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Enriquez Marulanda A, Young M, Shutran M, Taussky P, Kicielinski K, Ogilvy CS. Acute Coiling With Delayed Flow Diversion for Posterior Communicating Segment Internal Carotid Artery Aneurysms: A Multicenter Case Series. Neurosurgery 2024; 94:729-735. [PMID: 37931125 DOI: 10.1227/neu.0000000000002720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 08/22/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVES In ruptured posterior communicating artery (PcomA) aneurysms, the protection of the aneurysm dome alone with initial subtotal coiling decreases the risk of rerupture in the acute setting but does not provide durable/definitive long-term protection against delayed rupture. Delayed flow diverter (FD) placement can be a potential alternative to definitively secure these aneurysms without increasing the risk of complications and PComA occlusion. We analyzed PComA aneurysms treated with a planned delayed FD after primary coiling and assess radiographic and clinical outcomes. METHODS We performed a retrospective study of prospectively collected data for intracranial aneurysms treated with planned FD at 2 institutions from 2013 to 2022. PComA aneurysms that underwent primary coiling and delayed FD placement were included for analysis. RESULTS There were 29 PComA aneurysms identified that were included in the analysis. Patients were mostly female (79.3%), with a median age of 60 years. The mean aneurysm maximum diameter was 7.2 mm ± (5.3). Immediate Raymond-Roy occlusion grade after primary coiling was I in 48.3%, II in 41.4%, and III in 10.3% of aneurysms. The median time from initial coiling to planned delayed FD placement was 6.3 months (3.2-18.6). A total of 21 (72.4%) aneurysms underwent follow-up radiological imaging. Complete and near-complete occlusion status was achieved in 76.2% of the evaluated aneurysms. There were no retreatments and no evidence of delayed aneurysm rupture. One case (3.5%) presented thromboembolic complications and 1 (3.5%) intracranial hemorrhagic complication after FD placement, which was associated with mortality. Most patients (90.5%) had a modified Rankin scale of ≤2 on the last follow-up. CONCLUSION Primary coiling with planned staged FD placement is effective for treating ruptured PComA aneurysms with high occlusion rates and low complications.
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Affiliation(s)
- Alejandro Enriquez Marulanda
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute. Harvard Medical School, Boston , Massachusetts , USA
| | - Michael Young
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute. Harvard Medical School, Boston , Massachusetts , USA
| | - Max Shutran
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute. Harvard Medical School, Boston , Massachusetts , USA
| | - Philipp Taussky
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute. Harvard Medical School, Boston , Massachusetts , USA
| | - Kimberly Kicielinski
- Neurosurgery Department, Medical University of South Carolina, Charleston , South Carolina , USA
| | - Christopher S Ogilvy
- Neurosurgical Division, Beth Israel Deaconess Medical Center Brain Aneurysm Institute. Harvard Medical School, Boston , Massachusetts , USA
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Rantamo A, Gallé C, Numminen J, Virta J, Tanskanen P, Lindroos AC, Resendiz-Nieves J, Lehecka M, Niemelä M, Haeren R, Raj R. Flow diversion of ruptured intracranial aneurysms: a single-center study with a standardized antithrombotic treatment protocol. Acta Neurochir (Wien) 2024; 166:130. [PMID: 38467916 PMCID: PMC10927838 DOI: 10.1007/s00701-024-06029-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 02/28/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND The use of antithrombotic medication following acute flow diversion for a ruptured intracranial aneurysm (IA) is challenging with no current guidelines. We investigated the incidence of treatment-related complications and patient outcomes after flow diversion for a ruptured IA before and after the implementation of a standardized antithrombotic medication protocol. METHODS We conducted a single-center retrospective study including consecutive patients treated for acutely ruptured IAs with flow diversion during 2015-2023. We divided the patients into two groups: those treated before the implementation of the protocol (pre-protocol) and those treated after the implementation of the protocol (post-protocol). The primary outcomes were hemorrhagic and ischemic complications. A secondary outcome was clinical outcome using the modified Ranking Scale (mRS). RESULTS Totally 39 patients with 40 ruptured IAs were treated with flow diversion (69% pre-protocol, 31% post-protocol). The patient mean age was 55 years, 62% were female, 63% of aneurysms were in the posterior circulation, 92% of aneurysms were non-saccular, and 44% were in poor grade on admission. Treatment differences included the use of glycoprotein IIb/IIIa inhibitors (pre-group 48% vs. post-group 100%), and the use of early dual antiplatelets (pre-group 44% vs. 92% post-group). The incidence of ischemic complications was 37% and 42% and the incidence of hemorrhagic complications was 30% and 33% in the pre- and post-groups, respectively, with no between-group differences. There were three (11%) aneurysm re-ruptures in the pre-group and none in the post-group. There were no differences in mortality or mRS 0-2 between the groups at 6 months. CONCLUSION We found no major differences in the incidence of ischemic or hemorrhagic complications after the implementation of a standardized antithrombotic protocol for acute flow diversion for ruptured IAs. There is an urgent need for more evidence-based guidelines to optimize antithrombotic treatment after flow diversion in the setting of subarachnoid hemorrhage.
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Affiliation(s)
- Anni Rantamo
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland.
| | - Camille Gallé
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
- Department of Neurosurgery, Maastricht University Medical Center, PO box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Jussi Numminen
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
| | - Jyri Virta
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
| | - Päivi Tanskanen
- Anaesthesiology and Intensive Care Medicine, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Ann-Christine Lindroos
- Anaesthesiology and Intensive Care Medicine, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Julio Resendiz-Nieves
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
| | - Martin Lehecka
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
| | - Mika Niemelä
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
| | - Roel Haeren
- Department of Neurosurgery, Maastricht University Medical Center, PO box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
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Garton ALA, Berger K, Merkler AE, Kamel H, Knopman J, Zhang C, Murthy SB. Antiplatelet therapy and outcomes after aneurysmal subarachnoid hemorrhage: A systematic review and meta-analysis. Clin Neurol Neurosurg 2023; 235:108025. [PMID: 37925994 PMCID: PMC10841860 DOI: 10.1016/j.clineuro.2023.108025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 09/04/2023] [Accepted: 10/25/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND The efficacy of antiplatelet therapy (APT) after aneurysmal subarachnoid hemorrhage (aSAH) remains unclear. We performed a systematic review and meta-analysis to summarize the associations of APT use after aSAH with outcomes. METHODS We searched published medical literature to identify cohort studies involving adults with aSAH. The exposure was APT use after aSAH. Outcome measures were good functional outcome (modified Rankin Score 0-2 or Glasgow Outcome Scale 4-5), delayed cerebral ischemia (infarcts on neuroimaging), and intracranial hemorrhage. After assessing study heterogeneity and publication bias, we performed a meta-analysis using random-effects models to assess the strength of association between APT and SAH outcomes. RESULTS A total of 14 studies with 4228 aSAH patients were included. APT after aSAH was associated with good functional outcome (pooled relative risk, 1.08; 95% confidence interval, [CI], 1.02-1.15; I2 = 45%, p for heterogeneity = 0.04), but there was no relationship with delayed cerebral ischemia (pooled relative risk, 0.80; 95% confidence interval, [CI], 0.63-1.02; I2 = 61%, p for heterogeneity <0.01) or intracranial hemorrhage (pooled relative risk, 1.50; 95% confidence interval, [CI], 0.98-2.31; I2 = 0, p for heterogeneity =0.71). In additional analyses, APT resulted in good functional outcomes in endovascularly-treated patients. When stratified by type of medication, aspirin, clopidogrel, and ticlopidine were associated with good functional outcomes. CONCLUSIONS APT after aSAH was associated with a modest improvement in functional outcome, but there was no relationship with delayed cerebral ischemia or intracranial hemorrhage.
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Affiliation(s)
- Andrew L A Garton
- Department of Neurological Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Karen Berger
- Department of Pharmacy, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, USA
| | - Alexander E Merkler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Jared Knopman
- Department of Neurological Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Santosh B Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA.
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Outcomes after Flow Diverter Treatment in Subarachnoid Hemorrhage: A Meta-Analysis and Development of a Clinical Prediction Model (OUTFLOW). Brain Sci 2022; 12:brainsci12030394. [PMID: 35326350 PMCID: PMC8946659 DOI: 10.3390/brainsci12030394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/07/2022] [Accepted: 03/10/2022] [Indexed: 02/01/2023] Open
Abstract
Background: patients with a subarachnoid hemorrhage (SAH) might need a flow diverter (FD) placement for complex acutely ruptured intracranial aneurysms (IAs). We conducted a meta-analysis and developed a prediction model to estimate the favorable clinical outcome after the FD treatment in acutely ruptured IAs. Methods: a systematic literature search was performed from 2010 to January 2021 in PubMed and Embase databases. Studies with more than five patients treated with FDs within fifteen days were included. In total, 1157 studies were identified. The primary outcome measure was the favorable clinical outcome (mRS 0–2). Secondary outcome measures were complete occlusion rates, aneurysm rebleeding, permanent neurologic deficit caused by procedure-related complications, and all-cause mortality. A prediction model was constructed using individual patient-level data. Results: 26 retrospective studies with 357 patients and 368 aneurysms were included. The pooled rates of the favorable clinical outcome, mortality, and complete aneurysm occlusion were 73.7% (95% CI 64.7–81.0), 17.1% (95% CI 13.3–21.8), and 85.6% (95% CI 80.4–89.6), respectively. Rebleeding occurred in 3% of aneurysms (11/368). The c-statistic of the final model was 0.83 (95% CI 0.76–0.89). All the studies provided a very low quality of evidence. Conclusions: FD treatment can be considered for complex ruptured IAs. Despite high complication rates, the pooled clinical outcomes seem favorable. The prediction model needs to be validated by larger prospective studies before clinical application.
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Foreman PM, Ilyas A, Cress MC, Vachhani JA, Hirschl RA, Agee B, Griessenauer CJ. Ruptured Intracranial Aneurysms Treated with the Pipeline Embolization Device: A Systematic Review and Pooled Analysis of Individual Patient Data. AJNR Am J Neuroradiol 2021; 42:720-725. [PMID: 33602746 DOI: 10.3174/ajnr.a7002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 11/02/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The Pipeline Embolization Device (PED) is a flow-diverting stent for the treatment of intracranial aneurysms and is used off-label for a subset of ruptured aneurysms not amenable to traditional treatment. PURPOSE Our aim was to evaluate the safety and efficacy of the PED for treatment of ruptured intracranial aneurysms. DATA SOURCES A systematic review of the MEDLINE, EMBASE, and Scopus data bases from January 2011 to March 2020 was performed for articles reporting treatment of ruptured intracranial aneurysms with the PED. STUDY SELECTION A total of 12 studies comprising 145 patients with 145 treated aneurysms were included for analysis. DATA ANALYSIS Individual patient data were collected. Nonparametric tests were used to compare differences among patients. Logistic regression was used to determine an association with outcome variables. DATA SYNTHESIS Mean aneurysm size was 5.9 mm, and most were blister (51.0%) or dissecting (26.9%) in morphology. Three (2.1%) aneurysms reruptured following PED placement. Univariate logistic regression identified larger aneurysm size as a significant predictor of aneurysm rerupture (P = .008). Of patients with radiographic follow-up, 87.5% had complete aneurysm occlusion. Symptomatic neurologic complications occurred in 16.5%. LIMITATIONS Analysis was limited by the quality of the included data, most of which were from small case series representing class III medical evidence. No study assessed outcome in a blinded or independently adjudicated manner. CONCLUSIONS Most ruptured aneurysms treated with the PED were blister or dissecting aneurysms. Treatment was associated with a rerupture rate of 2.1% and a complete occlusion rate of 87.5%.
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Affiliation(s)
- P M Foreman
- From the Neuroscience and Rehabilitation Institute (P.M.F., M.C.C., J.A.V., R.A.H.), Orlando Health, Orlando, Florida
| | - A Ilyas
- Department of Neurosurgery (A.I., B.A.), University of Alabama at Birmingham, Birmingham, Alabama
| | - M C Cress
- From the Neuroscience and Rehabilitation Institute (P.M.F., M.C.C., J.A.V., R.A.H.), Orlando Health, Orlando, Florida
| | - J A Vachhani
- From the Neuroscience and Rehabilitation Institute (P.M.F., M.C.C., J.A.V., R.A.H.), Orlando Health, Orlando, Florida
| | - R A Hirschl
- From the Neuroscience and Rehabilitation Institute (P.M.F., M.C.C., J.A.V., R.A.H.), Orlando Health, Orlando, Florida
| | - B Agee
- Department of Neurosurgery (A.I., B.A.), University of Alabama at Birmingham, Birmingham, Alabama
| | - C J Griessenauer
- Department of Neurosurgery (C.J.G.), Geisinger Health System, Danville, Pennsylvania
- Research Institute of Neurointervention (C.J.G.), Paracelsus Medical University, Salzburg, Austria
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6
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AlMatter M, Aguilar Pérez M, Hellstern V, Mitrovic G, Ganslandt O, Bäzner H, Henkes H. Flow Diversion for Treatment of Acutely Ruptured Intracranial Aneurysms : A Single Center Experience from 45 Consecutive Cases. Clin Neuroradiol 2020; 30:835-842. [PMID: 31686121 PMCID: PMC7728654 DOI: 10.1007/s00062-019-00846-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 10/03/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Reports about the use of flow diverter stents (FDS) in the acute setting of subarachnoid hemorrhage (SAH) are limited. This article presents a single center experiences based on 45 consecutive cases with emphasis on complication rates and clinical and radiologic outcomes. METHODS A prospectively maintained database of all cases treated with FDS as a stand-alone or adjunct device was retrospectively reviewed. All patients treated within 30 days of SAH were included. Records were made of clinical presentation, details of endovascular treatment, procedural complications, clinical outcome, and degree of occlusion on follow-up. RESULTS In this study 45 patients (48.9% females; mean age 58.8 ± 12.4 years) were included. Flow diversion was performed after a median of 4 days. The procedural complication rate was 13.3% resulting in 2.2% permanent morbidities and 4.4% mortalities. No major hemorrhagic complications related to antiplatelet therapy were recorded. Immediate complete occlusion was achieved in 13.3%. Among survivors, complete occlusion was achieved in 94.6%. Excellent clinical outcome was recorded in 68.9% and 81.6% of the total population and survivors, respectively. There were no records of rebleeding from the target lesions. CONCLUSION Flow diversion is an attractive alternative strategy for management of acutely ruptured aneurysms with high rates of delayed complete occlusion and acceptable complication rates.
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Affiliation(s)
- Muhammad AlMatter
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany.
| | - Marta Aguilar Pérez
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Victoria Hellstern
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Goran Mitrovic
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Oliver Ganslandt
- Neurochirurgische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - Hansjörg Bäzner
- Neurologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
- Medizinische Fakultät, der Universität Duisburg-Essen, Essen, Germany
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7
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Abstract
Neuroendovascular surgery and interventional neuroradiology both describe the catheter-based (most often) endovascular diagnosis and treatment of vascular lesions affecting the brain and spinal cord. This article traces the evolution of these techniques and their current role as the dominant and frequently standard approach for many of these conditions. The article also discusses the important changes that have been brought to bear on open cerebrovascular neurosurgery by neuroendovascular surgery and their effects on resident and fellow training and describes new concepts for clinical care.
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8
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Chen SH, McCarthy DJ, Sheinberg D, Hanel R, Sur S, Jabbour P, Atallah E, Chalouhi N, Dumont A, Amenta P, Hasan D, Raper D, Liu K, Jane JA, Crowley RW, Aguilar-Salinas P, Bentley J, Monteith S, Mitchell BD, Yavagal DR, Peterson EC, Starke RM. Pipeline Embolization Device for the Treatment of Intracranial Pseudoaneurysms. World Neurosurg 2019; 127:e86-e93. [PMID: 30849553 DOI: 10.1016/j.wneu.2019.02.135] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 02/16/2019] [Accepted: 02/18/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Intracranial pseudoaneurysms (PSAs) are associated with high rupture and mortality rates and have traditionally been treated by parent vessel sacrifice. There has been recent interest in using flow-diverting devices for treatment of these complex lesions while preserving flow through the parent artery. The objective of this study is to examine the safety and efficacy of these devices in the treatment of intracranial PSA. METHODS We performed a multi-institutional retrospective study of intracranial PSAs treated with the Pipeline Embolization Device (PED) between 2014 and 2017 at 7 institutions. Complications and clinical and radiographic outcomes were reviewed. RESULTS A total of 19 patients underwent PED placement for intracranial PSA. Iatrogenic injury and trauma comprised most etiologies in our series. The mean pseudoaneurysm diameter was 8.8 mm, and 18 of 19 PSAs (95%) involved the internal carotid artery (ICA). Multiple PEDs were deployed in a telescoping fashion in 7 patients (37%). Of the 18 patients with follow up imaging, 14 (78%) achieved complete pseudoaneurysm obliteration and 2 achieved near-complete obliteration (11%). Two patients (11%) were found to have significant pseudoaneurysm progression on short-term follow-up and required ICA sacrifice. No patients experienced new neurologic deficits or deterioration secondary to PED placement. No patients experienced bleeding or rebleeding from PSA. CONCLUSIONS In well-selected patients, the use of flow-diverting stents may be a feasible alternative to parent vessel sacrifice. Given the high morbidity and mortality associated with PSA, we recommend short- and long-term radiographic follow-up for patients treated with flow-diverting stents.
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Affiliation(s)
- Stephanie H Chen
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - David J McCarthy
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA.
| | - Dallas Sheinberg
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Ricardo Hanel
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA; Department of Neurological Surgery, Baptist Health, Miami, Florida, USA
| | - Samir Sur
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Jefferson University, Philadelphia, Pennsylvania, USA
| | - Elias Atallah
- Department of Neurological Surgery, Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nohra Chalouhi
- Department of Neurological Surgery, Jefferson University, Philadelphia, Pennsylvania, USA
| | - Aaron Dumont
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana, USA
| | - Peter Amenta
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana, USA
| | - David Hasan
- Department of Neurological Surgery, University of Iowa, Iowa City, Iowa, USA
| | - Daniel Raper
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Kenneth Liu
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - John A Jane
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - R Webster Crowley
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Josh Bentley
- Department of Neurological Surgery, Swedish Health, Seattle, Washington, USA
| | - Stephen Monteith
- Department of Neurological Surgery, Swedish Health, Seattle, Washington, USA
| | - Bartley D Mitchell
- Department of Neurological Surgery, Methodist Institute, Houston, Texas, USA
| | - Dileep R Yavagal
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Eric C Peterson
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
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9
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Dossani RH, Patra DP, Kosty J, Jumah F, Kuybu O, Mohammed N, Waqas M, Riaz M, Cuellar H. Early Versus Delayed Flow Diversion for Ruptured Intracranial Aneurysms: A Meta-Analysis. World Neurosurg 2019; 126:41-52. [PMID: 30822578 DOI: 10.1016/j.wneu.2019.02.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 02/03/2019] [Accepted: 02/05/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The use and timing of flow diversion for aneurysmal subarachnoid hemorrhage is controversial. The objective of this study is to perform a meta-analysis and systematic review to compare overall complication rate between early versus delayed flow diversion for ruptured aneurysms. METHODS A literature search for all eligible articles was performed using PubMed, Cochrane, and Web of Science databases. The primary outcome was the overall complication rate (any complication in the perioperative period), and secondary outcomes were 1) hemorrhage and 2) stroke/death (all hemorrhagic/ischemic strokes and/or death). RESULTS Thirteen articles including 142 patients met inclusion criteria. Eighty-nine (62.7%) patients underwent early deployment of flow diverters (i.e., 2 days or less). The odds ratio for overall complication rate with early versus delayed flow diversion was 0.95 (95% confidence interval [CI] 0.36-2.49, P = 0.42). The odds ratio for the secondary outcome of hemorrhagic complication for early versus delayed flow diversion was 1.44 (95% CI 0.45-4.52, P = 0.87) and of stroke/death was 1.67 (95% CI 0.5-4.9, P = 0.69). The odds ratio of early versus delayed flow diversion for blister/dissecting/fusiform aneurysms was 0.82 (95% CI 0.29-2.30) and for saccular/giant aneurysms was 2.23 (95% CI 0.17-29.4). At last follow-up, 71.6% of patients had good performance status (modified Rankin Scale score 0-2), and the rate of angiographic aneurysm occlusion was 90.2%. CONCLUSIONS This meta-analysis did not show a difference in overall complication rate between early versus delayed flow diversion for ruptured aneurysms. Early flow diversion for ruptured blister/fusiform/dissecting aneurysms carries a lower risk of aneurysm rerupture and overall complications as compared with that for ruptured saccular/giant aneurysms.
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Affiliation(s)
- Rimal Hanif Dossani
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA.
| | - Devi P Patra
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Jennifer Kosty
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Fareed Jumah
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Okkes Kuybu
- Department of Neurology, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Nasser Mohammed
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Muhammad Waqas
- Section of Neurosurgery, The Aga Khan University Hospital, Karachi, Pakistan
| | - Muhammad Riaz
- Section of Neurosurgery, The Aga Khan University Hospital, Karachi, Pakistan
| | - Hugo Cuellar
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
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10
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Gritti P, Lorini FL, Lanterna LA, Bilotta F. Periprocedural management of patients with subarachnoid hemorrhage. Curr Opin Anaesthesiol 2019; 31:511-519. [PMID: 30020154 DOI: 10.1097/aco.0000000000000627] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Anesthesiologists and intensivists may be involved in the management of aneurysmal subarachnoid hemorrhage (aSAH) patients at various stages of care. This article will review the recent advances in the periprocedural management of aSAH patients. RECENT FINDINGS New scoring systems to assess gravity and prognosis of aSAH patients have been evaluated and proposed. Rebleeding still remains, with early aneurysmal treatment, a major challenge in the first hours of aSAH management. In the last decades, the treatment of the aSAH has shifted from clipping to coiling and more recently, the use of flow diversion technique has been introduced in selected patients. Although these improvements allow treatment of more complex aneurysms, they have implications for the anesthesiologist, including requiring the management of anticoagulation with its inherent risks. Even though knowledge, monitoring, and management of postprocedural phase of aSAH patients has improved, vasospasm and cerebral-delayed ischemia still remain the major and devastating complications in the postoperative course of aSAH patients. SUMMARY Despite recent progress in the scoring, diagnosis, and treatment of aSAH patients, the periprocedural management of these patients is still a major challenge for anesthesiologists and intensivists, who are involved from the first phase of the aneurysm rupture through the postoperative phases and vasospasm period.
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Affiliation(s)
- Paolo Gritti
- Department of Anaesthesia and Critical Care Medicine
| | | | - Luigi A Lanterna
- Department of Neurosurgery, Ospedale Papa Giovanni XXIII, Bergamo
| | - Federico Bilotta
- Department of Anaesthesia and Critical Care Medicine, 'Sapienza' University, Rome, Italy
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11
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Abstract
Management of anticoagulation and antiplatelet medications after neurosurgery can be complex, especially given that these patients have multiple medical comorbidities. In turn, neurosurgical patients are at high risk for the development of venous thromboembolism after surgery, so neurosurgeons must consider the use of pharmacologic prophylaxis. Developments in endovascular neurosurgery have produced therapies that require close management of antiplatelet medications to prevent postoperative complications. Any of these patient populations may need intrathecal access. This article highlights current strategies for managing these issues in the neurosurgical patient population.
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Affiliation(s)
- Joel Z Passer
- Department of Neurosurgery, Temple University Hospital, 3401 North Broad Street, Suite C540, Philadelphia, PA 19140, USA
| | - Christopher M Loftus
- Department of Neurosurgery, Lewis Katz School of Medicine, Temple University, Temple University Hospital, 3401 North Broad Street, Suite C540, Philadelphia, PA 19140, USA.
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12
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Urasyanandana K, Songsang D, Aurboonyawat T, Chankaew E, Withayasuk P, Churojana A. Treatment outcomes in cerebral artery dissection and literature review. Interv Neuroradiol 2018; 24:254-262. [PMID: 29433365 DOI: 10.1177/1591019918755692] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Methods Patients with cerebral artery dissections were reviewed in a hospital setting from 2008 to 2015. Clinical presentations, lesion locations, treatment modalities, functional outcomes, and mortality were reviewed. Parent artery occlusion was the first choice for surgery or endovascular treatment of a hemorrhagic dissecting cerebral artery. Endovascular or surgical reconstructive treatment was indicated in patients whose parent artery could not be occluded. Favorable functional outcomes were determined using modified Rankin Scale (mRS) scores of 0-2. Results In total, 61 patients with cerebral artery dissections were admitted to the hospital. Seven (11.5%) had traumatic dissections. All traumatic dissections were located in the internal carotid arteries. Overall favorable outcome rate was about 57% (4/7). Spontaneous cerebral artery dissections were found in 54 patients. No difference in favorable outcomes was observed between parent vessel occlusion and selective occlusion with parent vessel preservation (or vessel reconstruction) (70% and 63%, respectively, p = 1.000). Patients who presented with spontaneous dissection without intracranial hemorrhage had more favorable outcomes than those with intracranial hemorrhage (79% and 52%, respectively, p = 0.045). The mortality rate of patients with spontaneous dissection was 7.4%. Conclusions Most of the traumatic dissections were located on the internal carotid arteries and spontaneous dissections were commonly located on vertebral arteries. Nonhemorrhagic spontaneous cerebral dissections had better functional outcomes after treatment. Endovascular and surgical management were effective treatments by parent vessel occlusion or reconstructions.
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Affiliation(s)
- Karanarak Urasyanandana
- 1 Department of Surgery, Phramongkutklao Hospital, Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Dittapong Songsang
- 2 Department of Diagnostic Radiology, Mahidol University Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Taweesak Aurboonyawat
- 2 Department of Diagnostic Radiology, Mahidol University Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Ekawut Chankaew
- 2 Department of Diagnostic Radiology, Mahidol University Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Pattarawit Withayasuk
- 2 Department of Diagnostic Radiology, Mahidol University Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Anchalee Churojana
- 2 Department of Diagnostic Radiology, Mahidol University Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
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