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Reddy A, Masoud HE. Endovascular and Medical Management of Unruptured Intracranial Aneurysms. Semin Neurol 2023; 43:480-492. [PMID: 37517406 DOI: 10.1055/s-0043-1771299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
Unruptured intracranial aneurysms are often discovered incidentally on noninvasive imaging. As use of noninvasive imaging has increased, our understanding of the presumed prevalence of intracranial aneurysms in adults has increased. Incidentally found aneurysms are often asymptomatic; however, they can rarely rupture and cause life-threatening illness. Elective treatment of intracranial aneurysms carries risks which need to be considered along with patient-specific factors (e.g., anatomy, medical comorbidities, personal preferences). In this article, we review the natural history, risk factors for cerebral aneurysm formation and rupture, evidence for medical management, and the safety profile and efficacy of available endovascular treatment options.
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Affiliation(s)
- Aravind Reddy
- Department of Neurology, SUNY Upstate Medical University, Syracuse, New York
| | - Hesham E Masoud
- Department of Neurology, SUNY Upstate Medical University, Syracuse, New York
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Park W, Park JC, Han K, Ahn JS, Kwun BD. Anterior Optic Pathway Compression Due to Internal Carotid Artery Aneurysms: Neurosurgical Management and Outcomes. J Stroke 2015; 17:344-53. [PMID: 26438000 PMCID: PMC4635711 DOI: 10.5853/jos.2015.17.3.344] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Revised: 07/16/2015] [Accepted: 08/03/2015] [Indexed: 01/09/2023] Open
Abstract
Background and Purpose Compression of the anterior optic pathway results in visual deficits that can lead to the detection of unruptured aneurysms in the internal carotid artery (ICA). The general types of treatment modalities for aneurysms and visual deficits include surgery and endosaccular coiling. This study retrospectively analyzed and compared the resolution of visual deficits following surgery or endosaccular coiling. Methods We reviewed data on 33 patients with unruptured ICA aneurysms who presented with visual field deficits caused by mass effects over the anterior optic pathway. Statistical analyses were performed to identify the variables associated with the recovery of visual symptoms. Results Eighteen patients underwent aneurysm clipping, 2 underwent bypass surgery with endovascular trapping, and 2 underwent endovascular trapping without bypass surgery (group A). Ten patients received endosaccular coiling (group B). The visual outcomes included the following: in group A, 17 patients (73.9%) demonstrated improvement and 6 patients (26.1%) demonstrated no changes or worse outcomes; in group B, 2 patients (20.0%) demonstrated improvement and 8 patients (80.0%) demonstrated no changes or worse outcomes. Group A was associated with a higher rate of favorable outcome than group B (P = 0.007). According to the multivariate analysis, treatment without endosaccular coiling (group A) was the only variable significantly associated with improvement of visual outcome (P = 0.005; OR = 28.523; 95% CI = 2.683-303.171). Conclusions Treatment modality was the only predictor of improvement in visual deficits. Treatment without endosaccular coiling resulted in visual improvement significantly more often in comparison with endosaccular coiling.
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Affiliation(s)
- Wonhyoung Park
- Department of Neurosurgery, University of Ulsan College of Medicine, Asan Medical center, Seoul, Korea
| | - Jung Cheol Park
- Department of Neurosurgery, University of Ulsan College of Medicine, Asan Medical center, Seoul, Korea
| | - Kyunghwa Han
- Biostatistics Collaboration Unit, Gangnam Medical Research Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Sung Ahn
- Department of Neurosurgery, University of Ulsan College of Medicine, Asan Medical center, Seoul, Korea
| | - Byung Duk Kwun
- Department of Neurosurgery, University of Ulsan College of Medicine, Asan Medical center, Seoul, Korea
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McCracken DJ, Lovasik BP, McCracken CE, Caplan JM, Turan N, Nogueira RG, Cawley CM, Dion JE, Tamargo RJ, Barrow DL, Pradilla G. Resolution of Oculomotor Nerve Palsy Secondary to Posterior Communicating Artery Aneurysms. Neurosurgery 2015; 77:931-9; discussion 939. [DOI: 10.1227/neu.0000000000000965] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND:
Previous studies have attempted to determine the best treatment for oculomotor nerve palsy (ONP) secondary to posterior communicating artery (PCoA) aneurysms, but have been limited by small sample sizes and limited treatment.
OBJECTIVE:
To analyze the treatment of ONP secondary to PCoA with both coiling and clipping in ruptured and unruptured aneurysms.
METHODS:
Data from 2 large academic centers was retrospectively collected over 22 years, yielding a total of 93 patients with ONP secondary to PCoA aneurysms. These patients were combined with 321 patients from the literature review for large data analyses. Onset symptoms, recovery, and time to resolution were evaluated with respect to treatment and aneurysm rupture status.
RESULTS:
For all patients presenting with ONP (n = 414) 56.6% of those treated with microsurgical clipping made a full recovery vs 41.5% of those treated with endovascular coil embolization (P = .02). Of patients with a complete ONP (n = 229), full recovery occurred in 47.3% of those treated with clipping but in only 20% of those undergoing coiling (P = .01). For patients presenting with ruptured aneurysms (n = 130), full recovery occurred in 70.9% compared with 49.3% coiled patients (P = .01). Additionally, although patients with full ONP recovery had a median time to treatment of 4 days, those without full ONP recovery had a median time to treatment of 7 days (P = .01).
CONCLUSION:
Patients with ONP secondary to PCoA aneurysms treated with clipping showed higher rates of full ONP resolution than patients treated with coil embolization. Larger prospective studies are needed to determine the true potential of recovery associated with each treatment.
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Affiliation(s)
- D. Jay McCracken
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | | | | | - Justin M. Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nefize Turan
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Raul G. Nogueira
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - C. Michael Cawley
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Jacques E. Dion
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Rafael J. Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel L. Barrow
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Gustavo Pradilla
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
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Oculomotor nerve palsy induced by internal carotid artery aneurysm: prognostic factors for recovery. Acta Neurochir (Wien) 2015; 157:1103-11. [PMID: 25956395 DOI: 10.1007/s00701-015-2440-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 04/28/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND Aneurysms at the posterior face of the internal carotid artery can lead to oculomotor nerve palsy (ONP) with an uncertain prognosis of recovery post-treatment. The aim of this study was to define the prognostic factors for ONP recovery, with particular interest in treatment modality (surgery or endovascular techniques). METHOD A literature review was performed to select the most pertinent prognostic factors. A retrospective study was then performed to determine whether these factors had significantly modified the prognosis of ONP recovery in our series of patients. RESULTS In the literature, factors linked to poorer outcome were age, vascular risk factors, initial ONP severity and delay before treatment; better recovery was associated with surgical treatment. Between 2000 and 2013, 23 consecutive patients were treated in our department for ONP-inducing aneurysms: 14 by endovascular embolization and 9 by surgical clipping and aneurysm puncture. Mean follow-up was 48.8 months. After treatment, overall recovery occurred in 87% of cases, always within 6 months. Apart from treatment modality, no selected prognostic factor significantly modified the quality or timing of ONP recovery. In the endovascular group, four patients recovered completely, seven partially and three did not recover. In the surgical group, seven patients recovered completely and two partially. Surgery was significantly associated with a more complete and earlier ONP recovery (p < 0.05). CONCLUSIONS Surgery was associated with a more complete and earlier ONP recovery as compared to endovascular treatment, confirming the results of previous studies. However, conclusions must be confirmed by a prospective randomized study.
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Thompson BG, Brown RD, Amin-Hanjani S, Broderick JP, Cockroft KM, Connolly ES, Duckwiler GR, Harris CC, Howard VJ, Johnston SCC, Meyers PM, Molyneux A, Ogilvy CS, Ringer AJ, Torner J. Guidelines for the Management of Patients With Unruptured Intracranial Aneurysms: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2015; 46:2368-400. [PMID: 26089327 DOI: 10.1161/str.0000000000000070] [Citation(s) in RCA: 633] [Impact Index Per Article: 70.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE The aim of this updated statement is to provide comprehensive and evidence-based recommendations for management of patients with unruptured intracranial aneurysms. METHODS Writing group members used systematic literature reviews from January 1977 up to June 2014. They also reviewed contemporary published evidence-based guidelines, personal files, and published expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulated recommendations using standard American Heart Association criteria. The guideline underwent extensive peer review, including review by the Stroke Council Leadership and Stroke Scientific Statement Oversight Committees, before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee. RESULTS Evidence-based guidelines are presented for the care of patients presenting with unruptured intracranial aneurysms. The guidelines address presentation, natural history, epidemiology, risk factors, screening, diagnosis, imaging and outcomes from surgical and endovascular treatment.
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Toyota S, Taki T, Wakayama A, Yoshimine T. Unruptured internal carotid-posterior communicating artery aneurysm splitting the oculomotor nerve: a case report and literature review. J Neurol Surg Rep 2014; 75:e180-2. [PMID: 25083381 PMCID: PMC4110146 DOI: 10.1055/s-0034-1378155] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Accepted: 04/22/2014] [Indexed: 11/21/2022] Open
Abstract
Objective To report a rare case of unruptured internal carotid-posterior communicating artery (IC-PC) aneurysm splitting the oculomotor nerve treated by clipping and to review the previously published cases. Case Presentation A 42-year-old man suddenly presented with left oculomotor paresis. Three-dimensional digital subtraction angiography (3D DSA) demonstrated a left IC-PC aneurysm with a bulging part. During surgery, it was confirmed that the bulging part split the oculomotor nerve. After the fenestrated oculomotor nerve was dissected from the bulging part with a careful microsurgical technique, neck clipping was performed. After the operation, the symptoms of oculomotor nerve paresis disappeared within 2 weeks. Conclusions We must keep in mind the possibility of an anomaly of the oculomotor nerve, including fenestration, and careful observation and manipulation should be performed to preserve the nerve function during surgery, even though it is very rare.
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Affiliation(s)
- Shingo Toyota
- Department of Neurosurgery, Kansai Rosai Hospital, Hyogo, Japan
| | - Takuyu Taki
- Department of Neurosurgery, Kansai Rosai Hospital, Hyogo, Japan
| | - Akatsuki Wakayama
- Department of Neurosurgery, Osaka Neurological Institute, Osaka, Japan
| | - Toshiki Yoshimine
- Department of Neurosurgery, Osaka University Medical School, Osaka, Japan
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Kang CW, Kwon HJ, Jeong SJ, Koh HS, Choi SW, Kim SH. Intentional sparing of daughter sac from coil packing in the embolization of aneurysms causing the third cranial nerve palsy : initial clinical and radiological results. J Korean Neurosurg Soc 2010; 48:115-8. [PMID: 20856658 DOI: 10.3340/jkns.2010.48.2.115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2010] [Revised: 07/11/2010] [Accepted: 08/09/2010] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Cerebral aneurysms which cause oculomotor nerve [cranial nerve (CN) III] palsy, are frequently found with a daughter sac of the aneurysm dome. We assumed that CN III might be compressed by the daughter sac and it would be more helpful not to fill the daughter sac with coils than vice versa during endosaccular embolization for recovering from CN III palsy, because it may give a greater chance for the daughter sac to shrink by itself later. We reviewed the initial results of our experiences of such cases. METHODS Among 9 aneurysms accompanied by CN III palsy, 7 (6 unruptured, 1 ruptured) showed a daughter sac. We tried to fill the main dome completely and spare the daughter sac from coil filling to increase the possibility of decompression. We evaluated the short-term effectiveness of this concept using medical records and angiograms. RESULTS After initial embolization, all of CN III palsy caused by unruptured aneurysms (6/6) resolved completely after various periods (3-90 days) of time. No adverse effects were noted during and after the procedures except for one case of harmless coil stretching during coil filling using double microcatheter. CONCLUSION During the coil embolization of the cerebral aneurysm causing CN III palsy, sparing the daughter sac from coil packing while tightly packing the main dome, can be helpful in increasing the effectiveness of decompression. However, a long-term follow-up will be required.
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Affiliation(s)
- Chang-Woo Kang
- Department of Neurosurgery, Chungnam National University Hospital & Medical School, Daejeon, Korea
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Nam KH, Choi CH, Lee JI, Ko JG, Lee TH, Lee SW. Unruptured Intracranial Aneurysms with Oculomotor Nerve Palsy : Clinical Outcome between Surgical Clipping and Coil Embolization. J Korean Neurosurg Soc 2010; 48:109-14. [PMID: 20856657 DOI: 10.3340/jkns.2010.48.2.109] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2010] [Revised: 06/18/2010] [Accepted: 08/09/2010] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To evaluate the clinical outcome of coil embolization for unruptured intracranial aneurysm (UIA) with oculomotor nerve palsy (ONP) compared with surgical clipping. METHODS A total of 19 patients presented with ONP caused by UIAs between Jan 2004 and June 2008. Ten patients underwent coil embolization and nine patients surgical clipping. The following parameters were retrospectively analyzed to evaluate the differences in clinical outcome observed in both coil embolization and surgical clipping : 1) gender, 2) age, 3) location of the aneurysm, 4) duration of the symptom, and 5) degree of ONP. RESULTS Following treatment, complete symptomatic recovery or partial relief from ONP was observed in 15 patients. Seven of the ten patients were treated by coil embolization, compared to eight of the nine patients treated by surgical clipping (p = 0.582). Patient's gender, age, location of the aneurysm, size of the aneurysm, duration of symptom, and degree of the ONP did not statistically correlate with recovery of symptoms between the two groups. No significant differences were observed in mean improvement time in either group (55 days in coil embolization and 60 days in surgical clipping). CONCLUSION This study indicates that no significant differences were observed in the clinical outcome between coil embolization and surgical clipping techniques in the treatment of aneurysms causing ONP. Coil embolization seems to be more feasible and safe treatment modality for the relief and recovery of oculomotor nerve palsy.
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Affiliation(s)
- Kyoung Hyup Nam
- Department of Neurosurgery, School of Medicine, Pusan National University, Busan, Korea
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Kang HS, Kwon BJ, Kwon OK, Jung C, Kim JE, Oh CW, Han MH. Endovascular coil embolization of anterior choroidal artery aneurysms. Clinical article. J Neurosurg 2009; 111:963-9. [PMID: 19463045 DOI: 10.3171/2009.4.jns08934] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Anterior choroidal artery (AChA) aneurysms are difficult to treat, and the clinical outcome of patients is occasionally compromised by ischemic complications after clipping operations. The purpose of this study was to document the outcome and follow-up results of endovascular coil embolization in patients with AChA aneurysms. METHODS Between July 1999 and March 2008, 88 patients with 90 AChA aneurysms (31 ruptured and 59 unruptured aneurysms) were treated with endovascular coil embolization in 91 sessions. There were 87 small aneurysms (< 10 mm) and 3 large aneurysms, with a mean aneurysm volume of 60.9 +/- 83.3 mm(3). Preprocedural oculomotor nerve palsy associated with AChA aneurysms was noted in 8 patients. Efficacy and safety were evaluated based on the degree of initial occlusion, procedure-related complications, patient outcome based on the Glasgow Outcome Scale score, and follow-up results. RESULTS The degree of angiographic occlusion of the aneurysms was complete for 15 aneurysms (17%), near complete for 69 aneurysms (77%) and partial for 6 aneurysms (7%). There were 4 (4.4%) symptomatic procedure-related complications (3 thromboembolic events and 1 procedural hemorrhage). The procedural hemorrhage resulted in death; however, the thromboembolic events only caused transient deficits. A favorable outcome (Glasgow Outcome Scale score of 5 or 4) was achieved in 90% (79 of 88) of the patients at the time of discharge. No patient showed signs of bleeding or rebleeding during the follow-up period (mean 25 months). Major aneurysm recanalization occurred in 2 cases. The AChA aneurysm-associated oculomotor nerve palsy tended to become aggravated transiently after coil embolization and then completely recovered over the course of 2-9 months. CONCLUSIONS Coil embolization is a safe and effective treatment modality in cases of AChA aneurysms. Coil embolization enables procedural recognition of arterial compromise and immediate reestablishment of flow, thus contributing to a favorable outcome.
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Affiliation(s)
- Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
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