire de Montpellier, Montpellier, France.
| | - D Mantilla
- From the Neuroradiology Department, University Hospital Güi-de-Chauliac, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - P-H Lefevre
- From the Neuroradiology Department, University Hospital Güi-de-Chauliac, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - C Dargazanli
- From the Neuroradiology Department, University Hospital Güi-de-Chauliac, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - G Gascou
- From the Neuroradiology Department, University Hospital Güi-de-Chauliac, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - V Costalat
- From the Neuroradiology Department, University Hospital Güi-de-Chauliac, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
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Bender MT, Wendt H, Monarch T, Lin LM, Jiang B, Huang J, Coon AL, Tamargo RJ, Colby GP. Shifting Treatment Paradigms for Ruptured Aneurysms from Open Surgery to Endovascular Therapy Over 25 Years. World Neurosurg 2017; 106:919-924. [DOI: 10.1016/j.wneu.2017.07.074] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 07/12/2017] [Accepted: 07/13/2017] [Indexed: 12/11/2022]
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Platz J, Wagner M, Güresir E, You SJ, Konczalla J, de Rochemont RDM, Berkefeld J, Seifert V. Early diffusion-weighted MRI lesions after treatment of unruptured intracranial aneurysms: a prospective study. J Neurosurg 2017; 126:1070-1078. [DOI: 10.3171/2016.2.jns152456] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Diffusion-weighted MRI was used to assess periprocedural lesion load after repair of unruptured intracranial aneurysms (UIA) by microsurgical clipping (MC) and endovascular coiling (EC).
METHODS
Patients with UIA were assigned to undergo MC or EC according to interdisciplinary consensus and underwent diffusion-weighted imaging (DWI) 1 day before and 1 day after aneurysm treatment. Newly detected lesions by DWI after treatment were the primary end point of this prospective study. Lesions detected by DWI were categorized as follows: A) 1–3 DWI spots < 10 mm, B) > 3 DWI spots < 10 mm, C) single DWI lesion > 10 mm, or D) DWI lesion related to surgical access.
RESULTS
Between 2010 and 2014, 99 cases were included. Sixty-two UIA were treated by MC and 37 by EC. There were no significant differences between groups in age, sex, aneurysm size, occurrence of multiple aneurysms in 1 patient, or presence of lesions detected by DWI before treatment. Aneurysms treated by EC were significantly more often located in the posterior circulation (p < 0.001). Diffusion-weighted MRI detected new lesions in 27 (43.5%) and 20 (54.1%) patients after MC and EC, respectively (not significant). The pattern of lesions detected by DWI varied significantly between groups (p < 0.001). Microembolic lesions (A and B) found on DWI were detected more frequently after EC (A, 14 cases; B, 5 cases) than after MC (A, 5 cases), whereas C and D were rare after EC (C, 1 case) and occurred more often after MC (C, 12 cases and D, 10 cases). No procedure-related unfavorable outcomes were detected.
CONCLUSIONS
According to the specific techniques, lesion patterns differ between MC and EC, whereas the frequency of new lesions found on DWI is similar after occlusion of UIA. In general, the lesion load was low in both groups, and lesions were clinically silent.
Clinical trial registration no.: NCT01490463 (clinicaltrials.gov)
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Affiliation(s)
| | - Marlies Wagner
- 2Neuroradiology, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | | | - Se-Jong You
- 2Neuroradiology, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | | | | | - Joachim Berkefeld
- 2Neuroradiology, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
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Gory B, Aguilar-Pérez M, Pomero E, Turjman F, Weber W, Fischer S, Henkes H, Biondi A. One-year Angiographic Results After pCONus Stent-Assisted Coiling of 40 Wide-Neck Middle Cerebral Artery Aneurysms. Neurosurgery 2017; 80:925-933. [DOI: 10.1093/neuros/nyw131] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 12/08/2016] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND: Bifurcation middle cerebral artery (MCA) aneurysms with wide neck are amenable to endovascular coiling with pCONus stent, a recent device dedicated to wide-neck bifurcation intracranial aneurysms.
OBJECTIVE: To evaluate the 1-year angiographic follow-up of wide-neck MCA aneurysms treated with pCONus.
METHODS: Forty MCA aneurysms (mean dome size, 7.7 mm; mean neck size, 5.6 mm) coiled with pCONus were retrospectively evaluated. “Recanalization” was defined as worsening, and “progressive thrombosis” was defined as improvement on the Raymond scale.
RESULTS: Angiographic midterm (mean, 11.9 months; range, 3-20) follow-up was obtained in all aneurysms. Retreatment was performed in 9 aneurysms (22.5%) without clinical complications, and postoperative angiographic outcome included 2 complete occlusions and 7 neck remnants. Six aneurysms were followed after retreatment (mean, 8.8 months), and presented complete occlusion in 1 case, neck remnant in 4 cases, and aneurysm remnant in 1 case. Among the 31 aneurysms, follow-up showed complete occlusion in 67.7% (21/31), neck remnants in 29% (9/31), and aneurysm remnants in 3.3% (1/31). Adequate aneurysm occlusion (total occlusion and neck remnant) was obtained in 96.7% (30/31). Among these 31 aneurysms, improvement of the rate of occlusion was observed in 15 aneurysms (48.4%), and recurrence in 2 aneurysms (6.5%). There was no 1-year angiographic recurrence of 3- or 6-month totally occluded aneurysms.
CONCLUSION: pCONus stent allows a safe coiling of wide-neck MCA aneurysms usually considered as surgical with a low recanalization rate for those adequately occluded at 3 to 6 months. Angiographic results improve over time due to progressive aneurysm thrombosis in around 50% of cases.
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Affiliation(s)
- Benjamin Gory
- FHU IRIS, Department of Interventional Neuroradiology, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
| | | | - Elisa Pomero
- Depart-ment of Neuroradiology and Vascular Unit, University Hospital Jean-Minjoz, Besançon, France
| | - Francis Turjman
- FHU IRIS, Department of Interventional Neuroradiology, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
| | - Werner Weber
- Department of Neuroradiology, Knappschaftskranken-haus, Recklinghausen, Germany
| | - Sebastian Fischer
- Department of Neuroradiology, Knappschaftskranken-haus, Recklinghausen, Germany
| | - Hans Henkes
- Department of Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - Alessandra Biondi
- Depart-ment of Neuroradiology and Vascular Unit, University Hospital Jean-Minjoz, Besançon, France
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Treatment of Large and Giant Middle Cerebral Artery Aneurysms: Risk Factors for Unfavorable Outcomes. World Neurosurg 2017; 102:301-312. [PMID: 28323182 DOI: 10.1016/j.wneu.2017.03.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 03/06/2017] [Accepted: 03/07/2017] [Indexed: 12/26/2022]
Abstract
OBJECTIVE This study aimed to assess the clinical and radiologic outcomes after neurosurgical treatment of large and giant aneurysms of the middle cerebral artery (MCA). In addition, we aimed to identify risk factors for unfavorable outcomes. METHODS This retrospective study included 105 patients with 106 large or giant MCA aneurysms treated with neurosurgical methods, including microsurgery and endovascular treatment, over a 15-year period. RESULTS The mean aneurysm size was 15.3 ± 7.1 mm. Ten (9.4%) were giant aneurysms. The MCA bifurcation was the most common aneurysm site, followed by the MCA trunk and distal MCA. Aneurysm clipping was the most common treatment method, followed by clipping or trapping with bypass surgery and endovascular treatment. However, acute cerebral infarction was the most common complication (16.0%), poor outcomes (modified Rankin Scale score, 3-6) developed in 12.3% of aneurysms after treatment, and 6.6% of treated aneurysms needed retreatment. Multivariate analysis showed that independent risk factors for acute cerebral infarction after treatment were aneurysms located on the MCA trunk and 2 or more underlying diseases. Initial presentation with subarachnoid hemorrhage and complications during treatment were independent risk factors for poor outcomes. In addition, endosaccular coiling was an independent risk factor for retreatment. CONCLUSIONS Neurosurgical management should be considered a priority for large and giant MCA aneurysms because of the high rupture rate and clinical symptoms. However, treatment outcomes remain unsatisfactory. Therefore, tailored management with consideration of risk factors for unfavorable outcomes should be implemented.
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Bhogal P, AlMatter M, Bäzner H, Ganslandt O, Henkes H, Aguilar Pérez M. Flow Diversion for the Treatment of MCA Bifurcation Aneurysms-A Single Centre Experience. Front Neurol 2017; 8:20. [PMID: 28210239 PMCID: PMC5288345 DOI: 10.3389/fneur.2017.00020] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 01/13/2017] [Indexed: 11/13/2022] Open
Abstract
Background Intracranial aneurysms located at the bifurcation of the middle cerebral artery (MCA) can often be challenging for the neurointerventionalist. We aimed to evaluate the efficacy and safety of flow diverting stents (FDS) in the treatment of these aneurysms. Materials and methods We retrospectively reviewed our prospectively maintained database to collect information for all patients with unruptured saccular bifurcation MCA aneurysms treated with FDS between January 2010 and January 2016. In addition to demographic data, we recorded the location, aneurysm characteristics, previous treatments, number and type of FDS, complications, and clinical and angiographic follow-up. Results Our search identified 13 patients (7 males) with an average age of 61.7 years (47–74 years). All patients had a single bifurcation aneurysm of the MCA, and none of the aneurysms were acutely ruptured. The average fundus size of the saccular aneurysms was 3 mm (range 1.5–10 mm). Follow-up studies were available for 12 patients. Based on the most recent follow-up angiograms, six aneurysms (50%) were totally occluded; five aneurysms (41.7%) showed only a small remnant; and one aneurysm (8.3%) remained unchanged. One patient suffered from an ischemic stroke with resultant permanent hemiparesis (mRS 3). In another case, there was an in-stent thrombosis during the intervention, which resolved upon intra-arterial infusion of Eptifibatide (mRS 0). There were no intra-operative vessel or aneurysm ruptures and no mortalities. Angiography of the covered MCA branches showed no change in the caliber or flow of the vessel in six (50%), a reduction in caliber in five (41.7%), and a complete occlusion in one (8.3%). All caliber changes and occlusions of the vessels were asymptomatic. Conclusion In our series, 91.7% of treated MCA bifurcation aneurysms were either completely occluded or showed only a small remnant with a good safety profile. Flow diversion of MCA bifurcation aneurysms should be considered as an alternative treatment strategy when microsurgical clipping or alternative endovascular treatment options are not feasible.
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Affiliation(s)
- Pervinder Bhogal
- Neuroradiologic Clinic, Klinikum Stuttgart , Stuttgart , Germany
| | | | | | | | - Hans Henkes
- Neuroradiologic Clinic, Klinikum Stuttgart, Stuttgart, Germany; Medizinische Fakultät der Universität Duisburg-Essen, Essen, Germany
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86
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The incidence of and risk factors for ischemic complications after microsurgical clipping of unruptured middle cerebral artery aneurysms and the efficacy of intraoperative monitoring of somatosensory evoked potentials: A retrospective study. Clin Neurol Neurosurg 2016; 151:128-135. [DOI: 10.1016/j.clineuro.2016.10.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 10/11/2016] [Accepted: 10/13/2016] [Indexed: 11/16/2022]
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87
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Srinivasan VM, Kan P, Germanwala AV, Pelargos P, Bohnen A, Choy W, Yang I, Smith ZA. Key perspectives on Woven EndoBridge device for wide-necked bifurcation aneurysms, endoscopic endonasal clipping of intracranial aneurysms, retrosigmoid versus translabyrinthine approaches for acoustic neuromas, and impact of local intraoperative steroid administration on postoperative dysphagia following anterior cervical discectomy and fusion. Surg Neurol Int 2016; 7:S720-S724. [PMID: 27857863 PMCID: PMC5093912 DOI: 10.4103/2152-7806.192511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 03/14/2016] [Indexed: 11/04/2022] Open
Affiliation(s)
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Anand V Germanwala
- Department of Neurological Surgery, Stritch School of Medicine, Loyola University Chicago, Chicago, IL, USA
| | - Panayiotis Pelargos
- Department of Neurosurgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - Angela Bohnen
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Winward Choy
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Isaac Yang
- Department of Neurosurgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - Zachary A Smith
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Ding D. Surgical treatment of unruptured middle cerebral artery aneurysms: Complication avoidance. Clin Neurol Neurosurg 2016; 153:107-108. [PMID: 27836403 DOI: 10.1016/j.clineuro.2016.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 11/02/2016] [Accepted: 11/03/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Dale Ding
- University of Virginia, Department of Neurosurgery, P.O. Box 800212, Charlottesville, VA 22908, United States.
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89
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Tayebi Meybodi A, Lawton MT, Griswold D, Mokhtari P, Payman A, Benet A. The anterior temporal artery: an underutilized but robust donor for revascularization of the distal middle cerebral artery. J Neurosurg 2016; 127:740-747. [PMID: 27834592 DOI: 10.3171/2016.8.jns161225] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The anterior temporal artery (ATA) supplies an area of the brain that, if sacrificed, does not cause a noticeable loss of function. Therefore, the ATA may be used as a donor in intracranial-intracranial (IC-IC) bypass procedures. The capacities of the ATA as a donor have not been studied previously. In this study, the authors assessed the feasibility of using the ATA as a donor for revascularization of different segments of the distal middle cerebral artery (MCA). METHODS The ATA was studied in 15 cadaveric specimens (8 heads, excluding 1 side). First, the cisternal segment of the artery was untethered from arachnoid adhesions and small branches feeding the anterior temporal lobe and insular cortex, to evaluate its capacity for a side-to-side bypass to insular, opercular, and cortical segments of the MCA. Any branch entering the anterior perforated substance was preserved. Then, the ATA was cut at the opercular-cortical junction and the capacity for an end-to-side bypass was assessed. RESULTS From a total of 17 ATAs, 4 (23.5%) arose as an early MCA branch. The anterior insular zone and the frontal parasylvian cortical arteries were the best targets (in terms of mobility and caliber match) for a side-to-side bypass. Most of the insula was accessible for end-to-side bypass, but anterior zones of the insula were more accessible than posterior zones. End-to-side bypass was feasible for most recipient cortical arteries along the opercula, except for posterior temporal and parietal regions. Early ATAs reached significantly farther on the insular MCA recipients than non-early ATAs for both side-to-side and end-to-side bypasses. CONCLUSIONS The ATA is a robust arterial donor for IC-IC bypass procedures, including side-to-side and end-to-side techniques. The evidence provided in this work supports the use of the ATA as a donor for distal MCA revascularization in well-selected patients.
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Affiliation(s)
- Ali Tayebi Meybodi
- Skull Base and Cerebrovascular Laboratory, Department of Neurosurgery, University of California, San Francisco, California
| | - Michael T Lawton
- Skull Base and Cerebrovascular Laboratory, Department of Neurosurgery, University of California, San Francisco, California
| | - Dylan Griswold
- Skull Base and Cerebrovascular Laboratory, Department of Neurosurgery, University of California, San Francisco, California
| | - Pooneh Mokhtari
- Skull Base and Cerebrovascular Laboratory, Department of Neurosurgery, University of California, San Francisco, California
| | - Andre Payman
- Skull Base and Cerebrovascular Laboratory, Department of Neurosurgery, University of California, San Francisco, California
| | - Arnau Benet
- Skull Base and Cerebrovascular Laboratory, Department of Neurosurgery, University of California, San Francisco, California
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90
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Tayebi Meybodi A, Huang W, Benet A, Kola O, Lawton MT. Bypass surgery for complex middle cerebral artery aneurysms: an algorithmic approach to revascularization. J Neurosurg 2016; 127:463-479. [PMID: 27813463 DOI: 10.3171/2016.7.jns16772] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Management of complex aneurysms of the middle cerebral artery (MCA) can be challenging. Lesions not amenable to endovascular techniques or direct clipping might require a bypass procedure with aneurysm obliteration. Various bypass techniques are available, but an algorithmic approach to classifying these lesions and determining the optimal bypass strategy has not been developed. The objective of this study was to propose a comprehensive and flexible algorithm based on MCA aneurysm location for selecting the best of multiple bypass options. METHODS Aneurysms of the MCA that required bypass as part of treatment were identified from a large prospectively maintained database of vascular neurosurgeries. According to its location relative to the bifurcation, each aneurysm was classified as a prebifurcation, bifurcation, or postbifurcation aneurysm. RESULTS Between 1998 and 2015, 30 patients were treated for 30 complex MCA aneurysms in 8 (27%) prebifurcation, 5 (17%) bifurcation, and 17 (56%) postbifurcation locations. Bypasses included 8 superficial temporal artery-MCA bypasses, 4 high-flow extracranial-to-intracranial (EC-IC) bypasses, 13 IC-IC bypasses (6 reanastomoses, 3 reimplantations, 3 interpositional grafts, and 1 in situ bypass), and 5 combination bypasses. The bypass strategy for prebifurcation aneurysms was determined by the involvement of lenticulostriate arteries, whereas the bypass strategy for bifurcation aneurysms was determined by rupture status. The location of the MCA aneurysm in the candelabra (Sylvian, insular, or opercular) determined the bypass strategy for postbifurcation aneurysms. No deaths that resulted from surgery were found, bypass patency was 90%, and the condition of 90% of the patients was improved or unchanged at the most recent follow-up. CONCLUSIONS The bypass strategy used for an MCA aneurysm depends on the aneurysm location, lenticulostriate anatomy, and rupture status. A uniform bypass strategy for all MCA aneurysms does not exist, but the algorithm proposed here might guide selection of the optimal EC-IC or IC-IC bypass technique.
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Affiliation(s)
- Ali Tayebi Meybodi
- Department of Neurosurgery and.,Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California
| | | | - Arnau Benet
- Department of Neurosurgery and.,Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California
| | - Olivia Kola
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California
| | - Michael T Lawton
- Department of Neurosurgery and.,Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California
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91
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Zhao B, Tan X, Zhao Y, Cao Y, Wu J, Zhong M, Wang S. Variation in Patient Characteristics and Outcomes Between Early and Delayed Surgery in Poor-Grade Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2016; 78:224-31. [PMID: 26421588 DOI: 10.1227/neu.0000000000001038] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND There is no consensus regarding the optimal timing for surgery for poor-grade aneurysmal subarachnoid hemorrhage. OBJECTIVE To retrospectively evaluate variation in patient characteristics and outcomes between early and delayed surgery groups. METHODS Poor-grade aneurysmal subarachnoid hemorrhage was defined as a World Federation of Neurosurgical Societies grade of IV or V after resuscitation. Early surgery was defined as surgery performed within 72 hours of ictus, and delayed surgery was defined as surgery after 72 hours. Outcomes were assessed by modified Rankin score. The mean time of follow-up was 12.5 ± 3.4 months. RESULTS Of the 118 patients included in the study, 80 (68%) underwent early surgery and 38 (32%) underwent delayed surgery. Patients with brain herniation (P < .001) and a lower Fisher grade (P = .02) more often underwent early surgery. Patients in the early group more often underwent decompressive craniectomy (P < .001). Postoperative complications and length of hospital stay did not differ, and outcomes were similar between the 2 groups. Forty (34%) patients had an excellent outcome (modified Rankin score 0-1). Multivariate analysis showed a slight trend toward an excellent outcome in the early surgery group. Younger age, World Federation of Neurosurgical Societies grade IV after resuscitation, and middle cerebral artery aneurysms were independent predictors of an excellent outcome. CONCLUSION Although patients with brain herniation and a lower Fisher grade were more likely to undergo early surgery, there was a slight trend toward an excellent outcome in the early surgery group. Patients with a younger age, World Federation of Neurosurgical Societies grade IV after resuscitation, and middle cerebral artery aneurysms were more likely to experience an excellent outcome.
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Affiliation(s)
- Bing Zhao
- *Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; ‡Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China; §Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
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92
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Zhao X, Li Z, Fang X, Liu J, Wu D, Lai N. Treatment of ruptured middle cerebral artery aneurysms by endovascular approach: a single-center experience. Int J Neurosci 2016; 127:433-438. [PMID: 27189026 DOI: 10.1080/00207454.2016.1190923] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE The optimal treatment modalities of ruptured middle cerebral artery aneurysm are still controversial. The objective of this study is to analyze the outcomes of patients with ruptured middle cerebral artery aneurysms treated by endovascular coiling. MATERIALS AND METHODS From October 2011 to October 2015, 67 patients with 71 ruptured middle cerebral artery aneurysms received endovascular coiling in our hospital. We retrospectively reviewed the clinical, radiologic records and outcomes. RESULTS Of all the 71 aneurysms (67 patients), 42 were treated by coil embolization merely, 27 by stent-assisted coiling and 2 unruptured aneurysms in patients with bilateral middle cerebral artery aneurysms without receiving treatment. Complete occlusion was achieved in 82.6% (57/69) of all the procedures. Each of incomplete and partial occlusion rates was 8.7% (6/69). Intraoperative rupture of aneurysms occurred in two procedures (2.9%). Thrombogenesis occurred in eight procedures (11.6%). Brain infarction occurred in eight patients (11.9%). Post-operative rebleeding occurred in seven patients (10.4%). Sixty-three patients were followed at a mean follow-up of 8.24 ± 7.16 months. The mortality and good outcome rate were 3.2% and 90.5%, respectively. Aneurysm recurrence occurred in 6 (13.3%) of the 45 aneurysms at a mean follow-up of 8.44 ± 7.83 months. CONCLUSIONS Endovascular coiling is effective for patients with ruptured middle cerebral artery aneurysms. Individualized treatment should be assessed by experienced specialist. It is essential to perform randomized large trials to confirm the efficiency of endovascular coiling.
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Affiliation(s)
- Xintong Zhao
- a Department of Neurosurgery, Yijishan Hospital , Wannan Medical College , Wuhu , P.R. China
| | - Zhenbao Li
- a Department of Neurosurgery, Yijishan Hospital , Wannan Medical College , Wuhu , P.R. China
| | - Xinggen Fang
- a Department of Neurosurgery, Yijishan Hospital , Wannan Medical College , Wuhu , P.R. China
| | - Jiaqiang Liu
- a Department of Neurosurgery, Yijishan Hospital , Wannan Medical College , Wuhu , P.R. China
| | - Degang Wu
- a Department of Neurosurgery, Yijishan Hospital , Wannan Medical College , Wuhu , P.R. China
| | - Niansheng Lai
- a Department of Neurosurgery, Yijishan Hospital , Wannan Medical College , Wuhu , P.R. China
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93
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Clajus C, Strasilla C, Fiebig T, Sychra V, Fiorella D, Klisch J. Initial and mid-term results from 108 consecutive patients with cerebral aneurysms treated with the WEB device. J Neurointerv Surg 2016; 9:411-417. [PMID: 27075486 DOI: 10.1136/neurintsurg-2016-012276] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 03/15/2016] [Accepted: 03/25/2016] [Indexed: 11/04/2022]
Abstract
IntroductionThe Woven EndoBridge (WEB) is a novel device for the treatment of wide-necked intracranial bifurcation aneurysms. The present series demonstrates our ‘real-world experience’ in the use of all iterations of WEB devices (available in Europe) in ruptured and unruptured aneurysms.MethodsWe analyzed our all-inclusive cerebrovascular database for patients treated with the WEB device between October 2010 and May 2015. Anatomic and clinical results are reported for all patients.ResultsOne hundred and eight patients with 114 intracranial aneurysms were included in the series. Forty-seven aneurysms (41.2%) were ruptured. Eighty-six patients received angiographic and clinical follow-up after a mean of 13.4 months. One hundred and ten of 114 WEB devices (96.5%) were deployed successfully. Thromboembolic complications occurred in 11 of 110 interventions (10.0%), with a new permanent deficit in one patient. Re-rupture after WEB treatment was detected in two aneurysms (4.3%), which had both initially presented with subarachnoid hemorrhage. Angiographic follow-up revealed adequate occlusion in 68 of 90 aneurysms (75.6%). Fifteen aneurysms required retreatment.ConclusionsThis series confirms a high level of safety and efficacy of the WEB device for the treatment of wide-necked intracranial aneurysms.
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Eliava S, Pilipenko Y, Shekhtman O, Konovalov A. Reversal of intraoperative arterial thrombosis with a fibrinolytic agent when treating large and giant partially thrombosed aneurysms of the middle cerebral artery. J Neurosurg 2016; 124:1114-22. [DOI: 10.3171/2015.2.jns142655] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Thrombosis of the cerebral arteries is one of the complications of microsurgical operations for partially thrombosed intracranial aneurysms. The object of this study was to assess the frequency of intraoperative arterial thrombosis (IAT) during microsurgical treatment of large and giant partially thrombosed aneurysms of the middle cerebral artery (MCA) and also to assess the efficacy of the treatment of this complication.
MATERIALS
The authors analyzed a consecutive series of 53 patients who underwent surgery for partially thrombosed aneurysms of the MCA at the Burdenko Neurosurgical Institute between January 2005 and September 2014. Thirty-two patients had large aneurysms (15–25 mm) and 21 had giant aneurysms (> 25 mm). Clipping of aneurysms was performed in 47 patients, trapping was performed in 3, and wrapping was performed in 3.
RESULTS
IAT was diagnosed in 10 patients (18.9%). The authors describe a technique for IAT reversal involving the injection of modified human recombinant prourokinase (mr-proUK). Of the 7 patients who underwent injection of mr-proUK in the thrombosed artery, 5 (71.4%) were discharged without any change in neurological status, 1 (14.3%) experienced moderate deterioration (modified Rankin Scale [mRS] score of 2), and 1 (14.3%) experienced severe deterioration (mRS score of 4). Among the 3 patients who had complications and did not receive an injection of mr-proUK, 2 experienced severe deterioration (mRS score of 3 and 4) and 1 had moderate deterioration (mRS score of 2).
CONCLUSIONS
The primary risk factor of thrombectomy with temporary trapping is thrombosis in the MCA branches. The injection of a fibrinolytic agent into thrombosed MCA branches is an effective method for the treatment of IAT.
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95
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"Clip first" policy in management of intracranial MCA aneurysms: Single-centre experience with a systematic review of literature. Acta Neurochir (Wien) 2016; 158:533-46; discussion 546. [PMID: 26733126 DOI: 10.1007/s00701-015-2687-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 12/17/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND The results of microsurgical treatment for middle cerebral artery (MCA) aneurysms (ANs) have been highly satisfying for decades, notoriously posing a challenge for interventional neuroradiologists. Following the International Subarachnoid Aneurysm Trial (ISAT) study results, most centres across Europe and the USA switched to a "coil first" policy. The purpose of this study is to evaluate and critically review the substantiation of this change. METHODS The authors conducted a single-institution retrospective study of MCA AN treatment between January 2000 and December 2013 maintaining a "clip first" policy. The results are supplied with a literature review. RESULTS A total of 315 MCA ANs were treated in 288 consecutive patients (209 females, 79 males). Microsurgical treatment was performed for 238 AN patients (116 ruptured, 122 unruptured) and 77 AN patients (46 ruptured, 31 unruptured) who underwent a coiling procedure. Treatment-related morbidity and mortality (MM) for unruptured ANs was 2.8 % in the microsurgical group and 10.3 % in the endovascular group. The percentage of patients with no/minor permanent neurological deficits after SAH in a good initial clinical state (HH 1-2) was 93 % in the microsurgical and 76 % in the endovascular group. A literature review identified 21 studies concerning MCA AN treatment with a specified decision-making algorithm. Microsurgery seemed superior to endovascular management regarding both clinical and radiological outcomes, although several aspects of the analysed reports might appear questionable. CONCLUSION Although this study has its inherent limitations, the effect brought about by microsurgical clipping of MCA ANs remains superior to that of endovascular embolisation and it should be sustained as the first treatment choice. The decision about the treatment strategy should be made by a multi-disciplinary team consisting of specialists from both teams, bearing in mind the higher occlusion rate and longevity of the surgical treatment.
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96
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Topcuoglu OM, Akgul E, Daglioglu E, Topcuoglu ED, Peker A, Akmangit I, Belen D, Arat A. Flow Diversion in Middle Cerebral Artery Aneurysms: Is It Really an All-Purpose Treatment? World Neurosurg 2016; 87:317-27. [DOI: 10.1016/j.wneu.2015.11.073] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 11/24/2015] [Indexed: 11/16/2022]
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97
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Flow Diversion for Treating Middle Cerebral Artery Aneurysms. World Neurosurg 2016; 90:627-629. [PMID: 26780283 DOI: 10.1016/j.wneu.2016.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 01/05/2016] [Indexed: 11/23/2022]
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Al-Schameri AR, Lunzer M, Daller C, Kral M, Killer M. Middle cerebral artery aneurysm surgery after stent misplacement: A case report. Interv Neuroradiol 2015; 22:49-52. [PMID: 26590180 DOI: 10.1177/1591019915617313] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 09/11/2015] [Indexed: 12/29/2022] Open
Abstract
Stent misplacement during endovascular treatment of middle cerebral artery (MCA) aneurysms can cause challenges and be problematic, if clipping becomes necessary. This article reports on a 56-year-old woman with an unruptured, multi-lobulated MCA aneurysm, whom primarily refused surgery; therefore, she was scheduled for stent-assisted coiling. After successful deployment of the stent, it unfortunately then became snagged by the microcatheter and was pulled backwards. The subsequent surgical procedure (i.e. clipping of the MCA aneurysm) was challenging, due to the position of the dislodged stent. Such as misplacement of the stent is rarely documented: It resulted in the difficult handling of a MCA aneurysm. Aneurysms of the MCA should primarily be considered for surgical clipping. In conclusion, an increased risk for eventual surgery should be considered, in cases where endovascular treatments with stents are performed.
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Affiliation(s)
| | - Manuel Lunzer
- Department of Neurosurgery, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Cornelia Daller
- Department of Neurosurgery, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Michael Kral
- Department of Neurosurgery, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Monika Killer
- Research Institute of Neurointervention, Paracelsus Medical University Salzburg, Salzburg, Austria
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Predictors of Complications with Unruptured Middle Cerebral Artery Aneurysm Clipping in a Surgically Treated Series of 416 Patients: A Clip First Approach Is Still Best. World Neurosurg 2015; 84:884-5. [DOI: 10.1016/j.wneu.2015.06.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Accepted: 06/09/2015] [Indexed: 11/30/2022]
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100
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Comprehensive Overview of Contemporary Management Strategies for Cerebral Aneurysms. World Neurosurg 2015; 84:1147-60. [DOI: 10.1016/j.wneu.2015.05.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 05/19/2015] [Accepted: 05/20/2015] [Indexed: 01/06/2023]
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