Wrapping of solitary ruptured intracranial aneurysms, outcome at five years

Falxuplication, a Novel Method for Wrap-Clipping a Fusiform Aneurysm: Technical Note

BACKGROUND

Various techniques have been used for wrap-clipping a ruptured, fusiform intracranial aneurysm; however, there is no available literature on use of the falx cerebri for wrap-clipping. We present a review of the literature, with an illustrative case, of a ruptured fusiform pericallosal artery aneurysm firmly attached to the lower edge of the falx cerebri and not amenable to endovascular intervention.

METHODS

Although the firm attachment between the inferior falx and the fusiform aneurysm was maintained, a section of the lower thinner part of the falx cerebri firmly attached to the aneurysm was dissected and wrapped around the fusiform aneurysm, and then stabilized with a fenestrated clip. We chose a segment slightly longer than the length of the fusiform aneurysm to avoid pre- and post-wrap-clipping stenosis.

RESULTS

Postprocedure, except for a small area of numbness on the left distal anterolateral left leg, the patient was neurologically intact and remained neurologically intact at a 12-month follow-up.

CONCLUSIONS

An inferior thin segment of the falx cerebri can be used for wrap-clipping of ruptured fusiform anterior cerebral artery aneurysms. Furthermore, the inferior falx can be wrapped around the attached fusiform anterior cerebral artery aneurysm without compromising flow, offering a safe solution in these unusually complex cases.

Techniques and Outcomes of Gore-Tex Clip-Wrapping of Ruptured and Unruptured Cerebral Aneurysms

OBJECTIVE

Some aneurysms without a definable neck and associated parent vessel pathology are particularly difficult to treat and may require clipping with circumferential wrapping. We report the largest available contemporary series examining the techniques of Gore-Tex clip-wrapping of ruptured and unruptured intracranial aneurysms and patient outcomes.

METHODS

The presentation, location, and shape of the aneurysm; wrapping technique; outcome at discharge and last follow-up; and any change in the aneurysm at last angiographic follow-up were reviewed retrospectively in 30 patients with Gore-Tex clip-wrapped aneurysms.

RESULTS

Gore-Tex clip-wrapping was used in 8 patients with ruptured aneurysms and 22 patients with unruptured aneurysms. Aneurysms included 23 fusiform, 3 blister, and 4 otherwise complex, multilobed, or giant aneurysms. Of the 30 aneurysms, 63% were in the anterior circulation. The overall mean patient age was 52.5 years (range, 17-80 years). Postoperatively, there were no deaths or worsening of neurologic status and no parent vessel stenoses or strokes. The mean Glasgow Outcome Scale score at last follow-up was 4.7. The mean follow-up time was 42.3 months (median, 37.0 months; range, 3-96 months). There were 105.8 patient follow-up years. Aneurysms recurred in 2 patients with Gore-Tex clip-wrapping. No patients developed rehemorrhage. Overall risk of recurrence was 1.9% annually.

CONCLUSIONS

Gore-Tex has excellent material properties for circumferential wrapping of aneurysms and parent arteries. It is inert and does not cause a tissue reaction or granuloma formation. Gore-Tex clip-wrapping can be used safely for microsurgical management of ruptured and unruptured cerebral aneurysms with acceptable recurrence and rehemorrhage rates.

Techniques and long-term outcomes of cotton-clipping and cotton-augmentation strategies for management of cerebral aneurysms

OBJECTIVE To address the challenges of microsurgically treating broad-based, frail, and otherwise complex aneurysms that are not amenable to direct clipping, alternative techniques have been developed. One such technique is to use cotton to augment clipping ("cotton-clipping" technique), which is also used to manage intraoperative aneurysm neck rupture, and another is to reinforce unclippable segments or remnants of aneurysm necks with cotton ("cotton-augmentation" technique). This study reviews the natural history of patients with aneurysms treated with cotton-clipping and cotton-augmentation techniques. METHODS The authors queried a database consisting of all patients with aneurysms treated at Barrow Neurological Institute in Phoenix, Arizona, between January 1, 2004, and December 31, 2014, to identify cases in which cotton-clipping or cotton-augmentation strategies had been used. Management was categorized as the cotton-clipping technique if cotton was used within the blades of the aneurysm clip and as the cotton-clipping technique if cotton was used to reinforce aneurysms or portions of the aneurysm that were unclippable due to the presence of perforators, atherosclerosis, or residual aneurysms. Data were reviewed to assess patient outcomes and annual rates of aneurysm recurrence or hemorrhage after the initial procedures were performed. RESULTS The authors identified 60 aneurysms treated with these techniques in 57 patients (18 patients with ruptured aneurysms and 39 patients with unruptured aneurysms) whose mean age was 53.1 years (median 55 years; range 24-72 years). Twenty-three aneurysms (11 cases of subarachnoid hemorrhage) were treated using cotton-clipping and 37 with cotton-augmentation techniques (7 cases of subarachnoid hemorrhage). In total, 18 patients presented with subarachnoid hemorrhage. The mean Glasgow Outcome Scale (GOS) score at the time of discharge was 4.4. At a mean follow-up of 60.9 ± 35.6 months (median 70 months; range 10-126 months), the mean GOS score at last follow-up was 4.8. The total number of patient follow-up years was 289.4. During the follow-up period, none of the cotton-clipped aneurysms increased in size, changed in configuration, or rebled. None of the patients experienced early rebleeding. The annual hemorrhage rate for aneurysms treated with cotton-augmentation was 0.52% and the recurrence rate was 1.03% per year. For all patients in the study, the overall risk of hemorrhage was 0.35% per year and the annual recurrence rate was 0.69%. CONCLUSIONS Cotton-clipping is an effective and durable treatment strategy for intraoperative aneurysm rupture and for management of broad-based aneurysms. Cotton-augmentation can be safely used to manage unclippable or partially clipped intracranial aneurysms and affords protection from early aneurysm re-rupture and a relatively low rate of late rehemorrhage.

Long-term follow-up of ruptured intracranial aneurysms treated by microsurgical wrapping with autologous muscle

The purpose of this study is to describe our series of nine unclippable and uncoilable ruptured aneurysms in eight patients treated by microsurgical wrapping with autologous muscle. Records were retrospectively reviewed for rebleeding rate, morbidity and mortality, changes in size or the aneurysm's configurations, and inflammatory reaction. We conducted a Medline search in the post-microsurgical era, excluding patients in whom wrapping was part of the aneurysm treatment in combination with clipping or coiling. The surgically related morbidity was 12.5%. Global mortality rate was 25% due to vasospasm (one case) and rebleeding (one case). Six patients are still alive. Rebleeding rate was 14.3% within 6 months; then, it was zero. Glasgow outcome scale (GOS) score at discharge was 1 and 4 in one patient, respectively, and 5 in the remaining six. Mean clinical follow-up was 126 months. GOS at last follow-up was 4 and 5 in 50% of patients, respectively. Mean mRS score was 0.8 at 2 months, and 2.4 at 12 months. Follow-up MR demonstrated persistence of the aneurysm's sac, without changes in size and configuration. Patients did not describe or exhibit symptoms attributable to complications inherent to the use of muscle. Microsurgical muscle-wrapping of ruptured intracranial aneurysm is safe, is associated with a low rate of acute and delayed postoperative complications and rebleeding, and could be a valid alternative for unclippable and non-amenable to endovascular procedure ruptured aneurysms.

Dissecting Aneurysms of the Posterior Cerebral Artery

BACKGROUND:

Posterior cerebral artery (PCA) aneurysms are relatively rare, making up 1% to 2% of all intracranial aneurysms. To date, most clinical series are heterogeneous in nature, with few reports of isolated PCA dissecting aneurysms. Their clinical presentation can vary greatly, and the potential for long-term sequelae during or after treatment remains relatively high.

OBJECTIVE:

To report our recent experience in 9 consecutive patients with PCA dissecting aneurysms with a discussion of the unique clinical challenges of their evaluation and treatment.

METHODS:

We conducted a retrospective review of 9 consecutive patients with PCA dissecting aneurysms from November 2003 to February 2010. Their hospital charts and follow-up records were reviewed and summarized.

RESULTS:

We identified 6 male and 3 female patients ranging in age from 7 months to 69 years (median age, 53 years). None had any associated trauma. Four patients presented with subarachnoid hemorrhage. Three presented with intraventricular and intracerebral hemorrhage. The remaining 2 presented with headache and acute onset of right-sided numbness, respectively. Four underwent endovascular embolization; 2 underwent surgical clipping; and the remaining 3 were managed medically and followed up conservatively. The dissecting aneurysms involved P1 (n = 2), P1-2 junction (n = 1), P2 (n = 4), and P2-3 junction (n = 1). At a mean follow-up of 3 months, 6 patients had excellent functional outcome with modified Rankin Scale score of 0 or 1. The remaining 3 patients who presented in deep coma did poorly (1 died and 2 had severe disabilities).

CONCLUSION:

PCA dissecting aneurysms pose a unique challenge and have many unresolved issues regarding treatment modalities.

The clip-wrap technique in the treatment of intracranial unclippable aneurysms

Fusiform and dolichoectatic aneurysms are challenging lesions to treat with direct clipping. Treatment of these aneurysms often requires alternative surgical strategies, including extracranial-intracranial bypass, wrapping, or clip-wrap techniques. Nonetheless, these alternatives methods of treatment have been underused and frequently overlooked.

OBJECTIVE

To report a series of nine cases of otherwise untreatable aneurysms managed using the clip-wrap technique and discuss its surgical nuances.

METHOD

In the last four years, 9 cases of ruptured aneurysms treated by the clip-wrap techniques were identified in the Division of Neurological Surgery, University of São Paulo, School of Medicine.

RESULTS

The aneurysms were located at middle cerebral artery (2), anterior choroidal artery (1), anterior communicating artery (1), carotid ophthalmic (3), posterior cerebral artery (1) and posterior-inferior cerebellar artery (1). Three were dolichoectatic, 4 were unsuitable to complete surgical clipping because parent or efferent vessels arises from the aneurysm sac (1 MCA, 1 AcomA, 1 CO, 1 PICA aneurysms) and two, although ruptured aneurysms, were too small (<2mm) to be directly clipped. No early or late rebleeding was observed after 2 years mean follow-up. One patient deceased due to pulmonary tromboembolism.

CONCLUSION

Clip-wrap techniques for the treatment of fusiform and otherwise unclippable aneurysms seem to be safe and it can be associated with a low rate of acute or delayed postoperative complications. It can prevent rebleeding and represents an improvement when compared with the natural history.

Clinical and angiographic results after treatment with combined clipping and wrapping technique for intracranial aneurysm

OBJECTIVE

There have been numerous follow-up studies of patients who had ruptured or unruptured intracranial aneurysms treated by wrapping technique using various materials have been reported. Our objective was to ascertain whether our particular wrapping technique using the temporalis muscle provides protection from rebleeding and any aneurysm configuration changes in follow-up studies.

METHODS

Clinical presentation, the location and shape of the aneurysm, outcomes at discharge and last follow-up, and any aneurysm configuration changes on last angiographic study were analyzed retrospectively in 21 patients. Reinforcement was acquired by clipping the wrapped temporalis muscle. Wrapping and clipping after incomplete clipping was also done. Follow-up loss and non-angiographic follow-up patient groups were excluded in this study.

RESULTS

The mean age was 53 years (range 29-67), and 15 patients were female. Among 21 patients, 10 patients had ruptured aneurysms (48%). Aneurysms in 21 patients were located in the anterior circulation. Aneurysm shapes were broad neck form (14 cases), fusiform (1 case), and bleb to adjacent vessel (6 cases). Five patients were treated by clipping the wrapped temporalis, and 16 patients by wrapping after partial clipping. The mean Glasgow coma scale (GCS) at admission was 14.2. The mean Glasgow outcome scale (GOS) at discharge was 4.8, and 18 patients were grade 5. The mean period between initial angiography and last angiography was 18.5 months (range 8-44). Aneurysm size was not increased in any of these patients and configuration also did not change. There was no evidence of rebleeding in any of these treated aneurysms.

CONCLUSION

Our study results show that wrapping technique, using the temporalis muscle and aneurysm clip(s), for intracranial aneurysm treatment provides protection from rebleeding or regrowth.

Granuloma formation and occlusion of an unruptured aneurysm after wrapping

Excessive granulomatous foreign-body reaction is a very rare complication after wrapping of intracranial aneurysms. The pathogenetic mechanisms underlying this process are unknown. We report on a patient who developed a space-occupying granulomatous abscess after wrapping of an unruptured aneurysm of the M2/M3 bifurcation. The patient underwent revision craniotomy for abscess removal. The aneurysm was explored and found to be completely thrombosed and excluded from the circulation. Exuberant granulomatous foreign-body reaction was pathologically confirmed and Candida parapsilosis was isolated from the pus. The patient underwent an antifungal treatment regimen and recovered with no residual neurological deficits. Our findings support the assumption that a low-grade infectious process might trigger excessive inflammatory reaction after wrapping. We suggest that this process may also result in complete thrombosis of cerebral aneurysms, which is otherwise a rarely observed phenomenon.

Long-term clinical and angiographic follow-up of unclippable wrapped intracranial aneurysms

OBJECTIVE

This is the largest contemporary series examining long-term clinical and angiographic follow-up of unclippable wrapped intracranial aneurysms.

METHODS

The presentation, location and shape of aneurysm, wrapping technique, outcome at discharge and last follow-up, and change in aneurysm at last angiographic follow-up were reviewed retrospectively in 74 patients with wrapped or clip-wrapped aneurysms. Patients in whom wrapping was used in conjunction with primary clipping were excluded.

RESULTS

Of the 74 patients, 11 were lost to follow-up. The mean age of the remaining 63 patients (16 males, 47 females) was 56.5 years (range, 13-89 yr). Fifty-one aneurysms were located in the anterior circulation, and 17 were located in the posterior circulation. Fourteen patients presented with a ruptured aneurysm. Seventeen aneurysms were fusiform. Seven aneurysms were clip-wrapped, and 61 were wrapped with cotton. At discharge the Glasgow Outcome Scale (GOS) score was 5 in 54 patients and 4 in 5 patients. Two patients died from their presenting hemorrhage, and one from a medical comorbidity. The mean clinical follow-up was 44.1 months (range, 1-120 mo). One patient under clinical follow-up experienced subarachnoid hemorrhage. The mean angiographic follow-up of 34 patients was 41.8 months (range, 3-120 mo). During this follow-up period, no patient's aneurysm changed in size or configuration.

CONCLUSION

Wrapping or clip-wrapping of unclippable intracranial aneurysms is safe and seems to confer protection against aneurysmal growth or subarachnoid hemorrhage.

That's a Wrap

Muslin-induced optochiasmatic arachnoiditis is a rare complication following surgical repair of an intracranial aneurysm but should be suspected in any delayed visual loss after aneurysm repair in which muslin was used. A 52-year-old male underwent clipping and muslin wrapping of a ruptured aneurysm of an anterior communicating artery. Eight months following surgery, the patient developed progressive visual loss, resulting in a bitemporal hemianopsia. Neuroimaging confirmed a suprasellar mass but no recurrent aneurysm. The patient was treated with prednisone and had significant improvement of his vision. Muslin wrapping of aneurysms should probably be avoided in aneurysms near the optic apparatus.

Experimental microaneurysms in rats: II. Comparison between cotton wrapping and microbipolar coagulation

BACKGROUND

Microsurgical aneurysm clipping is considered the best treatment for intracranial aneurysms, but often it cannot be used for microaneurysms. These aneurysms may require different type of treatment like bipolar coagulation or wrapping to reinforce the aneurysm wall, but these treatments have no experimentally proven efficacy. In this study the authors analyze the efficacy of 2 methods of treatment to prevent rupture of experimentally induced microaneurysms.

METHODS

Microaneurysms were induced using mechanical compression of the wall of the aortic bifurcation in 60 rats. The animals were divided in three groups according to aneurysm treatment: Group 1-aneurysms treated using microbipolar coagulation; Group 2-aneurysms wrapped with cotton, and Group 3-no treatment. Four weeks after the treatment, the resistance of the microaneurysm was tested applying intraluminal hyperpressure (up to 2,427 mm Hg). After that, the vessels were microscopically analyzed.

RESULTS

No rupture of the aneurysms was observed in Group 2 and all aneurysms ruptured in Groups 1 and 3 during the resistance test. Comparison between the mean bursting pressure of Groups 1 and 3 showed no significant difference (Student's t test, p > 0.05). The probability of rupture of the microaneurysms was significantly different between Groups 1 and 2, favoring Group 2 (Fisher exact test, p < 0.001).

CONCLUSIONS

Wrapping of experimental microaneurysms with cotton was effective to protect aneurysm rupture under hyperpressure; and there was no protection using microbipolar coagulation.