Prise en charge des anévrismes intracrâniens non rompus. Enquête de pratique des équipes neurochirurgicales et neuroradiologiques françaises

What is the role of neurosurgeons in the current management of intracranial aneurysm in France? An analysis of professional practices

STUDY DESIGN

Retrospective observational survey-based study.

INTRODUCTION

In France, intracranial aneurysm (IA) patients are managed by neurosurgeons and by interventional neuroradiologists. The growth of endovascular treatment led us to reflect on the role of neurosurgeons in the management of patients with IA. The present study aimed to highlight the current organization of IA management in France.

METHOD

A 60-question survey was sent to the neurosurgeons in 34 hospitals managing IA patients. Thirty-three questions dealt with standards of care, follow-up procedures and the involvement of the specific specialist.

RESULTS

Twenty-seven centers (79.4%) responded to the survey. A Vascular Multidisciplinary Discussion Team was organized, including both surgeons and neuroradiologists, in 92% of responding centers. There were department protocols in 66% of centers, a local registry in 33% and clinical trials in IA in 60%. Patients with unruptured IA were first seen by a neurosurgeon or by an interventional neuroradiologist, with different practices. For ruptured IA, the neurosurgeons were contacted first in 93% of cases, and were systematically involved in initial intensive care unit management. The patients were hospitalized in the neurosurgery department in 89% of the centers. The neurosurgeons took care of initial follow-up in 85% of the centers, and of lifetime follow-up in 36%. In most centers, radiological monitoring of IA was based on MRI angiography for patients who were embolized or under surveillance, and on CT angiography after microsurgery.

CONCLUSION

Despite the growth of endovascular treatments, the present survey and the literature highlight a major role of neurosurgeons in treatment, follow-up and care coordination.

Management of intracranial aneurysms in France: Place of microsurgery and demography of vascular neurosurgeons

STUDY DESIGN

Observational retrospective survey-based study.

INTRODUCTION

Intracranial aneurysms (IA) can be treated with microsurgery or by endovascular treatments (EVT). EVT have taken an increasingly important part in IA management; the ability of neurosurgical teams to perform such surgery as well as the quality of their training is being questioned. We therefore wanted to assess the proportion of IA treated by microsurgery in France, the demography and caseload of surgeons trained in vascular neurosurgery.

METHODOLOGY

A 60-question survey was sent to the 34 French neurosurgical centers treating IA. Twenty-seven questions dealt with the demography of neurovascular surgeons and caseload. Descriptive data are reported here.

RESULTS

Twenty-seven centers answered, giving us a response rate of 79.4%. A total of 209 neurosurgeons worked in these centers. Forty-six neurosurgeons were designated as referents in vascular neurosurgery, 47% of them were under 45 years old. Among the centers, 96.3% had at least one surgeon that was a referent in neurovascular surgery. A total of 88 surgeons performed IA surgery, but only 11 operated more than 20 IA per year. Two thousand four hundred and thirty seven unruptured IA were treated every year in these centers, 25% of which by microsurgery. A total of 2727 ruptured IA were treated in these centers, of which 15% were treated by microsurgery. The most common indications for microsurgical treatment of IA were: middle cerebral artery aneurysms, wide-neck intracranial aneurysms, and giant intracranial aneurysms, as well as aneurysms associated with a hematoma for the ruptured ones.

CONCLUSION

Demography of vascular neurosurgeons remains favorable, with a referent neurosurgeon in most centers, who, in half of the cases, is a young practitioner. The percentage of microsurgery in the treatment of IA is low, especially for ruptured ones. The most frequently operated types of intracranial aneurysm correspond to good practice recommendations.

[Variability in decision-making for treatment choice of intracranial aneurysms]

OBJECTIVES

To measure the variability in choosing treatment options in different clinical situations involving intracranial aneurysms.

MATERIALS AND METHODS

A questionnaire regarding 25 clinical cases was presented via visual projection, to attendees of the Congrès de la Société française de neurochirurgie et de la Société de langue française de neurochirurgie held in Toulouse from May 9th to May 12th, 2012. The audience (n=59) consisted of 58 neurosurgeons and one neuroradiologist. A minority of them (29.2%) stated that they specialized in vascular neurosurgery. The questionnaire dealt with 25 illustrative clinical cases, in which age, gender, and clinical context were provided along with the corresponding angiographic image of the aneurysm. The questionnaire asked whether the physician would have proposed treatment, and if so, which type of treatment (clip, coil or other). In addition, the physician had to indicate, on a scale of one to ten, the degree of confidence they had in their decision.

RESULTS

For one-third of the cases, there was at least 10% of the respondents who opted for a decision opposite to the one of the majority. For 41.7% of the cases, the proportion of respondents who opted for the clip was not significantly different from the proportion of those who opted for the coil.

CONCLUSION

Even in a relatively homogenous group of physicians, there were significantly diverging opinions regarding the management of cerebral aneurysms. This demonstrates the need for evidence-based data from controlled randomized studies.

Surgery for unruptured intracranial aneurysms in the ISAT and ISUIA era

BACKGROUND

The ISAT and ISUIA studies, along with the improvement of endovascular treatment (EVT) have strongly influenced the management of intracranial aneurysms (IAs). We present our experience in the microsurgical treatment of unruptured IAs (UIAs) in this context.

METHODS

We retrospectively reviewed a consecutive series of non-giant UIAs selected for surgery during a five-year period. Patients and aneurysms characteristics, surgical results and outcome assessed by the Glascow Outcome Scale (GOS) at three month follow-up were studied.

RESULTS

Eighty-five patients underwent 93 surgical procedures to obliterate 113 UIAs. Those were incidental in 89% of the cases and mainly located on the middle cerebral artery (65%). Patients were assigned to surgery according to their medical history (young, previous subarachnoid haemorrhage), aneurysm characteristics (wide neck, branch at the neck, "small" size, associated "surgical" aneurysm) or failure of EVT (5%). Operatively, 48% of UIAs had thin wall or blebs and 71% were occluded with one titanium clip. Thrombectomy or temporary clipping were necessary in 4% and 11% of the cases, three aneurysms peroperatively ruptured, four were deemed unclippable, three paraclinoid UIAs had an intracavernous residue and 16% were wrapped because of a small neck remnant (class 2). The mortality rate was 0% and 4% of the patients experienced a definitive major neurological deterioration. Final GOS was unchanged in 96% of the patients.

CONCLUSIONS

Despite reduction in operative cases and in appropriately selected patients ineligible to EVT, microsurgical clipping of non-giant anterior circulation UIAs can still achieve good outcome with very low mortality and neurological morbidity.

Solitaire stent for endovascular treatment of intracranial aneurysms: immediate and mid-term results in 15 patients with 17 aneurysms

INTRODUCTION

The Solitaire stent is the first fully retractable stent for endovascular treatment (EVT) of intracranial aneurysms. The aim of this study was to evaluate its use in a prospective series with mid-term follow-up.

METHODS

A retrospective review of our prospectively maintained database identified all patients treated with a Solitaire stent. Clinical charts, procedural data, angiographic results were reviewed.

RESULTS

Between June 2008 and September 2009, 15 patients with 17 wide-necked or fusiform aneurysms (16 unruptured/one ruptured) were identified. EVT was successfully performed in all but one patient in whom the stent was removed because it induced flow reduction in the 1.8-mm parent artery. Among 14 treated patients, 13 had an excellent outcome and one had a good outcome. In this latter patient, the first stent could not be delivered and was changed for another one that was successfully deployed. The patient experienced a thrombo-embolic complication 6 hours after EVT and kept a slight hand paresis. In all cases but one, the stent was thus easily navigated and positioned despite a relative poor visibility. Angiographic results included eight complete occlusions, two neck remnants, and six incomplete occlusions. Six-month control in 14 aneurysms showed 13 complete occlusions and one incomplete occlusion.

CONCLUSION

The Solitaire stent is useful for EVT of complex intracranial aneurysms because it is fully retractable, easy to navigate and to precisely place. However, it should be used with caution in arteries less than 2mm in diameter.

Clipping Versus Coiling for Ruptured Intracranial Aneurysms

OBJECTIVE

Patients with intracranial aneurysms, both ruptured and unruptured, are frequently eligible for both open surgery (“clipping”) and endovascular repair (“coiling”). Although results of randomized trials have informed this decision, the actual choice of clipping or coiling for individual patients remains complex. At the 2007 Congress of Neurological Surgeons (CNS) Annual Meeting, a novel active learning process called Integrated Medical Learning (IML) was applied to education about this critical treatment choice.

METHODS

CNS members received an electronically distributed premeeting survey and educational materials about the clipping versus coiling decision and related topics. At the Annual Meeting, participants used handheld devices to choose clipping or coiling for treatment of individual aneurysms, both before and after expert opinion presentations. After the meeting, members who had answered premeeting surveys received a follow-up questionnaire.

RESULTS

In the premeeting poll, respondents with self-described specialties of “vascular,” Cerebrovascular Section members, surgeons with active cerebrovascular practices, and surgeons in practice for less than 20 years had higher levels of baseline knowledge of cerebrovascular literature (P < .03). Surgeons' clinical volumes of clipping and coiling strongly influenced their vote for clipping or coiling for a hypothetical patient (P < .01). At the meeting, in 6 of 8 cases of ruptured aneurysms the audience was split 75%:25% or closer to “clinical equipoise” (50:50 split). Surgeons with vascular specialty, academic surgeons, and residents were more likely to recommend clipping for individual cases (P < .05). After experts' presentations, in 6 of 8 cases the audience opinion changed significantly. Vascular specialists and younger surgeons were less likely to change their opinion (P < .03). The 2 cases with no shift in opinion were the most-clippable and most-coilable cases. Postmeeting surveys showed evidence of retained knowledge from the meeting, and respondents thought IML had been helpful.

CONCLUSIONS

Using IML, we were able to study baseline knowledge and practice patterns for an important cerebrovascular treatment decision. Evidence suggested that expert presentations were effective in changing audience opinion, at least in cases where preexisting opinion was close to clinical equipoise.