1
|
Yang M, Li Y, Li J, An X, Li H, Wang B, Zhao Y, Zhu X, Hou C, Huan L, Yang X, Yu J. The safety and clinical outcomes of endovascular treatment versus microsurgical clipping of ruptured anterior communicating artery aneurysms: a 2-year follow-up, multicenter, observational study. Front Neurol 2024; 15:1389950. [PMID: 38846042 PMCID: PMC11153848 DOI: 10.3389/fneur.2024.1389950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 05/08/2024] [Indexed: 06/09/2024] Open
Abstract
Background and objective Current data on the optimal treatment modality for ruptured anterior communicating artery (AComA) aneurysms are limited. We conducted this multicenter retrospective study to evaluate the safety and clinical outcomes of endovascular treatment (EVT) and microsurgical clipping (MC) for the treatment of ruptured AComA patients. Methods Patients with ruptured AComA aneurysms were screened from the Chinese Multicenter Cerebral Aneurysm Database. Propensity score matching (PSM) was used to adjust for baseline characteristic imbalances between the EVT and MC groups. The safety outcomes included total procedural complications, procedure-related morbidity/death and remedial procedure for complication. The primary clinical outcome was 2-year functional independence measured by the modified Rankin scale (mRS) score. Results The analysis included 893 patients with ruptured AComA aneurysms (EVT: 549; MC: 346). PSM yielded 275 pairs of patients in the EVT and MC cohorts for comparison. Decompressive craniectomy being more prevalent in the MC group (19.3% vs. 1.5%, p < 0.001). Safety data revealed a lower rate of total procedural complications (odds ratio [OR] = 0.62, 95% CI 0.39-0.99; p = 0.044) in the EVT group and similar rates of procedure-related morbidity/death (OR = 0.91, 95% CI 0.48-1.73; p = 0.880) and remedial procedure for complication (OR = 1.35, 95% CI 0.51-3.69, p = 0.657) between the groups. Compared with that of MC patients, EVT patients had a greater likelihood of functional independence (mRS score 0-2) at discharge (OR = 1.68, 95% CI 1.14-2.50; p = 0.008) and at 2 years (OR = 1.89, 95% CI 1.20-3.00; p = 0.005), a lower incidence of 2-year all-cause mortality (OR = 0.54, 95% CI 0.31-0.93; p = 0.023) and a similar rate of retreatment (OR = 1.00, 95% CI 0.23-4.40; p = 1.000). Conclusion Clinical outcomes after treatment for ruptured AComA aneurysms appear to be superior to those after treatment with MC, with fewer overall procedure-related complications and no increase in the retreatment rate. Additional studies in other countries are needed to verify these findings.
Collapse
Affiliation(s)
- Minghao Yang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Department of Cerebrovascular Disease, The Second Affiliated Hospital of Guilin Medical University, Guangxi Zhuang, China
| | - Yang Li
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Jia Li
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Department of Neurosurgery, Baoding No.1 Central Hospital, Hebei, China
| | - Xiuhu An
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Hongwen Li
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Bangyue Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Yan Zhao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiaowei Zhu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Changkai Hou
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Linchun Huan
- Department of Neurosurgery, Linyi People’s Hospital, Shandong, China
| | - Xinyu Yang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Jianjun Yu
- Department of Neurosurgery, Linyi People’s Hospital, Shandong, China
| |
Collapse
|
2
|
Ferreira T, Awuah WA, Tan JK, Adebusoye FT, Ali SH, Bharadwaj HR, Aderinto N, Fernandes C, Zahid MJ, Abdul-Rahman T. The current landscape of intracranial aneurysms in Africa: management outcomes, challenges, and strategies-a narrative review. Neurosurg Rev 2023; 46:194. [PMID: 37548805 DOI: 10.1007/s10143-023-02102-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/19/2023] [Accepted: 07/30/2023] [Indexed: 08/08/2023]
Abstract
Intracranial aneurysms (IAs) pose complex and potentially life-threatening challenges in Africa, where limited resources, restricted access to specialised healthcare facilities, and disparities in healthcare provision amplify the difficulties of management. Timely diagnosis and treatment are pivotal in preventing complications, including subarachnoid haemorrhage. Treatment options encompass observation, surgical clipping, endovascular coiling, and flow diversion. Positive outcomes observed in IA management in Africa include high survival rates, favourable functional outcomes, successful treatment techniques, and the absence of complications in some cases. However, negative outcomes such as postoperative complications, reduced quality of life, perioperative mortality, and the risk of recurrence persist. Challenges in IA management encompass limited access to diagnostic tools, a scarcity of specialised healthcare professionals, and an unequal distribution of services. Addressing these challenges requires interventions focused on improving access to diagnostic tools, expanding the number of trained professionals, and establishing specialised IA treatment centres. Collaboration, research, and capacity-building efforts hold significant importance in improving patient outcomes and reducing disparities in IA management across Africa.
Collapse
Affiliation(s)
- Tomas Ferreira
- Department of Clinical Neurosciences, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Wireko Andrew Awuah
- Faculty of Medicine, Sumy State University, Sanatorna St, 31, Sumy, Sumy Oblast, 40000, Ukraine
| | | | - Favour Tope Adebusoye
- Faculty of Medicine, Sumy State University, Sanatorna St, 31, Sumy, Sumy Oblast, 40000, Ukraine.
| | - Syed Hasham Ali
- Faculty of Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | | | - Nicholas Aderinto
- Internal Medicine Department, LAUTECH Teaching Hospital, Oyo, Nigeria
| | | | | | - Toufik Abdul-Rahman
- Faculty of Medicine, Sumy State University, Sanatorna St, 31, Sumy, Sumy Oblast, 40000, Ukraine
| |
Collapse
|
3
|
Sattari SA, Shahbandi A, Lee RP, Feghali J, Rincon-Torroella J, Yang W, Abdulrahim M, Ahmadi S, So RJ, Hung A, Caplan JM, Gonzalez F, Tamargo RJ, Huang J, Xu R. Surgery or Endovascular Treatment in Patients with Anterior Communicating Artery Aneurysm: A Systematic Review and Meta-Analysis. World Neurosurg 2023; 175:31-44. [PMID: 37011760 DOI: 10.1016/j.wneu.2023.03.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 03/27/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND AND OBJECTIVE Although randomized controlled trials have compared surgery versus endovascular treatment for intracranial aneurysms, the literature is sparse in terms of subgroup analysis for anterior communicating artery (ACoA) aneurysm management. This systematic review and meta-analysis sought to compare surgical versus endovascular treatment for ACoA aneurysms. METHODS Medline, PubMed, and Embase were searched from inception to December 12, 2022. Primary outcomes were post-treatment modified Rankin Scale (mRS) >2 and mortality. Secondary outcomes were aneurysm obliteration, retreatment and recurrence, rebleeding, technical failure, vessel rupture, aneurysmal subarachnoid hemorrhage-related hydrocephalus, symptomatic vasospasm, and stroke. RESULTS Eighteen studies yielded 2368 patients, from which 1196 (50.5%) and 1172 (49.4%) patients underwent surgery and endovascular treatment, respectively. The odds ratio (OR) of mortality was similar in total (OR = 0.92 [0.63-1.37], P = 0.69), ruptured (OR = 0.92 [0.62-1.36], P = 0.66), and unruptured cohorts (OR = 1.58 [0.06-39.60], P = 0.78). The OR of mRS > 2 was similar in total (OR = 0.75 [0.50-1.13], P = 0.17), ruptured (OR = 0.77 [0.49-1.20], P = 0.25), and unruptured cohorts (OR = 0.64 [0.21-1.96], P = 0.44). The OR of obliteration was higher with surgery in the total (OR = 2.52 [1.49-4.27], P = 0.0008) and ruptured cohorts (OR = 2.61 [1.33-5.10], P = 0.005) and unruptured group (OR = 3.46 [1.30-9.20], P = 0.01). The OR of retreatment was lower with surgery in the total (OR = 0.37 [0.17-0.76], P = 0.007) and ruptured cohorts (OR = 0.31 [0.11-0.89], P = 0.03), thought it was similar in the unruptured group (OR = 0.51 [0.08-3.03], P = 0.46). The OR of recurrence was lower with surgery in the total (OR = 0.22 [0.10, 0.47], P = 0.0001), ruptured (OR = 0.16 [0.03, 0.90], P = 0.04), and mixed (un) ruptured cohorts (OR = 0.22 [0.09-0.53], P = 0.0009). The OR of rebleeding in ruptured group was similar (OR = 0.66 [0.29-1.52], P = 0.33). The ORs of other outcomes were similar. CONCLUSIONS ACoA aneurysms may be safely treated with either surgery or endovascular treatment, although microsurgical clipping demonstrates higher obliteration rates and lower rates of retreatment and recurrence.
Collapse
Affiliation(s)
- Shahab Aldin Sattari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ataollah Shahbandi
- Tehran School of Medicine, Tehran University of Medical Science, Tehran, Iran
| | - Ryan P Lee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - James Feghali
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jordina Rincon-Torroella
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mostafa Abdulrahim
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sina Ahmadi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Raymond J So
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alice Hung
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Justin M Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Fernando Gonzalez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| |
Collapse
|
4
|
Yamazaki H, Fujinaka T, Ozaki T, Kidani T, Nishimoto K, Taki K, Nishizawa N, Murakami K, Kanemura Y, Nakajima S. Staged treatment for ruptured wide-neck intracranial aneurysm with intentional partial coiling in the acute phase followed by definitive treatment. Surg Neurol Int 2022; 13:322. [PMID: 35928305 PMCID: PMC9345100 DOI: 10.25259/sni_529_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 07/06/2022] [Indexed: 11/06/2022] Open
Abstract
Background: Evidence supports endovascular coiling for ruptured intracranial aneurysms (RIAs). However, in some cases, it is difficult to achieve complete occlusion by coiling, such as with wide-neck aneurysms. We report our experience with intentional staged RIA treatment using targeted endovascular coiling at the rupture point in the acute phase, followed by delayed stent-assisted coiling, flow diverter stenting, or surgical clipping. Methods: Consecutive patients with RIAs treated between April 2015 and June 2021 were retrospectively investigated. Clinical characteristics, treatment complications, and patient outcomes data were collected. Results: Among 108 RIAs treated in our hospital, 60 patients underwent initial coiling; 10 patients underwent staged treatment. The aneurysm locations were the anterior communicating artery (n = 5), internal carotid-posterior communicating artery (n = 3), internal carotid-paraclinoid (n = 1), and vertebral artery-posterior inferior cerebellar artery (n = 1). The mean ± standard deviation aneurysmal diameter was 9.6 ± 5.4 mm and the mean aspect ratio was 1.2 ± 0.7. As the second treatment to obliterate blood flow to the neck area, we performed five stent-assisted coiling, two flow-diverter stentings, and three surgical clippings. Only one minor perioperative complication occurred. The median duration between the first and second treatments was 18 days (range, 14– 42 days). Good clinical outcome (modified Rankin scale score 0–2) at 90 days was achieved in 5 (50%) cases. The median follow-up duration was 6.5 months (range, 3–35 months); no rerupture occurred. Conclusion: Intentional staged treatment with a short time interval for RIA was effective and feasible.
Collapse
|
5
|
Nariai Y, Takigawa T, Kawamura Y, Suzuki R, Hyodo A, Suzuki K. Treatment results and long-term outcomes of endovascular treatment of 96 unruptured anterior communicating artery aneurysms: A large single-center study. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|
6
|
A comparative analysis of the endoscopic endonasal and pterional approaches for clipping anterior communicating artery aneurysms on three-dimensional printed models. Chin Med J (Engl) 2021; 134:2113-2115. [PMID: 34224407 PMCID: PMC8439996 DOI: 10.1097/cm9.0000000000001593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
|
7
|
Chen J, Li M, Zhu X, Chen Y, Zhang C, Shi W, Chen Q, Wang Y. Anterior Communicating Artery Aneurysms: Anatomical Considerations and Microsurgical Strategies. Front Neurol 2020; 11:1020. [PMID: 33013671 PMCID: PMC7509403 DOI: 10.3389/fneur.2020.01020] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 08/04/2020] [Indexed: 11/29/2022] Open
Abstract
Anterior communicating artery aneurysms account for 23–40% of ruptured intracranial aneurysms and 12–15% of unruptured aneurysms and are the most common intracranial ruptured or unruptured aneurysms. Because they have relatively complex anatomical structures and anatomical variations and are adjacent to important blood vessels and structures, in the process of microsurgical exposure of an Anterior communicating artery aneurysm, attention should be paid not only to the anatomical characteristics of the aneurysm itself but also to the adjacent important blood vessels and perforating arteries; therefore, both surgical clipping and endovascular embolization are serious challenges for neurosurgeons. No matter which treatment is chosen, it is necessary to determine the structure of the Anterior communicating artery and its perforating arteries as well as whether there is a fenestration deformity of the Anterior communicating artery and the relationship between bilateral A1-A2 before surgery. The shape and size of the aneurysm itself and its location relative to adjacent blood vessels also need to be considered to better complete the procedure, and this is especially true for microsurgical clipping. Clarifying the anatomy before surgery is helpful for better selecting the surgical approach and surgical side, which could affect the intraoperative exposure of the aneurysm and adjacent arteries, the surgical difficulty, the resection rate, and the postoperative complications. Therefore, starting with Anterior communicating artery aneurysms and their adjacent structures and variations, this paper reviews the latest progress in surgical treatment based on anatomic specificity as well as the most recent clinical studies.
Collapse
Affiliation(s)
- Junhui Chen
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China.,Department of Neurosurgery, 904th Hospital of Joint Logistic Support Force of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, China
| | - Mingchang Li
- Department of Neurosurgery, 904th Hospital of Joint Logistic Support Force of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, China
| | - Xun Zhu
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yan Chen
- Department of Internal Medicine, Hexian Hospital of Traditional Chinese Medicine, Ma'anshan, China
| | - Chunlei Zhang
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Wenwen Shi
- Department of Internal Medicine, Hexian Hospital of Traditional Chinese Medicine, Ma'anshan, China
| | - Qianxue Chen
- Department of Neurosurgery, 904th Hospital of Joint Logistic Support Force of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, China
| | - Yuhai Wang
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| |
Collapse
|
8
|
Terakado T, Nakai Y, Ikeda G, Uemura K, Matsumaru Y. The Relationships between Anatomical Factors and Treatment Procedures for the Endovascular Treatment of Anterior Communicating Artery Aneurysms. JOURNAL OF NEUROENDOVASCULAR THERAPY 2020; 15:142-149. [PMID: 37502729 PMCID: PMC10370672 DOI: 10.5797/jnet.oa.2020-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 07/23/2020] [Indexed: 07/29/2023]
Abstract
Objective Endovascular treatment of anterior communicating artery aneurysms is difficult due to their complex anatomical structure. We retrospectively analyzed the relationships among the anatomical features, initial microcatheter positions, and initial occlusion outcomes. Methods In all, 66 cases were treated at our hospital. We investigated the relationships among the anatomical features of the aneurysm and A1 segment of the anterior cerebral artery (ACA), treatment procedures, and initial occlusion outcomes. We divided the initial microcatheter positions into greater and lesser curvatures based on the curvature from A1 to the aneurysm, and evaluated the outcomes. Results In total, 54 out of 66 patients (82%) achieved complete obliteration (CO) or had residual neck (RN) aneurysms, and 12 had residual aneurysms (RAs: 18%). Neck diameters and superior position aneurysms were correlated with initial occlusion outcomes in the multivariate analysis. The relationship between initial occlusion outcomes and initial microcatheter positions in superior position aneurysms (37 patients) was then examined. Eleven out of 26 patients (42.3%) had residual aneurysms at the greater curvature microcatheter position, whereas no residual aneurysms were detected at the lesser curvature microcatheter position. The A1 angle was not correlated with the outcomes. Conclusion Wide-necked aneurysms and superior position aneurysms were identified as factors leading to incomplete occlusion in the endovascular treatment of anterior communicating artery aneurysms. The microcatheter position at the greater curvature in superior position aneurysms was a factor for incomplete occlusion. This suggests that guiding the microcatheter to the lesser curvature position of A1 is important in the treatment of superior position aneurysms.
Collapse
Affiliation(s)
- Toshitsugu Terakado
- Department of Neurosurgery, Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan
- Department of Neurosurgery, Hitachi General Hospital, Hitachi, Ibaraki, Japan
| | - Yasunobu Nakai
- Department of Neurosurgery, Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan
- Intravascular Treatment Center, Yokohama Brain and Spine Center, Yokohama, Kanagawa, Japan
| | - Go Ikeda
- Department of Neurosurgery, Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan
| | - Kazuya Uemura
- Department of Neurosurgery, Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan
| | - Yuji Matsumaru
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| |
Collapse
|
9
|
Navrátil O, Ďuriš K, Juráň V, Svoboda K, Hustý J, Hovorka E, Neuman E, Mrlian A, Smrčka M. Current Treatment of Anterior Communicating Artery Aneurysms: Single Center Study. Brain Sci 2020; 10:E501. [PMID: 32751951 PMCID: PMC7465251 DOI: 10.3390/brainsci10080501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/20/2020] [Accepted: 07/27/2020] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Anterior communicating artery aneurysms (ACoAAs) are the most frequent intracranial aneurysms treated at neurosurgical departments with a vascular program. MATERIAL AND METHODS We reviewed patients with ACoAAs in a single institution over ten years (2008-2017). The focus was on the final outcome; complications, age, and clinical condition with respect to modalities were analyzed. RESULTS A total of 198 patients treated during this period was included in the study: 176 patients had a ruptured ACoAA and 22 had an unruptured ACoAA. Then, 127 (71%) were treated surgically and 51 (29%) by endovascular means. Out of the whole series, a good recovery occurred in 123 patients (62%), moderate disability in 11 (5.5%), severe disability in 19 (10%), vegetative state in 11 (5.5%), and death in 34 (17%). In the 157 patients (72.5%) with a subarachnoid hemorrhage (SAH), both modalities had a favorable outcome: 27.5% had an unfavorable outcome, 12% had complications in surgery versus 17.6% during endovascular treatment. No statistical difference in outcome, complications, and age was noted between modalities. Surgical treatment was more frequently adopted for patients in a better clinical condition (p ≤ 0.05). CONCLUSION More than two thirds of the patients (72.5%) reached a favorable outcome. There was no difference in age between the treatment modalities. Risks of complications are present and specific for both modalities.
Collapse
Affiliation(s)
- Ondřej Navrátil
- Department of Neurosurgery, Faculty of Medicine, Masaryk University Brno, 62500 Brno, Czech Republic; (K.Ď.); (V.J.); (K.S.); (E.H.); (E.N.); (A.M.); (M.S.)
- Department of Neurosurgery, University Hospital Brno, 62500 Brno, Czech Republic
| | - Kamil Ďuriš
- Department of Neurosurgery, Faculty of Medicine, Masaryk University Brno, 62500 Brno, Czech Republic; (K.Ď.); (V.J.); (K.S.); (E.H.); (E.N.); (A.M.); (M.S.)
- Department of Neurosurgery, University Hospital Brno, 62500 Brno, Czech Republic
- Department of Pathophysiology, Faculty of Medicine, Masaryk University Brno, 62500 Brno, Czech Republic
| | - Vilém Juráň
- Department of Neurosurgery, Faculty of Medicine, Masaryk University Brno, 62500 Brno, Czech Republic; (K.Ď.); (V.J.); (K.S.); (E.H.); (E.N.); (A.M.); (M.S.)
- Department of Neurosurgery, University Hospital Brno, 62500 Brno, Czech Republic
| | - Karel Svoboda
- Department of Neurosurgery, Faculty of Medicine, Masaryk University Brno, 62500 Brno, Czech Republic; (K.Ď.); (V.J.); (K.S.); (E.H.); (E.N.); (A.M.); (M.S.)
- Department of Neurosurgery, University Hospital Brno, 62500 Brno, Czech Republic
| | - Jakub Hustý
- Department of Radiology and Nuclear Medicine, Faculty of Medicine, Masaryk University Brno, 62500 Brno, Czech Republic;
- Department of Radiology and Nuclear Medicine, University Hospital Brno, 62500 Brno, Czech Republic
| | - Evžen Hovorka
- Department of Neurosurgery, Faculty of Medicine, Masaryk University Brno, 62500 Brno, Czech Republic; (K.Ď.); (V.J.); (K.S.); (E.H.); (E.N.); (A.M.); (M.S.)
- Department of Neurosurgery, University Hospital Brno, 62500 Brno, Czech Republic
| | - Eduard Neuman
- Department of Neurosurgery, Faculty of Medicine, Masaryk University Brno, 62500 Brno, Czech Republic; (K.Ď.); (V.J.); (K.S.); (E.H.); (E.N.); (A.M.); (M.S.)
- Department of Neurosurgery, University Hospital Brno, 62500 Brno, Czech Republic
| | - Andrej Mrlian
- Department of Neurosurgery, Faculty of Medicine, Masaryk University Brno, 62500 Brno, Czech Republic; (K.Ď.); (V.J.); (K.S.); (E.H.); (E.N.); (A.M.); (M.S.)
- Department of Neurosurgery, University Hospital Brno, 62500 Brno, Czech Republic
| | - Martin Smrčka
- Department of Neurosurgery, Faculty of Medicine, Masaryk University Brno, 62500 Brno, Czech Republic; (K.Ď.); (V.J.); (K.S.); (E.H.); (E.N.); (A.M.); (M.S.)
- Department of Neurosurgery, University Hospital Brno, 62500 Brno, Czech Republic
| |
Collapse
|
10
|
Nussbaum ES, Touchette JC, Madison MT, Goddard JK, Lassig JP, Nussbaum LA. Microsurgical Treatment of Unruptured Anterior Communicating Artery Aneurysms: Approaches and Outcomes in a Large Contemporary Series and Review of the Literature. Oper Neurosurg (Hagerstown) 2020; 19:678-690. [DOI: 10.1093/ons/opaa214] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 05/03/2020] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
With advances in endovascular techniques, the relative roles of microsurgery and endovascular therapy in the management of intracranial aneurysms have become less clear, and data regarding treatment-specific outcomes are increasingly important.
OBJECTIVE
To describe our experience with microsurgery in a large series of unruptured anterior communicating artery aneurysms (ACOMMAAs) and detail our treatment decision-making process based on individual aneurysm morphology.
METHODS
We retrospectively reviewed unruptured ACOMMAAs treated microsurgically at our center between 1997 and 2018, recording aneurysm size, surgical approach, occlusion rates, neurological outcomes, and complications.
RESULTS
We treated 300 unruptured ACOMMAAs in 300 patients, mean age 49 yr, 180 (60.0%) female, including 245 (81.7%) small, 50 (16.7%) large, and 5 (1.7%) giant aneurysms. Most underwent a pterional approach (253, 84.3%), with orbitozygomatic or anterior interhemispheric approaches in 35 (11.7%) and 12 (4%), respectively. Greater than 95% occlusion was achieved in 284 (94.7%), 90% to 95% occlusion in 13 (4.3%), and 3 (1.0%) underwent wrapping. Serious complications occurred in 3 patients (1.0%) resulting in 2 deaths (0.7%), and minor complications in 12 (4.0%). At final follow-up, good neurological outcome was observed in 297 (99.0%) patients.
CONCLUSION
Given clinical equipoise regarding optimal treatment of unruptured ACOMMAAs, this work provides a benchmark for achievable microsurgical outcomes. Future surgical/endovascular studies should separate results of ruptured and unruptured lesions and describe aneurysm morphology to allow for better comparison of outcomes between treatments. We suggest that open microsurgery represents an important option for select, morphologically complex ACOMMAAs, and that a multidisciplinary approach offers optimal patient outcomes.
Collapse
Affiliation(s)
- Eric S Nussbaum
- Department of Neurosurgery, National Brain Aneurysm & Tumor Center, United Hospital, Twin Cities, Minnesota
| | | | | | | | | | - Leslie A Nussbaum
- Department of Neurosurgery, National Brain Aneurysm & Tumor Center, United Hospital, Twin Cities, Minnesota
| |
Collapse
|
11
|
Soares FP, Velho MC, Antunes ACM. Clinical and morphological profile of aneurysms of the anterior communicating artery treated at a neurosurgical service in Southern Brazil. Surg Neurol Int 2019; 10:193. [PMID: 31637094 PMCID: PMC6800289 DOI: 10.25259/sni_41_2019] [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] [Received: 01/23/2019] [Accepted: 07/09/2019] [Indexed: 11/25/2022] Open
Abstract
Background: The aim of the study was to characterize the clinical profile of patients with anterior communicating artery (ACoA) aneurysms and examine potential correlations between clinical findings, aneurysm morphology, and outcome. Methods: A review of medical records and diagnostic neuroimaging reports of patients treated at a neurosurgical service in Porto Alegre, Brazil, between August 2008 and January 2015 was performed. Results: During the period, 100 patients underwent surgery for ACoA aneurysms. Fifteen had unruptured aneurysms and 85 had ruptured aneurysms. Ruptured aneurysms had a higher aspect ratio than unruptured ones (2.37 ± 0.71 vs. 1.93 ± 0.51, P = 0.02). Intraoperative rupture occurred in 3%, and temporary clipping was performed in 15%. Clinical vasospasm occurred in 43 patients with ruptured aneurysms (50.6%). Overall, mortality was 26%; 25 patients in the ruptured group (29.4%) and one in the unruptured group (6%). The Glasgow Outcome Scale (GOS) was favorable (GOS 4 or 5) in 54% of patients, significantly more so in those with unruptured aneurysms (P = 0.01). In patients with ruptured aneurysms, mortality was associated with preoperative Hunt and Hess (HH) score (P < 0.001), hydrocephalus (P < 0.001), and clinical complications (P < 0.001). Unfavorable outcomes were associated with HH score (P < 0.001), Fisher grade (P = 0.015), clinical vasospasm (P = 0.012), external ventricular drain (P = 0.015), hydrocephalus (P < 0.001), and presence of clinical complications (P = 0.001). In patients with unruptured aneurysms, presence of clinical complications was the only factor associated with mortality (P < 0.001). Conclusion: Despite advances in the management of subarachnoid hemorrhage and surgical treatment of aneurysms, mortality is still high, especially due to clinical complications.
Collapse
Affiliation(s)
| | - Maira Cristina Velho
- Graduate Program in Surgical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | |
Collapse
|
12
|
Acioly MA, Shaikh KA, White IK, Ziemba-Davis M, Bohnstedt BN, Cohen-Gadol A. Predictors of Outcomes and Complications After Microsurgical and Endovascular Treatment of 1300 Intracranial Aneurysms. World Neurosurg 2019; 122:e516-e529. [PMID: 31108070 DOI: 10.1016/j.wneu.2018.10.094] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 10/13/2018] [Accepted: 10/16/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND We performed a rigorous statistical analysis of the complications and outcomes of patients with ruptured or unruptured intracranial aneurysms. Our emphasis was on the potential predictive factors when both surgical and endovascular management are offered by a team with balanced microsurgical and endovascular expertise. METHODS From January 2005 to December 2011, 1297 consecutive patients presenting with ruptured (n=829) or unruptured (n=468) aneurysms were prospectively enrolled in our vascular database. The treatment modality was determined by consensus of the endovascular and microsurgical teams. The patients' medical and neurological conditions and aneurysm characteristics were compared against the postintervention complication rates and outcomes using multivariate analyses. RESULTS The patients mostly underwent clipping for ruptured (63.7%) or unruptured (56.6%) aneurysms. For ruptured aneurysms, higher Hunt and Hess and Fisher grades on admission were key predictors of increased neurological (P < 0.001 and P < 0.001, respectively) and medical (P < 0.001 and P=0.041, respectively) complication rates. No significant differences in the outcomes were observed between the coiling or clipping groups during the follow-up period. For the unruptured group, a family history of intracranial aneurysms was the most relevant predictor for reducing neurological complication rates and increasing survival at 6 months. Hypertension was, however, the strongest factor associated with complications negatively affecting the outcomes. CONCLUSIONS For the ruptured and unruptured groups both, the outcomes were generally good, although neurological and medical complications were reasonably more frequent for the ruptured aneurysms. Coiling provided a sustained benefit in lowering the complication rates only in the short term for the unruptured aneurysms. Smoking was associated, paradoxically, with improved outcomes.
Collapse
Affiliation(s)
- Marcus André Acioly
- Division of Neurosurgery, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Division of Neurosurgery, Fluminense Federal University, Niterói-Rio de Janeiro, Brazil
| | - Kashif A Shaikh
- Department of Neurological Surgery, Indiana University School of Medicine and Goodman Campbell Brain and Spine, Indianapolis, Indiana, USA
| | - Ian K White
- Department of Neurological Surgery, Indiana University School of Medicine and Goodman Campbell Brain and Spine, Indianapolis, Indiana, USA
| | - Mary Ziemba-Davis
- Department of Neurological Surgery, Indiana University School of Medicine and Goodman Campbell Brain and Spine, Indianapolis, Indiana, USA
| | - Bradley N Bohnstedt
- Department of Neurosurgery, Oklahoma University, Oklahoma City, Oklahoma, USA
| | - Aaron Cohen-Gadol
- Department of Neurological Surgery, Indiana University School of Medicine and Goodman Campbell Brain and Spine, Indianapolis, Indiana, USA.
| |
Collapse
|