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Grüter BE, Catalano K, Anon J, Gruber P, Thanabalasingam A, Andereggen L, Schubert GA, Remonda L, Marbacher S. Intra-aneurysmal contrast agent stasis during intraoperative digital subtraction angiography may predict long-term occlusion after clipping. Acta Neurochir (Wien) 2024; 166:309. [PMID: 39078422 DOI: 10.1007/s00701-024-06162-3] [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: 04/04/2024] [Accepted: 06/05/2024] [Indexed: 07/31/2024]
Abstract
PURPOSE The routine use of intraoperative digital subtraction angiography (iDSA) increases detection of intracranial aneurysm (IA) remnants after microsurgical clipping. Spontaneous thrombosis of IA remnants after clipping is considered a rare phenomenon. We analyse iDSA characteristics to find predictors for IA remnant thrombosis. METHODS IA with intraoperative detection of a remnant after clipping were identified and divided into remnants experiencing spontaneous thrombosis, and remnants with long-term patency and/or remnant growth. Angiographic features of iDSA were analysed and compared between the two groups. RESULTS Of 37 IAs with intraoperative remnant on 3D-iDSA, five sustained a spontaneous remnant thrombosis and remained occluded in long-term follow-up. In all five cases, iDSA revealed delayed inflow and consequent stasis of the contrast agent until the late venous phase. On the other hand, in all cases with persistent long-term IA remnants (n = 32) iDSA demonstrated timely arterial contrast inflow and wash-out without stasis of intra-aneurysmal contrast agent. CONCLUSIONS Contrast stasis in IA remnants during iDSA appears to predict long-term IA occlusion, indicating that clip correction manoeuvres or even attempted endovascular treatment of the remnant IA may be avoided in these patients.
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Affiliation(s)
- Basil E Grüter
- Division of Neuroradiology, Aarau Cantonal Hospital, Aarau, Switzerland.
- Department of Neurosurgery, Aarau Cantonal Hospital, Aarau, Switzerland.
| | - Kristina Catalano
- Department of Neurosurgery, Aarau Cantonal Hospital, Aarau, Switzerland
| | - Javier Anon
- Division of Neuroradiology, Aarau Cantonal Hospital, Aarau, Switzerland
| | - Philipp Gruber
- Division of Neuroradiology, Aarau Cantonal Hospital, Aarau, Switzerland
| | | | - Lukas Andereggen
- Department of Neurosurgery, Aarau Cantonal Hospital, University of Bern, Bern, Switzerland
| | - Gerrit A Schubert
- Department of Neurosurgery, Aarau Cantonal Hospital, Aarau, Switzerland
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Luca Remonda
- Division of Neuroradiology, Aarau Cantonal Hospital, University of Bern, Bern, Switzerland
| | - Serge Marbacher
- Department of Neurosurgery, Aarau Cantonal Hospital, University of Bern, Bern, Switzerland
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2
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Choi JH, Park W, Park JC, Kwun BD, Ahn JS. Clipping of Unruptured Anterior Choroidal Artery Aneurysms Together with Small Branches: Safety Confirmation Using Intraoperative Indocyanine Green Video-Angiography and Intraoperative Neurophysiological Monitoring. World Neurosurg 2023; 180:e19-e29. [PMID: 37331470 DOI: 10.1016/j.wneu.2023.06.033] [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: 05/26/2023] [Accepted: 06/11/2023] [Indexed: 06/20/2023]
Abstract
BACKGROUND In treating anterior choroidal artery (AChA) aneurysms, preserving the AChA main trunk is of course necessary to prevent postoperative ischemic complications. However, in practice, complete occlusions are often limited by small branches. OBJECTIVE We aimed to demonstrate that even in cases where complete occlusion of the AChA aneurysm is complex due to small branches, complete occlusion can be safely achieved using indocyanine green video-angiography and intraoperative neurophysiological monitoring (IONM). METHODS We performed a retrospective review of all unruptured AChA aneurysms surgically treated at our institution from 2012 to 2021. All available surgical videos were reviewed to find AChA aneurysms clipped with small branches; clinical and radiological data were collected for these cases. RESULTS Among 391 cases of unruptured AChA aneurysms treated surgically, 25 AChA aneurysms were clipped with small branches. AChA-related ischemic complications occurred in 2 cases (8%) without retrograde indocyanine green filling to the branches. These 2 cases had changes in IONM. There were no ischemic complications in the remaining cases with retrograde indocyanine green filling to the branches and no change in IONM. During an average follow-up of 47 months (12-111 months), a small residual neck was observed in 3 cases (12%) and recurrence or progression of the aneurysm was observed in only 1 case (4%). CONCLUSIONS The surgical treatment of AChA aneurysms carries the risk of devastating ischemic complications. Even in cases where complete clip ligation seems impossible due to small branches associated with AChA aneurysms, complete occlusion can be safely achieved using indocyanine green video-angiography and IONM.
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Affiliation(s)
- June Ho Choi
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Wonhyoung Park
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Cheol Park
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byung Duk Kwun
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Sung Ahn
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Yang K, Begley SL, Lynch D, Turpin J, Aminnejad M, Farrokhyar F, Dehdashti AR. Long-term outcomes of surgical clipping of saccular middle cerebral artery aneurysms: a consecutive series of 92 patients. Neurosurg Rev 2023; 46:271. [PMID: 37843680 DOI: 10.1007/s10143-023-02167-1] [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: 07/13/2023] [Revised: 09/17/2023] [Accepted: 09/24/2023] [Indexed: 10/17/2023]
Abstract
Despite advances in endovascular treatment, microsurgical clipping of middle cerebral artery (MCA) aneurysms remains appropriate. We review the high occlusion rate and treatment durability seen with surgical clipping of MCA aneurysms. We retrospectively reviewed patients who underwent microsurgical clipping of saccular MCA aneurysms by a single surgeon. Outcomes included aneurysm occlusion rate and durability, modified Rankin scale (mRS), and postoperative neurological morbidities. Ninety-two patients with 92 saccular MCA aneurysms were included, 50% of which were ruptured aneurysms. The mean follow-up period was 59 months. Complete aneurysm occlusion was achieved in all except one patient (99%) with near-complete occlusion. MCA aneurysm clipping was durable, with only one patient (1%) requiring retreatment after 4 years due to regrowth. Of the cohort, 79.3% achieved mRS 0-2 at last follow-up, including all with unruptured aneurysms. Poor outcome at discharge was associated with age > 65 (p = .03), postoperative neurological morbidities (p = .006), and aneurysm rupture (p < .001). Older age remained the single correlate for poor long-term outcome (p = .04). For ruptured aneurysms, predictors of poor long-term outcome included hemiparesis on presentation (p = .017), clinical vasospasm requiring treatment (p = .026), and infarction related to vasospasm (p = .041). Older age (p = .046) and complex anatomy (p = .036) were predictors of new postoperative neurological morbidities in the unruptured group. MCA aneurysm clipping is safe, durable, and should be considered first-line treatment for patients with saccular MCA aneurysms, especially in centers with abundant surgical experience.
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Affiliation(s)
- Kaiyun Yang
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr Manhasset, Hempstead, NY, 11030, USA
- Community Neurosciences Institute, Community Health Partners, Fresno, CA, USA
| | - Sabrina L Begley
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr Manhasset, Hempstead, NY, 11030, USA
| | - Daniel Lynch
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr Manhasset, Hempstead, NY, 11030, USA
| | - Justin Turpin
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr Manhasset, Hempstead, NY, 11030, USA
| | - Minoo Aminnejad
- Department of Surgery, Department of Health, Evidence, Impact, McMaster University, Hamilton, ON, Canada
| | - Forough Farrokhyar
- Department of Surgery, Department of Health, Evidence, Impact, McMaster University, Hamilton, ON, Canada
| | - Amir R Dehdashti
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr Manhasset, Hempstead, NY, 11030, USA.
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Samuelsson J, Rentzos A, Rawshani A, Karlsson A, Ståleby M, Nilsson D. Risk of de novo aneurysm formation in patients previously diagnosed with a ruptured or unruptured aneurysm: 18-year follow-up. Clin Neurol Neurosurg 2023; 233:107980. [PMID: 37717358 DOI: 10.1016/j.clineuro.2023.107980] [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: 05/25/2023] [Revised: 09/11/2023] [Accepted: 09/12/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Data on de novo aneurysm formation after treatment for intracranial aneurysms remains scarce. We studied the incidence of de novo aneurysm formation in patients who had undergone aneurysm treatment more than 18 years prior to follow-up. As it is a disease affecting a younger patient population more specific guidelines are needed when planning a follow-up regime. METHODS The rate of de novo aneurysm formation was assessed with Magnetic Resonance Angiography (MRA) follow-up >18 years after endovascular or microsurgical treatment for an intracranial aneurysm. Variables associated with de novo aneurysm formation were studied using logistic regression. Missing data were imputed using chained random forests. A data-driven model for the prediction of de novo aneurysm was created to calculate the relative variable importance of ten clinical features. RESULTS De novo aneurysms were identified in 11/81 (13.6 %) patients, of whom 1 was male, over a median follow-up of 20 years. Sex was the most important variable associated with de novo aneurysm formation. Regarding the development of de novo aneurysm, men displayed an odds ratio (OR) of 0.16 (0.01-0.97), compared with women. OR for mRS score 2 or more was 0.20 (95 % CI 0.01-1.34), and OR for smokers was 3.70 (0.54-31.18). Six out of 11 patients (54.5 %) needed treatment; 1 underwent endovascular treatment (EVT) and 5 underwent microsurgical treatment (MST). The overall annual de novo aneurysm formation rate was 0.92 %. CONCLUSIONS This study highlights the need for a longer follow-up imaging monitoring of patients that have previously undergone treatment for an intracranial aneurysm. These data are useful to take into consideration when planning a follow-up strategy.
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Affiliation(s)
- Jennifer Samuelsson
- Department of Clinical Neuroscience, Institute of Neurosciences and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Alexandros Rentzos
- Department of Radiology, Section of diagnostic and interventional neuroradiology, Sahlgrenska University Hospital, Region Vastra Gotaland, Gothenburg, Sweden; Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Araz Rawshani
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Adrian Karlsson
- Department of Radiology, Section of diagnostic and interventional neuroradiology, Sahlgrenska University Hospital, Region Vastra Gotaland, Gothenburg, Sweden; Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Marcus Ståleby
- Department of Radiology, Section of diagnostic and interventional neuroradiology, Sahlgrenska University Hospital, Region Vastra Gotaland, Gothenburg, Sweden; Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Daniel Nilsson
- Department of Clinical Neuroscience, Institute of Neurosciences and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
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Marbacher S, Andereggen L, Schubert GA, Grüter BE. Is there any risk for recurrence of a completely clipped intracranial aneurysm? Neurosurg Rev 2023; 46:242. [PMID: 37700146 DOI: 10.1007/s10143-023-02147-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 08/29/2023] [Accepted: 09/02/2023] [Indexed: 09/14/2023]
Affiliation(s)
- Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau, University of Bern, Aarau, Switzerland.
| | - Lukas Andereggen
- Department of Neurosurgery, Kantonsspital Aarau, University of Bern, Aarau, Switzerland
| | - Gerrit A Schubert
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Basil E Grüter
- Department of Neurosurgery, Kantonsspital Aarau, University of Bern, Aarau, Switzerland
- Division of Neuroradiology, Department of Radiology, Kantonsspital Aarau, Aarau, Switzerland
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Hoh BL, Ko NU, Amin-Hanjani S, Chou SHY, Cruz-Flores S, Dangayach NS, Derdeyn CP, Du R, Hänggi D, Hetts SW, Ifejika NL, Johnson R, Keigher KM, Leslie-Mazwi TM, Lucke-Wold B, Rabinstein AA, Robicsek SA, Stapleton CJ, Suarez JI, Tjoumakaris SI, Welch BG. 2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2023; 54:e314-e370. [PMID: 37212182 DOI: 10.1161/str.0000000000000436] [Citation(s) in RCA: 65] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
AIM The "2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage" replaces the 2012 "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage." The 2023 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with aneurysmal subarachnoid hemorrhage. METHODS A comprehensive search for literature published since the 2012 guideline, derived from research principally involving human subjects, published in English, and indexed in MEDLINE, PubMed, Cochrane Library, and other selected databases relevant to this guideline, was conducted between March 2022 and June 2022. In addition, the guideline writing group reviewed documents on related subject matter previously published by the American Heart Association. Newer studies published between July 2022 and November 2022 that affected recommendation content, Class of Recommendation, or Level of Evidence were included if appropriate. Structure: Aneurysmal subarachnoid hemorrhage is a significant global public health threat and a severely morbid and often deadly condition. The 2023 aneurysmal subarachnoid hemorrhage guideline provides recommendations based on current evidence for the treatment of these patients. The recommendations present an evidence-based approach to preventing, diagnosing, and managing patients with aneurysmal subarachnoid hemorrhage, with the intent to improve quality of care and align with patients' and their families' and caregivers' interests. Many recommendations from the previous aneurysmal subarachnoid hemorrhage guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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7
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Marbacher S, Grüter BE, Wanderer S, Andereggen L, Cattaneo M, Trost P, Gruber P, Diepers M, Remonda L, Steiger HJ. Risk of intracranial aneurysm recurrence after microsurgical clipping based on 3D digital subtraction angiography. J Neurosurg 2023; 138:717-723. [PMID: 35907194 DOI: 10.3171/2022.5.jns22424] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 05/16/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Current knowledge of recurrence rates after intracranial aneurysm (IA) surgery relies on 2D digital subtraction angiography (DSA), which fails to detect more than 75% of small aneurysm remnants. Accordingly, the discrimination between recurrence and growth of a remnant remains challenging, and actual assessment of recurrence risk of clipped IAs could be inaccurate. The authors report, for the first time, 3D-DSA-based long-term durability and risk factor data of IA recurrence and remnant growth after microsurgical clipping. METHODS Prospectively collected data for 305 patients, with a total of 329 clipped IAs that underwent baseline 3D-DSA, were evaluated. The incidence of recurrent IA was described by Kaplan-Meier curves. Risk factors for IA recurrence were analyzed by multivariable Cox proportional hazards and logistic regression models. RESULTS The overall observed proportion of IA recurrence after clipping was 2.7% (9 of 329 IAs) at a mean follow-up of 46 months (0.7% per year). While completely obliterated IAs did not recur during follow-up, incompletely clipped aneurysms (76 of 329) demonstrated remnant growth in 11.8% (3.4% per year). Young age and large initial IA size significantly increased the risk of IA recurrence. CONCLUSIONS The findings support those in previous studies that hypothesized that completely clipped IAs have an extremely low risk of recurrence. Conversely, the results highlight the significant risk posed by incompletely clipped IAs. Young patients with initial large IAs and incomplete obliteration have an especially high risk for IA recurrence and therefore should be monitored more closely.
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Affiliation(s)
- Serge Marbacher
- 1Department of Neurosurgery, Kantonsspital Aarau, University of Bern
| | - Basil Erwin Grüter
- 1Department of Neurosurgery, Kantonsspital Aarau, University of Bern.,2Division of Neurosurgery, Kantonsspital Aarau, University of Bern, and
| | - Stefan Wanderer
- 1Department of Neurosurgery, Kantonsspital Aarau, University of Bern
| | - Lukas Andereggen
- 1Department of Neurosurgery, Kantonsspital Aarau, University of Bern
| | - Marco Cattaneo
- 3Clinical Trial Unit, Department of Clinical Research, University of Basel, University Hospital Basel, Switzerland
| | - Patricia Trost
- 1Department of Neurosurgery, Kantonsspital Aarau, University of Bern
| | - Philipp Gruber
- 2Division of Neurosurgery, Kantonsspital Aarau, University of Bern, and
| | - Michael Diepers
- 2Division of Neurosurgery, Kantonsspital Aarau, University of Bern, and
| | - Luca Remonda
- 2Division of Neurosurgery, Kantonsspital Aarau, University of Bern, and
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8
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Abramyan AA, Pilipenko YV, Belousova OB, Shmelev ND, Eliava SS. [Microsurgical and endovascular treatment of residual and recurrent cerebral aneurysms]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2023; 87:107-115. [PMID: 37650283 DOI: 10.17116/neiro202387041107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Cerebral aneurysms are characterized by high risk of adverse outcome due to severe intracranial hemorrhages and their consequences. Aneurysm remnants after incomplete exclusion can cause hemorrhage. Filling of these fragments immediately after surgery is usually defined as residual aneurysms. Recurrent aneurysms develop in the area of excluded aneurysm in long-term period after surgery. The authors analyze foreign and national literature data on the diagnosis and management of residual and recurrent aneurysms. Risk factors, the most common classifications, diagnostic methods and surgical treatment are presented.
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Affiliation(s)
| | | | | | - N D Shmelev
- Burdenko Neurosurgical Center, Moscow, Russia
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Han HJ, Lee W, Kim J, Park KY, Park SK, Chung J, Kim YB. Incidence rate and predictors of recurrent aneurysms after clipping: long-term follow-up study of survivors of subarachnoid hemorrhage. Neurosurg Rev 2022; 45:3209-3217. [PMID: 35739336 DOI: 10.1007/s10143-022-01828-x] [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: 03/11/2022] [Revised: 06/08/2022] [Accepted: 06/16/2022] [Indexed: 10/17/2022]
Abstract
Recurrent aneurysms are a major cause of re-aneurysmal subarachnoid hemorrhage (aSAH), but information on long-term clip durability and predictors is insufficient. This study aimed to present the incidence rate of > 10 years and investigate predictors of a recurrent aneurysm in aSAH survivors. We included 1601 patients admitted with aSAH and treated by microsurgical clipping between January 1993 and May 2010. Of these patients, 435 aSAH survivors were included in this study (27.2%). The total follow-up time was 5680.9 patient-years, and the overall incidence rate was 0.77% per patient-year. The cumulative probability of recurrence without residua and regrowth of the neck remnant was 0.7% and 13.9% at 10 years, respectively. Neck remnant (hazard ratio [HR], 10.311; 95% confidence interval [CI], 5.233-20.313) and alcohol consumption over the moderate amount (HR, 3.166; 95% CI, 1.313-7.637) were independent risk factors of recurrent aneurysm. Current smoking and multiplicity at initial aSAH presentation were significant factors in a univariate analysis. Furthermore, de novo intracranial aneurysms (DNIAs) were more common in the recurrent group than in the non-recurrent group (40.9% vs. 11.5%, P < 0.001). In the present study, we noted the long-term clip durability and predictor of recurrence after microsurgical clipping. These findings can assist clinicians in identifying patients at a high risk of recurrent aneurysm and recommending selective long-term surveillance after microsurgical clipping.
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Affiliation(s)
- Hyun Jin Han
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Woosung Lee
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Junhyung Kim
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Keun Young Park
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Sang Kyu Park
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joonho Chung
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong Bae Kim
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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10
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Schartz D, Mattingly TK, Rahmani R, Ellens N, Akkipeddi SMK, Bhalla T, Bender MT. Noncurative microsurgery for cerebral aneurysms: a systematic review and meta-analysis of wrapping, residual, and recurrence rates. J Neurosurg 2022; 137:129-139. [PMID: 34798602 DOI: 10.3171/2021.9.jns211698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 09/03/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Microsurgery for cerebral aneurysms is called definitive, yet some patients undergo a craniotomy that results in noncurative treatment. Furthermore, the overall rate of noncurative microsurgery for cerebral aneurysms is unclear. The objective of this study was to complete a systematic review and meta-analysis to quantify three scenarios of noncurative treatment: aneurysm wrapping, postclipping remnants, and late regrowth of completely obliterated aneurysms. METHODS A PRISMA-guided systematic literature review of the MEDLINE and Cochrane Library databases and meta-analysis was completed. Studies were included that detailed rates of aneurysm wrapping, residua confirmed with imaging, and regrowth after confirmed total occlusion. Pooled rates were subsequently calculated using a random-effects model. An assessment of statistical heterogeneity and publication bias among the included studies was also completed for each analysis, with resultant I2 values and p values determined with Egger's test. RESULTS Sixty-four studies met the inclusion criteria for final analysis. In 41 studies, 573/15,715 aneurysms were wrapped, for a rate of 3.5% (95% CI 2.7%-4.2%, I2 = 88%). In 43 studies, 906/13,902 aneurysms had residual neck or dome filling, for a rate of 6.4% (95% CI 5.2%-7.6%, I2 = 93%). In 15 studies, 71/2568 originally fully occluded aneurysms showed regrowth, for a rate of 2.1% (95% CI 1.2%-3.1%, I2 = 58%). Together, there was a total rate of noncurative surgery of 12.0% (95% CI 11.5%-12.5%). Egger's test suggested no significant publication bias among the studies. Meta-regression analysis revealed that the reported rate of aneurysm wrapping has significantly declined over time, whereas the rates of aneurysm residua and recurrence have not significantly changed. CONCLUSIONS Open microsurgery for cerebral aneurysm results in noncurative treatment approximately 12% of the time. This metric may be used to counsel patients and as a benchmark for other treatment modalities. This investigation is limited by the high degree of heterogeneity among the included studies.
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Affiliation(s)
- Derrek Schartz
- 1Department of Imaging Sciences, University of Rochester Medical Center, Rochester, New York; and
- 2Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York
| | - Thomas K Mattingly
- 2Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York
| | - Redi Rahmani
- 2Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York
| | - Nathaniel Ellens
- 2Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York
| | | | - Tarun Bhalla
- 2Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York
| | - Matthew T Bender
- 2Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York
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11
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Halter M, Wanderer S, Grüter B, Anon J, Diepers M, Gruber P, Andereggen L, Remonda L, Marbacher S. Interrater and intrarater agreement superior for three-dimensional digital subtraction angiography (3D-DSA) over 2D-DSA classification for detecting remnants after intracranial aneurysm clipping, a GRRAS Reliability and Agreement Study. Acta Neurochir (Wien) 2022; 164:2173-2179. [PMID: 35239014 DOI: 10.1007/s00701-022-05156-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 02/07/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Growing evidence suggests that three-dimensional digital subtraction angiography (3D-DSA) is superior to 2D-DSA in detection of intracranial aneurysm (IA) remnants after clipping. With a simple, practical quantitative scale proposed to measure maximal remnant dimension on 3D-DSA, this study provides a rigorous interrater and intrarater reliability and agreement study comparing this newly established scale with a commonly used (Sindou) 2D-DSA scale. METHOD Records of 43 patients with clipped IAs harboring various sized remnants who underwent 2D- and 3D-DSA between 2012 and 2018 were evaluated. Using the 2D and 3D scales, six raters scored these remnants and repeated the scoring task 8 weeks later. Interrater and intrarater agreement for both grading schemes were calculated using kappa (κ) statistics. RESULTS Interrater agreement was highly significant, yielding κ-values at 95% CI (p = 0.000) of 0.225 for the first [0.185; 0.265] and 0.368 s [0.328; 0.408] time points for 2D-DSA and values of 0.700 for the first [0.654; 0.745] and 0.776 s [0.729; 0.822] time points for 3D-DSA. Intrarater agreement demonstrated κ-values between 0.139 and 0.512 for 2D-DSA and between 0.487 and 0.813 for 3D-DSA scores. CONCLUSION Interrater and intrarater agreement was minimal or weak for 2D-DSA scores, but strong for 3D-DSA scores. We propose that baseline 3D-DSA characterization may prove more reliable when categorizing clipped IA remnants for purposes of risk stratification and lifelong follow-up.
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12
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Pathogenic Factors and Prognosis of De Novo Aneurysms vAfter Aneurysm Clipping. J Craniofac Surg 2021; 33:1800-1805. [PMID: 34974461 DOI: 10.1097/scs.0000000000008451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 11/30/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To confirm this hypothesis, this study aimed to explore the pathogenic factors, prognosis, and their relationship in de novo aneurysms and to reach a consensus on their management. METHODS First, the clinical data of 5 patients with de novo aneurysms from April 1998 to October 2021 were analyzed retrospectively. Then, the English literature on de novo aneurysms reported in Pubmed from 1985 to 2021 was systematically reviewed, and 18 case reports from 17 articles and 16 case series were identified. Univariate and multivariate analyses and modified Fisher test were used to analyze the relationship between pathogenic factors and prognosis. RESULTS Hypertension was noted in 60% of our clinical cases, 50% of the case series identified in the literature review, and 66.7% of the case reports in the literature review. In the case reports identified from our literature review, the proportion of original aneurysms in the anterior circulation was 96.3%. Moreover, in our 5 cases, all original aneurysms occurred in the anterior circulation. The rupture rate of original aneurysms in our 5 cases was 100%, and that of the cases reported in the literature review was 88.9%. Univariate logistic analysis showed that the time interval was related to the prognosis of de novo aneurysms with a P value of 0.048 and an odds ratio of 0.968 (95% confidence interval 0.938-1.000). Modified Fisher exact tests showed that patient age at the occurrence of de novo aneurysm P = 0.029) was related to the prognosis of de novo aneurysms. CONCLUSIONS Hypertension, an original aneurysms located in the anterior circulation and rupture represent the pathogenic factors associated with de novo aneurysms. The time interval to de novo aneurysm and patient age at the occurrence of de novo aneurysm are predictive of prognosis. Based on the above information, we can prevent and improve the prognosis of de novo aneurysms.
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Han HJ, Lee W, Kim J, Park KY, Park SK, Chung J, Kim YB. Formation, Growth, or Rupture of De Novo Intracranial Aneurysms: Long-Term Follow-up Study of Subarachnoid Hemorrhage Survivors. Neurosurgery 2021; 89:1104-1111. [PMID: 34634821 DOI: 10.1093/neuros/nyab364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 08/06/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The survival rate of aneurysmal subarachnoid hemorrhage (aSAH) has gradually increased, leading to more clinical cases of de novo intracranial aneurysms (DNIAs). OBJECTIVE To identify the characteristics of patients with DNIA growth or rupture. METHODS We included 1601 patients with aSAH treated by clipping from January 1993 to May 2010. According to the inclusion and exclusion criteria, 233 patients had no DNIAs, and 63 patients had 77 DNIAs. We assessed the incidence rate of DNIAs and risk factors for DNIA formation. After dichotomizing the DNIA group into the heed (patients with DNIA rupture or growth) and stable groups (patients without DNIA growth), we assessed the risk factors for DNIA growth or rupture. RESULTS The total follow-up period was 4427.9 patient-years. The incidence rate per patient-year was 1.42%. Age ≤50 yr, family history of aneurysm, and multiplicity at initial aSAH were significant risk factors for DNIA formation. Multivariate regression analysis revealed that female sex (odds ratio [OR], 5.566; 95% confidence interval [CI], 1.241-24.952), duration from initial aSAH to DNIA detection <120 mo (OR, 5.043; 95% CI, 1.362-18.668), multiplicity at initial aSAH (OR, 4.859; 95% CI, 1.207-19.563), and maximum DNIA diameter ≥4 mm (OR, 11.104; 95% CI, 2.337-52.772) were significant risk factors for DNIA growth or rupture. CONCLUSION DNIAs had a higher incidence rate than expected. Taking into account the presented incidence rate and risk factors, long-term surveillance in aSAH survivors for more than a decade may be worth considering, at least on a case-by-case basis.
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Affiliation(s)
- Hyun Jin Han
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Woosung Lee
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Junhyung Kim
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Keun Young Park
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang Kyu Park
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joonho Chung
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong Bae Kim
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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Marbacher S, Halter M, Vogt DR, Kienzler JC, Magyar CTJ, Wanderer S, Anon J, Diepers M, Remonda L, Fandino J. Value of 3-Dimensional Digital Subtraction Angiography for Detection and Classification of Intracranial Aneurysm Remnants After Clipping. Oper Neurosurg (Hagerstown) 2021; 21:63-72. [PMID: 33861324 PMCID: PMC8279834 DOI: 10.1093/ons/opab087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/24/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The current gold standard for evaluation of the surgical result after intracranial aneurysm (IA) clipping is two-dimensional (2D) digital subtraction angiography (DSA). While there is growing evidence that postoperative 3D-DSA is superior to 2D-DSA, there is a lack of data on intraoperative comparison. OBJECTIVE To compare the diagnostic yield of detection of IA remnants in intra- and postoperative 3D-DSA, categorize the remnants based on 3D-DSA findings, and examine associations between missed 2D-DSA remnants and IA characteristics. METHODS We evaluated 232 clipped IAs that were examined with intraoperative or postoperative 3D-DSA. Variables analyzed included patient demographics, IA and remnant distinguishing characteristics, and 2D- and 3D-DSA findings. Maximal IA remnant size detected by 3D-DSA was measured using a 3-point scale of 2-mm increments. RESULTS Although 3D-DSA detected all clipped IA remnants, 2D-DSA missed 30.4% (7 of 23) and 38.9% (14 of 36) clipped IA remnants in intraoperative and postoperative imaging, respectively (95% CI: 30 [ 12, 49] %; P-value .023 and 39 [23, 55] %; P-value = <.001), and more often missed grade 1 (< 2 mm) clipped remnants (odds ratio [95% CI]: 4.3 [1.6, 12.7], P-value .005). CONCLUSION Compared with 2D-DSA, 3D-DSA achieves a better diagnostic yield in the evaluation of clipped IA. Our proposed method to grade 3D-DSA remnants proved to be simple and practical. Especially small IA remnants have a high risk to be missed in 2D-DSA. We advocate routine use of either intraoperative or postoperative 3D-DSA as a baseline for lifelong follow-up of clipped IA.
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Affiliation(s)
- Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Matthias Halter
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Deborah R Vogt
- Department of Clinical Research, Clinical Trial Unit, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Jenny C Kienzler
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | | | - Stefan Wanderer
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Javier Anon
- Division of Neuroradiology, Department of Radiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Michael Diepers
- Division of Neuroradiology, Department of Radiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Luca Remonda
- Division of Neuroradiology, Department of Radiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Javier Fandino
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
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Pflaeging M, Goertz L, Smyk MA, Turowski B, Mpotsaris A, Pennig L, Borggrefe J, Krischek B, Kabbasch C. Treatment of recurrent and residual aneurysms with the low-profile Acandis Acclino stent: Multi-center review of 19 patients. J Clin Neurosci 2021; 90:199-205. [PMID: 34275549 DOI: 10.1016/j.jocn.2021.05.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/18/2020] [Accepted: 05/23/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the safety and efficacy of the low-profile Acandis Acclino microstent for embolization of recurrent and residual intracranial aneurysms. METHODS Consecutive patients treated with the Acclino for aneurysm remnants at three German neurovascular centers were enrolled. The technical success, complications, angiographic and clinical outcome were investigated. RESULTS Nineteen patients (median age: 53 years) with 19 aneurysm remnants (median size: 5 mm, anterior circulation: 14) were included. Initial aneurysm treatment consisted of stand-alone coiling in 14 cases, stent-assisted coiling in 4 and clipping in 1. Acclino stent-assisted coil embolization was performed technically successfully in all patients. Morbidity occurred in one patient (5.3%) due to aneurysm perforation. At the angiographic follow-up with a median follow-up duration of 21 months (range: 5-37 months), complete occlusion was obtained in 76.9%. The retreatment rate was 7.7%. CONCLUSIONS Retreatment of aneurysm remnants with the Acclino microstent was associated with high aneurysm occlusion rates and acceptable morbidity. Further studies will be necessary to draw a definite conclusion.
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Affiliation(s)
- Muriel Pflaeging
- University of Cologne, Medical Faculty and University Hospital, Center for Neurosurgery, Kerpener Strasse 62, 50937 Cologne, Germany.
| | - Lukas Goertz
- University of Cologne, Medical Faculty and University Hospital, Center for Neurosurgery, Kerpener Strasse 62, 50937 Cologne, Germany; Department of Neuroradiology, University Hospital of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany.
| | - Michael Artur Smyk
- Department of Neuroradiology, University Hospital of Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany.
| | - Bernd Turowski
- Department of Neuroradiology, University Hospital of Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany.
| | - Anastasios Mpotsaris
- Department of Neuroradiology, University Hospital of Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany.
| | - Lenhard Pennig
- Department of Neuroradiology, University Hospital of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany.
| | - Jan Borggrefe
- Department of Neuroradiology, University Hospital of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany.
| | - Boris Krischek
- University of Cologne, Medical Faculty and University Hospital, Center for Neurosurgery, Kerpener Strasse 62, 50937 Cologne, Germany; Department of Neurosurgery, Hôpitaux Robert Schuman, 9 Rue Edward Steichen, 2540 Luxembourg, Luxembourg.
| | - Christoph Kabbasch
- Department of Neuroradiology, University Hospital of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany.
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Lee HJ, Choi JH, Shin YS, Lee KS, Kim BS. Risk Factors for the Recurrence of Posterior Communicating Artery Aneurysm: The Significance of Fetal-Type Posterior Cerebral artery. J Stroke Cerebrovasc Dis 2021; 30:105821. [PMID: 33915389 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105821] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 03/27/2021] [Accepted: 04/04/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES The purpose of this study was to investigate the risk factors associated with recurrence of posterior communicating artery aneurysms after treatment and to evaluate the significance of fetal-type posterior cerebral artery as an independent risk factor for recurrence of posterior communicating artery aneurysms. MATERIALS AND METHODS The clinical and radiological findings of 220 posterior communicating artery aneurysms treated between January 2009 and December 2016 in a single tertiary institute were retrospectively reviewed. Univariate and multivariate analyses were performed to evaluate the association between clinical and radiological variables and recurrence. RESULTS Of 220 posterior communicating artery aneurysms, 148 aneurysms were unruptured and 82 aneurysms were treated with surgery. Forty-six out of 220 aneurysms (20.9%) were associated with fetal-type posterior cerebral artery. Overall recurrence rate was 19% (42 out of 220 aneurysms) during mean 54.6 ± 29.8 months follow-up. Multivariate logistic regression analysis showed that size (OR=1.238; 95% CI, 1.087-1.409, p = 0.001), ruptured status (OR=2.699; 95% CI, 1.179-6.117, p = 0.019), endovascular treatment (OR=3.803; 95% CI, 1.330-10.875, p = 0.013), incomplete occlusion (OR=4.699; 95% CI, 1.999-11.048, p = <0.001) and fetal-type posterior cerebral artery (OR=3.533; 95% CI, 1.373-9.089, p = 0.009) were significantly associated with recurrence after treatment. CONCLUSIONS The results demonstrated that fetal-type posterior cerebral artery may be an independent risk factor for the recurrence of posterior communicating artery aneurysms. Therefore, fetal-type posterior cerebral artery can be considered as an important risk factor for the recurrence of posterior communicating artery aneurysms, along with other known risk factors such as size, ruptured status, endovascular treatment, and incomplete occlusion.
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Affiliation(s)
- Hyeong Jin Lee
- Department of Neurosurgery, Chuncheon Army Hospital, Chuncheon, Gangwon, South Korea.
| | - Jai Ho Choi
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, South Korea.
| | - Yong Sam Shin
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, South Korea.
| | - Kwan Sung Lee
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, South Korea.
| | - Bum Soo Kim
- Department of Radiology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, South Korea.
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You W, Feng J, Liu Q, Liu X, Lv J, Jiang Y, Liu P, Li Y. Case Report: De novo Vertebral Artery Dissection After Intravascular Stenting of the Contralateral Unruptured Vertebral Artery Aneurysm. Front Neurol 2021; 12:599197. [PMID: 33967933 PMCID: PMC8102744 DOI: 10.3389/fneur.2021.599197] [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: 08/26/2020] [Accepted: 03/15/2021] [Indexed: 12/03/2022] Open
Abstract
Spontaneous vertebral artery dissecting aneurysm has been increasingly attributed as a major cause of focal neurological deficits due to vertebrobasilar artery ischemia or subarachnoid hemorrhage (SAH). Although the development of spontaneous vertebral artery dissecting aneurysm (VADA) is rare, de novo VADA after treatment of contralateral vertebral artery (VA) is more less frequently observed. There are only a few reports related to de novo VADA after treatment of the contralateral VA in the medical literature. The mechanisms responsible for de novo dissection after treatment of unilateral VADA are still not clearly understood. In this manuscript, we report an unusual case of a patient with a de novo VADA after placement of a pipeline embolization device (PED) stent on the contralateral VA along with a thorough review of the literature. A 42-years old male patient was referred to the hospital with sudden onset of dizziness, nausea, and vomiting. Initial digital subtraction angiography (DSA) images demonstrated a VADA in the fourth segment of the left VA without the involvement of the posterior inferior cerebellar artery (PICA). There were no significant abnormalities found in the right vertebral artery. He underwent an endovascular pipeline embolization to treat the dissecting aneurysm (DA). Surprisingly, follow-up DSA imaging 14 months after the initial treatment showed a segmental dilatation and narrowing of the right VA, which suggested a de novo VADA on the right side that had occurred postoperatively. This was followed by a tent-assisted coil embolization therapy for occluding this de novo VADA. This patient showed an uneventful postoperative course with no neurological abnormalities. In addition to hemodynamic stress changes, the unique clinicopathological features of dissecting aneurysms may contribute significantly to the pathogenesis of de novo VA dissection. Given that VA in VADA patients may be vulnerable on both sides, it is important to consider the risk of de novo dissection after initial aneurysm treatment. The bilateral vertebral artery has to be carefully observed when treating any VADA patient to prevent any complications.
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Affiliation(s)
- Wei You
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Junqiang Feng
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Qinglin Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Xinke Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Jian Lv
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Yuhua Jiang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Peng Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
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Piao J, Luan T, Qu L, Yu J. Intracranial post-clipping residual or recurrent aneurysms: Current status and treatment options (Review). MEDICINE INTERNATIONAL 2021; 1:1. [PMID: 36698683 PMCID: PMC9855273 DOI: 10.3892/mi.2021.1] [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: 02/14/2021] [Accepted: 04/08/2021] [Indexed: 01/28/2023]
Abstract
Following the clipping of intracranial aneurysms, post-clipping residual or recurrent aneurysms (PCRRAs) can occur. In recent years, the incidence of PCRRAs has increased due to a prolonged follow-up period and advanced imaging techniques. However, several aspects of intracranial PCRRAs remain unclear. Therefore, the present study performed an in-depth review of the literature on PCRRAs. Herein, a summary of PCRRAs that can be divided into the following two categories is presented: i) Those occurring after the incomplete clipping of an aneurysm, where the residual aneurysm regrows into a PCRRA; and ii) those occurring after the complete clipping of an aneurysm, in which a de novo aneurysm occurs at the original aneurysm site. Currently, digital subtracted angiography remains the gold standard for the imaging diagnosis of PCRRAs as it can eliminate metallic clip artifacts. Intracranial symptomatic PCRRAs should be actively treated, particularly those that have ruptured. A number of methods are currently available for the treatment of intracranial PCRRAs; these mainly include re-clipping, endovascular treatment (EVT) and bypass surgery. Currently, re-clipping remains the most effective method used to treat PCRRAs; however, it is a very difficult procedure to perform. EVT can also be used to treat intracranial PCRRAs. EVT methods include coiling (stent- or balloon-assisted) and flow-diverting stents (or coiling-assisted). Bypass surgery can be selected for difficult-to-treat, complex PCRRAs. On the whole, following appropriate treatment, the majority of intracranial PCRRAs achieve a high occlusion rate and a good prognosis.
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Affiliation(s)
- Jianmin Piao
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Tengfei Luan
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Lai Qu
- Department of Intensive Care, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China,Correspondence to: Dr Jinlu Yu, Department of Neurosurgery, The First Hospital of Jilin University, 1 Xinmin Avenue, Changchun, Jilin 130021, P.R. China
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Angiographic results of surgical or endovascular treatment of intracranial aneurysms: a systematic review and inter-observer reliability study. Neuroradiology 2021; 63:1511-1519. [PMID: 33625550 DOI: 10.1007/s00234-021-02676-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/15/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE Results of surgical or endovascular treatment of intracranial aneurysms are often assessed using angiography. A reliable method to report results irrespective of treatment modality is needed to enable comparisons. Our goals were to systematically review existing classification systems, and to propose a 3-point classification applicable to both treatments and assess its reliability. METHODS We conducted two systematic reviews on classification systems of angiographic results after clipping or coiling to select a simple 3-category scale that could apply to both treatments. We then circulated an electronic portfolio of angiograms of clipped (n=30) or coiled (n=30) aneurysms, and asked raters to evaluate the degree of occlusion using this scale. Raters were also asked to choose an appropriate follow-up management for each patient based on the degree of occlusion. Agreement was assessed using Krippendorff's α statistics (αK), and relationship between occlusion grade and clinical management was analyzed using Fisher's exact and Cramer's V tests. RESULTS The systematic reviews found 70 different grading scales with heterogeneous reliability (kappa values from 0.12 to 1.00). The 60-patient portfolio was independently evaluated by 19 raters of diverse backgrounds (neurosurgery, radiology, and neurology) and experience. There was substantial agreement (αK=0.76, 95%CI, 0.67-0.83) between raters, regardless of background, experience, or treatment used. Intra-rater agreement ranged from moderate to almost perfect. A strong relationship was found between angiographic grades and management decisions (Cramer's V: 0.80±0.12). CONCLUSION A simple 3-point scale demonstrated sufficient reliability to be used in reporting aneurysm treatments or in evaluating treatment results in comparative randomized trials.
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Tamimi AF, Al Ryalat NT, Juweid ME, Doudeen RM, Al-Soub Q, Kanaan TM, Tamimi IA. Rupture of De Novo Middle Cerebral Artery Aneurysm 8 Years After the Clipping of Ruptured M1 Middle Cerebral Artery Aneurysm. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e929194. [PMID: 33551447 PMCID: PMC7883815 DOI: 10.12659/ajcr.929194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/27/2020] [Accepted: 12/05/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Development and rupture of a de novo intracranial aneurysm is rare. Little is known regarding its etiology and the appropriate timing of follow-up angiograms after surgical clipping or coiling. CASE REPORT We present a case report of a 39-year-old male smoker with history of hypertension who developed a de novo aneurysm 8 years after surgical clipping of an aneurysm in the middle cerebral artery in the same segment. He presented with neck rigidity and drowsiness. Laboratory analysis did not show blood dyscrasia. Brain computerized tomography showed right temporal lobe hematoma and 4-vessel angiogram demonstrated de novo aneurysm in the same segment of the M1 middle cerebral artery, which was confirmed by intraoperative microsurgical findings. We review the literature on such cases and discuss the pathophysiology, diagnosis, and treatment of this condition. De novo aneurysm, although rare, can develop within days to as long as 10 years after surgical clipping or coiling. CONCLUSIONS This rare case of de novo aneurysm supports follow-up imaging of patients after initial surgical clipping for up to 10 years.
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Affiliation(s)
- Ahmad F. Tamimi
- Department of Neurosurgery, Faculty of Medicine, University of Jordan, Amman, Jordan
| | - Nosaiba T. Al Ryalat
- Department of Radiology and Nuclear Medicine, Faculty of Medicine, University of Jordan, Amman, Jordan
| | - Malik E. Juweid
- Department of Radiology and Nuclear Medicine, Faculty of Medicine, University of Jordan, Amman, Jordan
| | - Rahmah M. Doudeen
- Department of Radiology and Nuclear Medicine, Faculty of Medicine, University of Jordan, Amman, Jordan
| | - Qutada Al-Soub
- Department of Neurosurgery, Faculty of Medicine, University of Jordan, Amman, Jordan
| | - Tareq M.A. Kanaan
- Department of Neurosurgery, Faculty of Medicine, University of Jordan, Amman, Jordan
| | - Iskandar A. Tamimi
- Department of Orthopedic Surgery, Malaga University Hospital Carlos Haya, Malaga, Spain
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21
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Gokbel A, Secer M, Polat O. Assessment of risk factors in de novo aneurysm development. Brain Circ 2020; 6:208-210. [PMID: 33210047 PMCID: PMC7646385 DOI: 10.4103/bc.bc_2_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 05/22/2020] [Accepted: 07/08/2020] [Indexed: 11/19/2022] Open
Abstract
Aneurysms that occur anywhere in intracranial except where primary aneurysms develop, are called “de novo aneurysms”. The risk factors and formation time of de novo aneurysms are not fully known. Congenital, environmental and hemodynamic factors can play a role in aneurysm development. The 43-year-old female patient was operated with the middle cerebral artery superior trunk aneurysm in our clinic. She came to us again after 17 months with a severe headache. In computed cranial tomography angiography, the middle cerebral artery superior trunk placement aneurysm was found to have a partial clip and “de novo aneurysm” was developed. She was re-operated for “de novo aneurysm”. In this study, the risk factors in development of “de novo aneurysms” were discussed in the light of literature through this patient.
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Affiliation(s)
- Aykut Gokbel
- Department of Neurosurgery, Kocaeli Provincial Health Directorate Health Sciences University Derince Training and Research Hospital, Kocaeli, Turkey
| | - Mehmet Secer
- Department of Neurosurgery, Kocaeli Provincial Health Directorate Health Sciences University Derince Training and Research Hospital, Kocaeli, Turkey
| | - Omer Polat
- Department of Neurosurgery, Duzce University Faculty of Medicine Hospital, Duzce, Turkey
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22
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Cho HW, Jang D, Jun HS. Rescue endovascular treatment for rapid regrowth of aneurysm remnant on middle cerebral artery trunk after unsuccessful surgical clipping in patients with a ruptured cerebral aneurysm: A report of two cases. J Cerebrovasc Endovasc Neurosurg 2020; 23:117-122. [PMID: 33017879 PMCID: PMC8256017 DOI: 10.7461/jcen.2020.e2020.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 09/14/2020] [Indexed: 11/23/2022] Open
Abstract
We report two rare cases treated with coiling after rapid regrowth (within a month) of an aneurysm remnant on the middle cerebral artery (MCA) trunk after incomplete surgical clipping. The first case, a 47-year-old man with subarachonoid hemorrhage (SAH) (Hunt-Hess grade II, Fisher grade III) underwent clipping of a ruptured saccular aneurysm with a wide neck on the right early frontal branch arising from the MCA trunk. Incomplete clipping with a 1 mm sized remnant neck was performed to avoid sacrificing the lenticulostriate artery. In a follow-up cerebral angiogram on postoperative day 30, a rapid regrowth of the aneurysm remnant was observed, and on that day, complete obliteration was obtained by rescue endovascular treatment. The second case, a 48-year-old healthy woman with SAH (Hunt-Hess grade II, Fisher grade III) underwent clipping of an anteroposteriorly projecting bilobulated aneurysm on the left M1. Incomplete clipping with a minimal remnant neck was performed. In follow-up digital subtraction angiogram on postoperative day 30, a rapid regrowth of an aneurysm remnant involving only a part of the initial aneurysm near the neck was observed, and on that day, complete obliteration was obtained by rescue coiling. These patients were both discharged without any neurological deficits.
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Affiliation(s)
- Hyun Wook Cho
- Department of Neurosurgery, Kangwon National University Hospital, Chuncheon, Korea
| | - Donghwan Jang
- Department of Neurosurgery, Kangwon National University College of Medicine, Chuncheon, Korea
| | - Hyo Sub Jun
- Department of Neurosurgery, Kangwon National University Hospital, Chuncheon, Korea.,Department of Neurosurgery, Kangwon National University College of Medicine, Chuncheon, Korea
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Howard BM, Hu R, Barrow JW, Barrow DL. Comprehensive review of imaging of intracranial aneurysms and angiographically negative subarachnoid hemorrhage. Neurosurg Focus 2020; 47:E20. [PMID: 31786554 DOI: 10.3171/2019.9.focus19653] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 09/20/2019] [Indexed: 11/06/2022]
Abstract
Intracranial aneurysms confer the risk of subarachnoid hemorrhage (SAH), a potentially devastating condition, though most aneurysms will remain asymptomatic for the lifetime of the patient. Imaging is critical to all stages of patient care for those who harbor an unruptured intracranial aneurysm (UIA), including to establish the diagnosis, to determine therapeutic options, to undertake surveillance in patients who elect not to undergo treatment or whose aneurysm(s) portends such a low risk that treatment is not indicated, and to perform follow-up after treatment. Neuroimaging is equally as important in patients who suffer an SAH. DSA remains the reference standard for imaging of intracranial aneurysms due to its high spatial and temporal resolution. As noninvasive imaging technology, such as CTA and MRA, improves, the diagnostic accuracy of such tests continues to increasingly approximate that of DSA. In cases of angiographically negative SAH, imaging protocols are necessary not only for diagnosis but also to search for an initially occult vascular lesion, such as a thrombosed, ruptured aneurysm that might be detected in a delayed fashion. Given the crucial role of neuroimaging in all aspects of care for patients with UIAs and SAH, it is incumbent on those who care for these patients, including cerebrovascular neurosurgeons, interventional neurologists and neuroradiologists, and diagnostic radiologists and neurointensivists, to understand the role of imaging in this disease and how individual members of the multispecialty team use imaging to ensure best practices to deliver cutting-edge care to these often complex cases. This review expounds on the role of imaging in the management of UIAs and ruptured intracranial aneurysms and in the workup of angiographically negative subarachnoid hemorrhage.
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Affiliation(s)
- Brian M Howard
- 1Department of Neurosurgery, and.,2Department of Radiology and Imaging Sciences, Division of Interventional Neuroradiology, Emory University School of Medicine, Atlanta; and
| | - Ranliang Hu
- 2Department of Radiology and Imaging Sciences, Division of Interventional Neuroradiology, Emory University School of Medicine, Atlanta; and
| | - Jack W Barrow
- 3Mercer University School of Medicine, Savannah, Georgia
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Surgical clipping compared to endovascular coiling of ruptured coil able middle cerebral aneurysms: A single-center experience. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2020.100708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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25
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Rotim K, Raguž M, Rotim A, Splavski B, Kalousek V. LATE ANEURYSM RELAPSE AFTER MICROSURGICAL TREATMENT OF MIDDLE CEREBRAL ARTERY ANEURYSM: A CASE REPORT AND LITERATURE REVIEW OF TREATMENT OPTIONS. Acta Clin Croat 2020; 59:532-538. [PMID: 34177065 PMCID: PMC8212637 DOI: 10.20471/acc.2020.59.03.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Recurrence of intracranial aneurysm after initial microsurgical or endovascular treatment is uncommon. Although the exact etiology remains unknown, recurrent aneurysms may be observed in surgical patients with big and multiple aneurysms, arterial hypertension, non-atherosclerotic cerebrovascular arteriopathies, as well as in those with a familial history of the disease. Such recurrence can occur over a wide period ranging from several months to years after the initial aneurysm treatment. Still, the occurrence delayed by more than 20 years is rather unusual. Herein, we present a case of a 70-year-old female patient who developed late intracranial aneurysm relapse 30 years after successful microsurgical clipping of the middle cerebral artery aneurysm. We also provide a brief review of relevant literature, discussing the etiology and pathophysiology of aneurysm reappearance, as well as different treatment options available. In conclusion, one should always consider the possibility of intracranial aneurysm recurrence regardless of the mode and time of primary surgery. In such a case, a multidisciplinary management approach using flow diverting endovascular techniques is advised in selected patients.
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Affiliation(s)
| | - Marina Raguž
- 1Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia; 3University of Applied Health Sciences, Zagreb, Croatia; 4Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia; 5Josip Juraj Strossmayer University of Osijek, School of Dental Medicine and Health, Osijek, Croatia; 6Department of Radiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Ante Rotim
- 1Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia; 3University of Applied Health Sciences, Zagreb, Croatia; 4Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia; 5Josip Juraj Strossmayer University of Osijek, School of Dental Medicine and Health, Osijek, Croatia; 6Department of Radiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Bruno Splavski
- 1Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia; 3University of Applied Health Sciences, Zagreb, Croatia; 4Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia; 5Josip Juraj Strossmayer University of Osijek, School of Dental Medicine and Health, Osijek, Croatia; 6Department of Radiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Vladimir Kalousek
- 1Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia; 3University of Applied Health Sciences, Zagreb, Croatia; 4Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia; 5Josip Juraj Strossmayer University of Osijek, School of Dental Medicine and Health, Osijek, Croatia; 6Department of Radiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
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26
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Kanat A, Turgut M, de Divitiis O. Letter to the Editor Regarding the Manuscript of "The Longest Angiographic and Clinical Follow-Up of Microsurgically Treated Giant Intracranial Aneurysms: Experience with 70 Cases". World Neurosurg 2020; 140:462. [PMID: 32797978 DOI: 10.1016/j.wneu.2020.05.179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 05/19/2020] [Indexed: 12/19/2022]
Affiliation(s)
- Ayhan Kanat
- Department of Neurosurgery, Medical Faculty, Recep Tayyip Erdogan University, Rize, Turkey.
| | - Mehmet Turgut
- Department of Neurosurgery, Aydın Adnan Menderes University Faculty of Medicine, Efeler, Aydın, Turkey
| | - Oreste de Divitiis
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli "Federico II," Naples, Italy
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Yeon EK, Cho YD, Yoo DH, Lee SH, Kang HS, Cho WS, Kim JE, Han MH. De Novo Intracranial Aneurysms Detected on Imaging Follow-Up of Coiled Aneurysms in a Korean Population. Korean J Radiol 2020; 20:1390-1398. [PMID: 31464117 PMCID: PMC6715560 DOI: 10.3348/kjr.2018.0914] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 06/12/2019] [Indexed: 11/29/2022] Open
Abstract
Objective Coiled aneurysms are known to recanalize over time, making follow-up evaluations mandatory. Although de novo intracranial aneurysms (DNIAs) are occasionally detected during routine patient monitoring, such events have not been thoroughly investigated to date. Herein, we generated estimates of DNIA development during long-term observation of coiled cerebral aneurysms, focusing on incidence and the risk factors involved. Materials and Methods In total, 773 patients undergoing coil embolization of intracranial aneurysms between 2008 and 2010 were reviewed retrospectively. Their medical records and radiologic data accrued over the extended period (mean, 52.7 ± 29.7 months) were analyzed. For the detection of DNIA, follow-up magnetic resonance angiography and/or conventional angiography were used. The incidence of DNIAs and related risk factors were analyzed using Cox proportional hazards regression and Kaplan-Meier product-limit estimator. Results In 19 (2.5%) of the 773 patients with coiled aneurysms, DNIAs (0.56% per patient-year) developed during continued long-term monitoring (3395.3 patient-years). Of these, 9 DNIAs (47.4%) were detected within 60 months, with 10 (52.6%) emerging thereafter. The most common site involved was the posterior communicating artery (n = 6), followed by the middle cerebral artery (n = 5) and the basilar top (n = 4). Multivariate analysis indicated that younger age (< 50 years) (hazard ratio [HR] = 1.045; p = 0.010) and recanalization of coiled aneurysms (HR = 2.560; p = 0.047) were significant factors in DNIA formation, whereas female sex, smoking, and hypertension fell short of statistical significance. Cumulative survival rates without DNIA were significantly higher in older subjects (> 60 years; p < 0.001) and in the absence of post-coiling aneurysm recurrence (p = 0.006). Conclusion In most patients with coiled aneurysms, development of DNIAs during long-term monitoring is rare. However, younger patients (< 50 years) or patients with recurring aneurysms appear to be predisposed to DNIAs.
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Affiliation(s)
- Eung Koo Yeon
- Department of Radiology, KyungHee University Medical Center, KyungHee University College of Medicine, Seoul, Korea
| | - Young Dae Cho
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
| | - Dong Hyun Yoo
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Su Hwan Lee
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Hyun Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Won Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Moon Hee Han
- Department of Radiology, Veterans Health Service Medical Center, Seoul, Korea
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28
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Spiessberger A, Vogt DR, Fandino J, Marbacher S. Formation of intracranial de novo aneurysms and recurrence after neck clipping: a systematic review and meta-analysis. J Neurosurg 2020; 132:456-464. [PMID: 30797217 DOI: 10.3171/2018.10.jns181281] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 10/26/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Incidence rates of de novo aneurysm formation and recurrence after clip ligation remain controversial. In this meta-analysis, the authors provide data on pooled annual incidence rates and the association of patient characteristics with time to formation of de novo aneurysms and time to recurrence after clipping. METHODS A search of the literature up to June 15, 2016, on PubMed and a systematic review were performed. The association of age, aneurysm rupture status, aneurysm multiplicity, and anatomical location with time to recurrence or formation of de novo aneurysm was estimated using multivariable Cox proportional-hazards models. Kaplan-Meier estimates (event-free survival curves) are shown. Pooled annualized incidence rates of recurrent and de novo aneurysms were estimated using Poisson regression. Proportions of aneurysms and average follow-up times are displayed as bubble plots with LOESS smoothers weighted for study size. RESULTS Of the 7606 articles screened, 92 were included in the study. Case reports on 101 patients with recurrent aneurysms and 132 patients with de novo aneurysms were analyzed. Long-term follow-up studies on de novo aneurysm formation included 13,723 patients with 101,378 patient-years of follow-up; studies on aneurysm recurrence included 5922 patients with 31,055 patient-years of follow-up. Mean time to recurrence was 12.9 ± 6.6 years (mean ± standard deviation), and mean time to de novo formation was 9.3 ± 6.1 years. No association with sex, aneurysm location, and initial rupture could be shown. De novo aneurysms occurred later in patients with multiplicity of aneurysms at diagnosis (HR 0.63, p = 0.03) and in patients with increasing age (HR per 10 yrs 0.88, p = 0.06). Pooled annualized incidence rates were 0.35% for de novo aneurysms and 0.13% for recurrent aneurysms. CONCLUSIONS Despite low reported annual incidence rates, the cumulative risk of 9.6%-22% for aneurysm recurrence or de novo formation 20 years after clip ligation warrants lifelong follow-up. Screening at 5, 10, and 20 years would detect 30.8% (95% CI 23.3%-37.6%), 64.2% (95% CI 55.9%-70.9%), and 95.9% (95% CI 90.9%-97.9%) of de novo aneurysms. Screening for recurrent aneurysms at 10, 15, and 20 years would detect 36.6% (95% CI 26.5%-45.4%), 65.3% (95% CI 54.7%-73.5%), and 95.1% (95% CI 85.8%-96.6%) of lesions.
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Affiliation(s)
| | - Deborah R Vogt
- 2Clinical Trial Unit, Department of Clinical Research, University of Basel, University Hospital Basel, Switzerland
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29
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Booth TC, Parra-Farinas C, deSouza RM, Kandasamy N, Bhattacharya J, Rangi P, Downer J. Woven Endobridge (WEB) Device as a Retreatment Strategy After Unsuccessful Surgical Clipping. World Neurosurg 2020; 139:111-120. [PMID: 32179191 DOI: 10.1016/j.wneu.2020.02.101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 02/16/2020] [Accepted: 02/17/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Surgical clipping of intracranial aneurysms is typically robust and durable. However, residual aneurysmal components may be seen after clipping. Furthermore, there may be occasional aneurysmal recurrence. These factors are both clinically relevant because subarachnoid hemorrhage after clipping is a rare but important event. The rationale for any treatment is to substantially decrease the future risk of hemorrhage. Small series have shown coiling as a retreatment strategy after unsuccessful clipping, but none has explored the feasibility of Woven Endobridge (WEB) implantation. CASE DESCRIPTION We examined the feasibility of WEB implantation as second-line treatment for wide-necked residual aneurysms after unsuccessful clipping. We also recorded the safety and efficacy in this small series of 6 patients. To determine safety, we measured the modified Rankin Scale score before and after the procedure, and at 2 later time points (mean follow-up, 5 months and 15 months). To determine efficacy, we obtained radiographic aneurysm occlusion outcomes (including WEB Occlusion Scale) at these 2 time points. Four middle cerebral artery and 2 anterior communicating artery complex aneurysms were treated with WEB implantation, showing feasibility in 6/6 cases (100%). Follow-up at 15 months showed no change from preprocedural modified Rankin Scale score and there were no other complications. There was adequate occlusion in 5/6 cases (83%). CONCLUSIONS WEB implantation provided a feasible option in this challenging retreatment scenario. This is a small series and prospective data are required to make outcome inferences for this population. Nonetheless, we observed no complications and high adequate occlusion rates.
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Affiliation(s)
- Thomas C Booth
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, United Kingdom; Department of Neuroradiology, King's College Hospital NHS Foundation Trust, London, United Kingdom.
| | | | - Ruth-Mary deSouza
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Naga Kandasamy
- Department of Neuroradiology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Jo Bhattacharya
- Department of Neuroradiology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Prem Rangi
- Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Jonathan Downer
- Department of Neuroradiology, Western General Hospital, Edinburgh, United Kingdom
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30
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Kim JJ, Cho KC, Suh SH, Chung J, Jang CK, Joo JY, Kim YB. Evaluation of the angiographic outcomes after clipping of intracranial aneurysms: determination of predisposing factors for occurrence of aneurysm remnants. Neurol Res 2020; 42:354-360. [PMID: 32100635 DOI: 10.1080/01616412.2020.1732594] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objectives: Aneurysm remnants after microsurgical clipping have a risk of regrowth and rupture and have not been validated in the era of three-dimensional angiography. Therefore, this study aimed to evaluate the angiographic outcome using three-dimensional rotational images and determine the predictors for remnants after microsurgical clipping.Methods: Between January 2014 and May 2017, 139 aneurysms in 106 patients who were treated with microsurgical clipping, were eligible for this study. For the determination of aneurysm remnants after microsurgical clipping, the angiographic outcomes were evaluated using follow-up digital subtraction angiography within 7 days for unruptured aneurysms or within 2 weeks for ruptured aneurysms. According to the Sindou classification, the aneurysm remnants were dichotomized, and subgroup analysis was performed to identify the predictors of aneurysm remnants after clipping with various imaging parameters and clinical information.Results: The overall rate of aneurysm remnants was 29.5% (41/139), in which retreatments were needed in 6.5% (9/139). The neck size and maximum diameter of aneurysms were independent predisposing factors for the aneurysm remnants that need retreatment (OR: 2.30; p < 0.001; OR: 1.38; p < 0.001, respectively).Conclusions: This study demonstrated a low incidence of aneurysm remnants after microsurgical clipping which need to retreatment. However, selective postoperative angiography could provide us clear information of surgical result and evidence for long-term follow-up for some aneurysms with larger neck size (>5.7 mm) and maximum diameter (>7.1 mm).
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Affiliation(s)
- Jung-Jae Kim
- Department of Neurosurgery, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul, South Korea
| | - Kwang-Chun Cho
- Department of Neurosurgery, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, South Korea
| | - Sang Hyun Suh
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Joonho Chung
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Chang Ki Jang
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jin-Yang Joo
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Yong Bae Kim
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
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31
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Fingerlin TJ, Rychen J, Roethlisberger M, Taub E, Mariani L, Guzman R, Zumofen DW. Long-term aneurysm recurrence and de novo aneurysm formation after surgical treatment of unruptured intracranial aneurysms: a cohort study and systematic review. Neurol Res 2020; 42:338-345. [PMID: 32048571 DOI: 10.1080/01616412.2020.1726587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: There is a relative lack of literature on long-term aneurysm recurrence and de novo aneurysm formation following surgical treatment of unruptured intracranial aneurysms. This retrospective single-center cohort study, therefore, analyzes the incidence of aneurysm recurrence, and the incidence of de novo aneurysms formation in patients with at least 10yrs of radiological follow-up. The data are put into the context of a systematic review of the literature.Methods: Patients that underwent surgical treatment of an unruptured intracranial aneurysm at the Basel University Hospital were retrospectively identified. The rate of recurrent or de novo aneurysm formation was assessed for all patients with imaging follow-up ≥10yrs. A systematic review including studies with a mean follow-up period of ≥10yrs was then performed.Results: A total of 95 patients had undergone surgical treatment of an unruptured intracranial aneurysm between 1994 and 2008. Twenty-one patients (22.1%) had available imaging follow-up ≥10yrs (mean: 13.1yrs). In these patients, aneurysm recurrence and de novo aneurysm formation were equally found in 23.8% (n = 5; 1.8%/yr). There was no case of aneurysm rupture from a recurrent or a de novo aneurysm. The systematic literature review covered a combined cohort of 1778 patients over a mean follow-up period of 14.0yrs. In this cohort, the aneurysm recurrence rate was 16.4% (0.7%/yr), and the rate of de novo aneurysm formation was 6.2% (0.4%/yr).Discussion: Despite some discrepancy regarding the incidence, both cohorts show a non-negligible long-term risk of aneurysm recurrence and de novo aneurysm formation, which warrants life-long imaging follow-up.Abbreviations: SD: standard deviation; DSA: digital subtraction angiography; CTA: computed tomography angiography; MRA: magnetic resonance angiography; MCA: middle cerebral artery; ACA: anterior cerebral artery; ACommA: anterior communicating artery; ICA: internal carotid artery; ADPKD: autosomal dominant polycystic kidney disease; MeSH: Medical Subject Headings.
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Affiliation(s)
- Tamara J Fingerlin
- Department of Neurosurgery, Basel University Hospital, University of Basel, Basel, Switzerland
| | - Jonathan Rychen
- Department of Neurosurgery, Basel University Hospital, University of Basel, Basel, Switzerland
| | - Michel Roethlisberger
- Department of Neurosurgery, Basel University Hospital, University of Basel, Basel, Switzerland
| | - Ethan Taub
- Department of Neurosurgery, Basel University Hospital, University of Basel, Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, Basel University Hospital, University of Basel, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, Basel University Hospital, University of Basel, Basel, Switzerland
| | - Daniel W Zumofen
- Department of Neurosurgery, Basel University Hospital, University of Basel, Basel, Switzerland.,Division of Neurosurgery, Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
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32
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İnci S, Akbay A, Aslan T. The Longest Angiographic and Clinical Follow-Up of Microsurgically Treated Giant Intracranial Aneurysms: Experience with 70 Cases. World Neurosurg 2020; 134:e412-e421. [DOI: 10.1016/j.wneu.2019.10.085] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 10/13/2019] [Accepted: 10/14/2019] [Indexed: 02/07/2023]
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Indocyanine green fluorescence video angiography reduces vascular injury-related morbidity during micro-neurosurgical clipping of ruptured cerebral aneurysms: a retrospective observational study. Acta Neurochir (Wien) 2019; 161:2397-2401. [PMID: 31489531 PMCID: PMC6820610 DOI: 10.1007/s00701-019-04029-6] [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: 03/19/2019] [Accepted: 07/31/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Specific procedural complications in aneurysm surgery are broadly related to vascular territory compromise and brain/nerve retraction; vascular complications account for about half of this. Intraoperative indocyanine green video angiography (ICG-VA) provides real-time high spatial resolution imaging of the cerebrovascular architecture, allowing immediate quality assurance of aneurysm occlusion and vessel integrity. The aim of this study was to examine whether the routine use of ICG-VA reduced early procedural complications related to vascular compromise or injury during micro-neurosurgical clipping of ruptured cerebral aneurysms. METHODS Retrospective comparative observational study of 412 adult good-grade (WFNS 1 or 2) SAH patients who had undergone microsurgical clipping without (n = 200, 2001-2004) or with (n = 212, 2009-2015) ICG-VA in a high-volume neurosurgical centre. RESULTS The ICG-VA group had a significantly lower incidence of procedural vascular complications (7/212; 3.3%) compared with the non-ICG-VA group (19/200; 9.5%) (Fisher's exact test p = 0.0137). CONCLUSIONS ICG-VA is a straightforward, easy-to-use, intraoperative adjunct which significantly reduces avoidable 'technical error' related morbidity.
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34
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Froelich JJ, Cheung N, de Lange JA, Monkhorst J, Carr MW, DeLeacy R. Residuals, recurrences and re-treatment after endovascular repair of intracranial aneurysms: A retrospective methodological comparison. Interv Neuroradiol 2019; 26:45-54. [PMID: 31403834 DOI: 10.1177/1591019919867841] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Incomplete aneurysm occlusions and re-treatment rates of 52 and 10-30%, respectively, have been reported following endovascular treatment of intracranial aneurysms, raising clinical concerns regarding procedural efficacy. We compare residual, recurrence and re-treatment rates subject to different endovascular techniques in both ruptured and unruptured intracranial aneurysms at a comprehensive state-wide tertiary neurovascular centre in Australia. METHODS Medical records, procedural and follow-up imaging studies of all patients who underwent endovascular treatment for intracranial aneurysms between July 2010 and July 2017 were reviewed retrospectively. Residuals, recurrences and re-treatment rates were assessed regarding initial aneurysm rupture status and applied endovascular technique: primary coiling, balloon- and stent-assisted coiling and flow diversion. RESULTS Among 233 aneurysms, residual, recurrence and re-treatment rates were 27, 11.2 and 9.4%, respectively. Compared with unruptured aneurysms, similar residual and recurrence (p > .05), but higher re-treatment rates (4.5% vs. 19%; p < .001) were found for ruptured aneurysms. Residual, recurrence and re-treatment rates were: 13.3, 16 and 12% for primary coiling; 12, 12 and 10.7% for balloon-assisted coiling; 14.9, 7.5 and 4.5% for stent-assisted coiling; 91.9, 0 and 5.4% for flow diversion. Stent-assistance and flow-diversion were associated with lower recurrence and re-treatment rates, when compared with primary- and balloon-assisted coiling (p < .05). CONCLUSIONS Residuals and recurrences after endovascular treatment of intracranial aneurysms are less common than previously reported. Stent assistance and flow diversion seem associated with reduced recurrence- and re-treatment rates, when compared with primary- and balloon-assisted coiling. Restrained use of stents in ruptured aneurysms may be a contributing factor for higher recurrence/retreatment rates compared to unruptured aneurysms.
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Affiliation(s)
- Jens J Froelich
- Department of Medical Imaging and Interventional Neuroradiology, Royal Hobart Hospital, Hobart, Australia.,Medical Science Precinct, Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Nicholas Cheung
- Department of Medical Imaging and Interventional Neuroradiology, Royal Hobart Hospital, Hobart, Australia.,Medical Science Precinct, Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Johan Ab de Lange
- Department of Medical Imaging and Interventional Neuroradiology, Royal Hobart Hospital, Hobart, Australia
| | - Jessica Monkhorst
- Department of Medical Imaging and Interventional Neuroradiology, Royal Hobart Hospital, Hobart, Australia
| | - Michael W Carr
- Department of Medical Imaging and Interventional Neuroradiology, Royal Hobart Hospital, Hobart, Australia
| | - Reade DeLeacy
- Department of Neurosurgery, Cerebrovascular Center, Mount Sinai Hospital, New York, NY, USA
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35
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Dundar TT, Aralasmak A, Kitiş S, Yılmaz FT, Abdallah A. Comparison of Subtracted Computed Tomography from Computed Tomography Perfusion and Digital Subtraction Angiography in Residue Evaluation of Treated Intracranial Aneurysms. World Neurosurg 2019; 132:e746-e751. [PMID: 31415894 DOI: 10.1016/j.wneu.2019.08.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 08/04/2019] [Accepted: 08/05/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Assessing clipped intracranial aneurysms for residues or incomplete occlusions is critical. Digital subtraction angiography (DSA) has been the gold standard for this. Previously, we presented subtracted computed tomography angiography (sub-CTA) from computed tomography perfusion as a more effective noninvasive technique for clipped aneurysms. The aim of this study was to compare effectiveness of sub-CTA with DSA in residue evaluation. METHODS A retrospective study of 17 patients with aneurysmal subarachnoid hemorrhage operated on at our institution between November 1, 2016, and December 31, 2018, was performed. Residue aneurysms were evaluated with both sub-CTA and DSA. Positive predictive value and negative predictive value were calculated. Correlation between techniques was determined by the McNemar test and κ value. RESULTS Sensitivity of sub-CTA in residue evaluation was low in aneurysms ≤3 mm (positive predictive value = 60%). DSA detected residue aneurysm in 29% (5/17) of patients, whereas sub-CTA detected residue aneurysm in 11% (2/17). Only 40% of aneurysms (2/5) were demonstrated by sub-CTA, all >3 mm; 60% (3/5) were missed, all ≤3 mm. CONCLUSIONS This is the first study comparing the effectiveness of sub-CTA from computed tomography perfusion with DSA in residue aneurysm evaluation. Our results were suggestive, but not conclusive. DSA is still the gold standard in residue evaluation. Sub-CTA from computed tomography perfusion can be a reliable method in evaluation of residual aneurysm >3 mm.
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Affiliation(s)
- Tolga Turan Dundar
- Department of Neurosurgery, Faculty of Medicine, Bezmi Alem University, İstanbul, Turkey.
| | - Ayse Aralasmak
- Department Radiology, Faculty of Medicine, Bezmi Alem University, İstanbul, Turkey
| | - Serkan Kitiş
- Department of Neurosurgery, Faculty of Medicine, Bezmi Alem University, İstanbul, Turkey
| | - Fatih Temel Yılmaz
- Department Radiology, Faculty of Medicine, Bezmi Alem University, İstanbul, Turkey
| | - Anas Abdallah
- Department of Neurosurgery, Faculty of Medicine, Bezmi Alem University, İstanbul, Turkey
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Giordan E, Lanzino G, Rangel-Castilla L, Murad MH, Brinjikji W. Risk of de novo aneurysm formation in patients with a prior diagnosis of ruptured or unruptured aneurysm: systematic review and meta-analysis. J Neurosurg 2019; 131:14-24. [PMID: 29979115 DOI: 10.3171/2018.1.jns172450] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 01/19/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE De novo aneurysms are rare entities periodically discovered during follow-up imaging. Little is known regarding the frequency with which these lesions form or the time course. This systematic review and meta-analysis was undertaken to estimate the incidence of de novo aneurysms and to determine risk factors for aneurysm formation. METHODS The authors searched multiple databases for studies of patients with unruptured and ruptured aneurysms describing the rate of de novo aneurysm formation. The primary outcome was incidence of de novo aneurysm formation. A meta-analysis was performed using a random-effects model. The authors examined the associations of multiple aneurysms, prior subarachnoid hemorrhage, smoking, sex, age at presentation, and hypertension with de novo aneurysm formation. RESULTS The meta-analysis included 14,968 aneurysm patients who received imaging follow-up from 35 studies. The overall incidence of de novo aneurysm formation was 2% (95% CI 2%-3%) over a mean follow-up time of 8.3 years. The estimated incidence density was 0.3%/patient-year. There was no statistically significant difference in rates of de novo aneurysm formation between patients who had ruptured aneurysms and those with unruptured aneurysms. In 8 studies, 11.2% of de novo aneurysms were found in patients with ≤ 5 years of follow-up and 88.8% were found at > 5 years. The mean time to rupture for de novo aneurysms was 10 years. CONCLUSIONS This systematic review demonstrates that formation of de novo aneurysms is rare. Overall, routine screening for de novo aneurysms is likely to be of low yield and could be performed at time intervals of at least 5 to 10 years.
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Abecassis IJ, Sen RD, Barber J, Shetty R, Kelly CM, Ghodke BV, Hallam DK, Levitt MR, Kim LJ, Sekhar LN. Predictors of Recurrence, Progression, and Retreatment in Basilar Tip Aneurysms: A Location-Controlled Analysis. Oper Neurosurg (Hagerstown) 2019; 16:435-444. [PMID: 29905850 DOI: 10.1093/ons/opy132] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 04/29/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Endovascular treatment of intracranial aneurysms is associated with higher rates of recurrence and retreatment, though contemporary rates and risk factors for basilar tip aneurysms (BTAs) are less well-described. OBJECTIVE To characterize progression, retreatement, and retreated progression of BTAs treated with microsurgical or endovascular interventions. METHODS We retrospectively reviewed records for 141 consecutive BTA patients. We included 158 anterior communicating artery (ACoA) and 118 middle cerebral artery (MCA) aneurysms as controls. Univariate and multivariate analyses were used to calculate rates of progression (recurrence of previously obliterated aneurysms and progression of known residual aneurysm dome or neck), retreatment, and retreated progression. Kaplan-Meier analysis was used to characterize 24-mo event rates for primary outcome prediction. RESULTS Of 141 BTA patients, 62.4% were ruptured and 37.6% were unruptured. Average radiographical follow-up was 33 mo. Among ruptured aneurysms treated with clipping, there were 2 rehemorrhages due to recurrence (6.1%), and none in any other cohorts. Overall rates of progression (28.9%), retreatment (28.9%), and retreated progression (24.7%) were not significantly different between surgical and endovascular subgroups, though ruptured aneurysms had higher event rates. Multivariate modeling confirmed rupture status (P = .003, hazard ratio = 0.14) and aneurysm dome width (P = .005, hazard ratio = 1.23) as independent predictors of progression requiring retreatment. In a separate multivariate analysis with ACoA and MCA aneurysms, basilar tip location was an independent predictor of progression, retreatment, and retreated progression. CONCLUSION BTAs have higher rates of progression and retreated progression than other aneurysm locations, independent of treatment modality. Rupture status and dome width are risk factors for progression requiring retreatment.
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Affiliation(s)
- Isaac Josh Abecassis
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Rajeev D Sen
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Rakshith Shetty
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Cory M Kelly
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | | | - Danial K Hallam
- Department of Radiology, University of Washington, Seattle, Washington
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington, Seattle, Washington.,Department of Radiology, University of Washington, Seattle, Washington.,Department of Mechanical Engineering, University of Washington, Seattle, Washington
| | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Seattle, Washington.,Department of Radiology, University of Washington, Seattle, Washington
| | - Laligam N Sekhar
- Department of Neurological Surgery, University of Washington, Seattle, Washington
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Evaluation of the yield of post-clipping angiography and nationwide current practice. Acta Neurochir (Wien) 2019; 161:783-790. [PMID: 30783804 PMCID: PMC6431297 DOI: 10.1007/s00701-019-03834-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 01/31/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Surgical treatment of intracranial saccular aneurysms aims to prevent (re)hemorrhage by complete occlusion of the aneurysmal lumen. It is unclear whether routine postoperative imaging, to assess aneurysmal occlusion, is necessary since intraoperative assessment by the neurosurgeon may be sufficient. We assessed routine clinical protocols for post-clipping imaging in the Netherlands and determined whether intraoperative assessment of aneurysm clippings sufficiently predicts aneurysm residuals. METHODS A survey was conducted to assess postoperative imaging protocols in centers performing clipping of intracranial aneurysms in the Netherlands (n = 9). Furthermore, a retrospective single-center cohort study was performed to determine the predictive value of intraoperative assessment of aneurysm occlusion in relation to postoperative digital subtraction angiography (DSA) findings, between 2009 and 2017. RESULTS No center performed intraoperative DSA in a hybrid OR, routinely. Respectively, four (44.4%), seven (77.8%), and three (33.3%) centers did not routinely perform early postoperative imaging, late follow-up imaging, or any routine imaging at all. Regarding our retrospective study, 106 patients with 132 clipped aneurysms were included. There were 23 residuals ≥ 1 mm (17.4%), of which 10 (43.5%) were unexpected. For the presence of these residuals, intraoperative assessment showed a sensitivity of 56.5%, a specificity of 86.2%, a positive predictive value of 46.4%, and a negative predictive value of 90.4%. CONCLUSIONS There is lack of consensus regarding the post-clipping imaging strategy in the Netherlands. Since intraoperative assessment is shown to be insufficient to predict postoperative aneurysm residuals, we advocate routine postoperative imaging after aneurysm clipping unless this is not warranted on the basis of patient age, clinical condition, and/or comorbidity.
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Prise en charge endovasculaire des anévrismes précédemment traités chirurgicalement, expérience mono-centrique. J Neuroradiol 2019. [DOI: 10.1016/j.neurad.2019.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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40
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Bender MT, Colby GP, Lin LM, Jiang B, Westbroek EM, Xu R, Campos JK, Huang J, Tamargo RJ, Coon AL. Predictors of cerebral aneurysm persistence and occlusion after flow diversion: a single-institution series of 445 cases with angiographic follow-up. J Neurosurg 2019; 130:259-267. [PMID: 29600915 DOI: 10.3171/2017.11.jns171738] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Accepted: 11/10/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Flow diversion requires neointimal stent overgrowth to deliver aneurysm occlusion. The existing literature on aneurysm occlusion is limited by heterogeneous follow-up, variable antiplatelet regimens, noninvasive imaging modalities, and nonstandard occlusion assessment. Using a large, single-center cohort with low attrition and standardized antiplatelet tapering, the authors evaluated outcomes after flow diversion of anterior circulation aneurysms to identify predictors of occlusion and aneurysm persistence. METHODS Data from a prospective, IRB-approved database was analyzed for all patients with anterior circulation aneurysms treated by flow diversion with the Pipeline embolization device (PED) at the authors' institution. Follow-up consisted of catheter cerebral angiography at 6 and 12 months postembolization. Clopidogrel was discontinued at 6 months and aspirin was reduced to 81 mg daily at 12 months. Occlusion was graded as complete, trace filling, entry remnant, or aneurysm filling. Multivariate logistic regression was performed to identify predictors of aneurysm persistence. RESULTS Follow-up catheter angiography studies were available for 445 (91%) of 491 PED procedures performed for anterior circulation aneurysms between August 2011 and August 2016. Three hundred eighty-seven patients accounted for these 445 lesions with follow-up angiography. The population was 84% female; mean age was 56 years and mean aneurysm size was 6.6 mm. Aneurysms arose from the internal carotid artery (83%), anterior cerebral artery (13%), and middle cerebral artery (4%). Morphology was saccular in 90% of the lesions, and 18% of the aneurysms has been previously treated. Overall, complete occlusion was achieved in 82% of cases at a mean follow-up of 14 months. Complete occlusion was achieved in 72%, 78%, and 87% at 6, 12, and 24 months, respectively. At 12 months, adjunctive coiling predicted occlusion (OR 0.260, p = 0.036), while male sex (OR 2.923, p = 0.032), aneurysm size (OR 3.584, p = 0.011), and incorporation of a branch vessel (OR 2.206, p = 0.035) predicted persistence. Notable variables that did not predict aneurysm occlusion were prior treatments, vessel of origin, fusiform morphology, and number of devices used. CONCLUSIONS This is the largest single-institution study showing high rates of anterior circulation aneurysm occlusion after Pipeline embolization. Predictors of persistence after flow diversion included increasing aneurysm size and incorporated branch vessel, whereas adjunctive coiling predicted occlusion.
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Affiliation(s)
- Matthew T Bender
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Geoffrey P Colby
- 2Department of Neurosurgery, University of California, Los Angeles; and
| | - Li-Mei Lin
- 3Department of Neurosurgery, University of California, Irvine, California
| | - Bowen Jiang
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Erick M Westbroek
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Risheng Xu
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jessica K Campos
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Judy Huang
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rafael J Tamargo
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexander L Coon
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Vourla E, Filis A, Cornelius JF, Bostelmann R, Turowski B, Kalakoti P, Rubbert C, Suresh MP, Tortora A, Steiger HJ, Petridis AK. Natural History of De Novo Aneurysm Formation in Patients with Treated Aneurysmatic Subarachnoid Hemorrhage: A Ten-Year Follow-Up. World Neurosurg 2018; 122:e291-e295. [PMID: 30321678 DOI: 10.1016/j.wneu.2018.10.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 10/01/2018] [Accepted: 10/03/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND De novo aneurysm formation after completely occluded aneurysms via clipping or coiling has not been well studied. Although known to occur several years after initial aneurysm management, the natural history of de novo aneurysms is obscure. We investigated the formation of new aneurysms in patients who had previously undergone treatment of intracranial aneurysms. METHODS In a retrospective, single-institutional series, eligible patients who had undergone treatment of ruptured cerebral aneurysms from 2000 to 2011 were included. The primary outcome measure was the development of de novo aneurysms during long-term follow-up. RESULTS Overall, 130 patients (63% women) who had undergone microsurgical clipping (n = 63; 48.5%) or endovascular coiling (n = 67%; 51.5%) for ruptured aneurysms were included. The average follow-up time for our cohort was 10 ± 2.7 years. De novo aneurysms occurred in 10 of 130 patients (7.7%), with a mean time of 7.9 years for aneurysm detection. No association between the formation of de novo aneurysms and the location of the treated aneurysms, smoking status, hypertension, age, or gender was found. Follow-up imaging studies were performed every 2 years. De novo aneurysms had formed in 2 patients within 2-5 years, 7 patients after 5-10 years, and 1 patient after 10 years of follow-up. In 2 of 10 patients, the de novo aneurysm had ruptured and led to subarachnoid haemorrhage. CONCLUSION The rate of de novo aneurysm occurrence was 7.6%, with a mean time to development of 7.9 years. This underscores the significance of long-term monitoring of patients with intracranial aneurysms. In our series, most new aneurysms had occurred after 5 years of follow-up.
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Affiliation(s)
- Eleni Vourla
- Department of Neurosurgery, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Andreas Filis
- Department of Neurosurgery, imland Klinik Rendsburg, Rendsburg, Germany.
| | - Jan F Cornelius
- Department of Neurosurgery, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Richard Bostelmann
- Department of Neurosurgery, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Bernd Turowski
- Institute of Neuroradiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Piyush Kalakoti
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Christian Rubbert
- Institute of Neuroradiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | | | - Angelo Tortora
- Department of Neurosurgery, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Hans Jakob Steiger
- Department of Neurosurgery, University Hospital Duesseldorf, Duesseldorf, Germany
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Marbacher S, Spiessberger A, Diepers M, Remonda L, Fandino J. Early Intracranial Aneurysm Recurrence after Microsurgical Clip Ligation: Case Report and Review of the Literature. J Neurol Surg Rep 2018; 79:e93-e97. [PMID: 30534511 PMCID: PMC6286179 DOI: 10.1055/s-0038-1676454] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 09/20/2018] [Indexed: 12/25/2022] Open
Abstract
Microsurgical clip ligation is considered a definitive treatment for intracranial aneurysms (IAs), resulting in low rates of local recurrence that range from 0.2 to 0.5% and a latency period that averages about a decade. Our case report describes an early asymptomatic recurrence (i.e., without sentinel headache or seizure) less than 1 year after this 20-year-old woman underwent clip ligation of a ruptured anterior communicating artery (AComA) aneurysm. At recurrence, the patient underwent coiling of the regrowth; follow-up imaging at 6 and 18 months demonstrated complete IA occlusion. To review the putative risk factors of this rare phenomenon, the authors searched the PubMed database using the keywords "intracranial aneurysm," "recurrence," and "clipping" in various combinations. In the seven cases identified, all occurred in initially ruptured IA, which was often at the AComA, and six of seven patients were younger than 50 years old. Although most IA remnants grow slowly, early recurrence may represent a more aggressive biological behavior that warrants special attention in younger patients, positive rupture status, and unintended remnant of any size. In such a constellation, early imaging follow-up within the first 6 months may be warranted to rule out early IA recurrence.
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Affiliation(s)
- Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau (KSA), Aarau, Switzerland
| | | | - Michael Diepers
- Division of Neuroradiology, Department of Radiology, Kantonsspital Aarau (KSA), Aarau, Switzerland
| | - Luca Remonda
- Division of Neuroradiology, Department of Radiology, Kantonsspital Aarau (KSA), Aarau, Switzerland
| | - Javier Fandino
- Department of Neurosurgery, Kantonsspital Aarau (KSA), Aarau, Switzerland
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Dimitriadis S, Qeadan F, Taylor CL, Yonas H, Carlson AP. Middle Cerebral Artery Aneurysm "Neck Overhang": Decreased Postclipping Residual Using the Intersecting Clipping Technique. Oper Neurosurg (Hagerstown) 2018. [PMID: 29529311 DOI: 10.1093/ons/opx278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Middle cerebral artery (MCA) aneurysms continue to be viewed by many as primarily surgical entities. OBJECTIVE To introduce a new, easily measurable dimension termed "neck overhang," defined as the amount of the aneurysm that extends proximal to the 2 dimensionally defined "neck" and to evaluate the utility of the intersecting clipping technique (use of straight clip and intersecting fenestrated clip) to adapt to this overhanging segment's specific dimensions and achieve better obliteration of the MCA aneurysms. METHODS We reviewed retrospectively 100 MCA aneurysms treated surgically over the last 10 yr at our institution. We identified the clipping technique that was performed (intersecting vs "standard" technique) and we evaluated the presence of a postoperative remnant. We then correlated these with the aneurysm's overhanging neck length. RESULTS Forty-three aneurysms were treated with the intersecting clipping technique. The overall rate of remnant was 16%. In the standard group, the rate of remnant was 23%, whereas with intersecting clipping that was 7% (P = .029). Within the standard clipping group, we found that the optimum threshold for length of the neck overhang was ≥1.9 mm in order to predict the occurrence of residual. Applying this threshold to the intersecting clipping technique group resulted in a reduction in remnant from 35% in the standard group to 9%. CONCLUSION Neck overhang >1.9 mm is associated with a higher chance of postclipping residual aneurysm in MCA aneurysms. The intersecting clipping technique is a versatile technique that can conform to various aneurysms' geometry and can reduce the rate of post clipping residual for aneurysms with high neck overhang.
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Affiliation(s)
- Stavros Dimitriadis
- Department of Neurological Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Fares Qeadan
- Department of Internal Medicine, division of Epidemiology, Biostatistics and Preventive Medicine University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Christopher L Taylor
- Department of Neurological Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Howard Yonas
- Department of Neurological Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Andrew P Carlson
- Department of Neurological Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
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Shekhtman OD, Gorozhanin VA, Kulikov AS, Okisheva EA. [Proximal clipping of a large fusiform aneurysm of the A2 segment of the left anterior cerebral artery with awakening of the patient (a case report and literature review)]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2018; 82:97-102. [PMID: 30137043 DOI: 10.17116/neiro201882497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Arterial aneurysms of the A2 segment are very rare (<1%) peripheral aneurysms of the anterior cerebral artery (ACA) territory. Usually, these are saccular aneurysms; there are single reports of fusiform aneurysms of this location. Surgical treatment of these aneurysms involves both microsurgical and endovascular interventions. In the presented case, we used deconstructive surgery (proximal clipping of the aneurysm) with intraoperative awakening of the patient, which verified sufficient collateral blood flow. In the case of focal deficit development, we planned to simultaneously perform an interarterial anastomosis between the A3 segments of the right and left ACAs.
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Affiliation(s)
| | | | - A S Kulikov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - E A Okisheva
- Sechenov First Moscow State Medical University, Moscow, Russia
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Hu S, Yu N, Li Y, Hao Z, Liu Z, Li MH. A Meta-Analysis of Risk Factors for the Formation of de novo Intracranial Aneurysms. Neurosurgery 2018; 85:454-465. [DOI: 10.1093/neuros/nyy332] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 06/20/2018] [Indexed: 01/11/2023] Open
Abstract
Abstract
BACKGROUND
Understanding the risk factors for the formation of de novo intracranial aneurysms (IAs) is important for patients who have ever suffered a cerebral aneurysm.
OBJECTIVE
To estimate the risk factors for the development of a de novo IA to identify which patients need more aggressive surveillance after aneurysm treatment.
METHODS
We followed the preferred reporting items for systematic reviews and meta-analyses guidelines and searched the PubMed, CENTRAL, EMBASE, and LILACS databases using the key words cerebral aneurysms, de novo, IAs, risk factors combined using and/or. The search was performed in July 2017.We calculated odds ratios (ORs) and 95% confidence intervals (CIs) using RevMan 5.3 (Cochrane, London, United Kingdom) to evaluate risk factors. Statistical significance was set at P < .05.
RESULTS
The analysis included 14 studies involving 6389 patients, of whom 197 patients had de novo IAs. The main risk factors for formation included sex (OR = 1.82, 95% CI [1.30,2.56], P = .0005, female vs male), age <40 yr (OR = 2.96, 95% CI [1.76,4.96], P < .0001), family history (OR = 2.05, 95% CI [1.07,3.93], P = .03), smoking history (OR = 2.73, 95% CI [1.81,4.12], P < .0001), and multiple saccular intracranial aneurysms (sIAs) at first diagnosis (OR = 2.10, 95% CI [1.12,3.91], P = .02), internal carotid artery (ICA) as the initial site (OR = 2.58, 95% CI [1.43,4.68], P = .002). Heterogeneous analysis showed that these I2 were less than 50% and the results were reliable.
CONCLUSION
Observational evidence identified multiple clinical and anatomic risk factors for the formation of de novo IAs, including female sex, age <40 yr, family history, smoking history, multiple sIAs at first diagnosis, and IC as the initial site. More aggressive long-term angiographic follow-up with digital subtraction angiography, computed tomography angiography, or magnetic resonance angiography is recommended for these patients.
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Affiliation(s)
- Si Hu
- Department of Neurosurgery, The First Affiliated Hospital, Nanchang University, Jiangxi, China
| | - NianZu Yu
- Department of Neurosurgery, The First Affiliated Hospital, Nanchang University, Jiangxi, China
| | - YiYun Li
- Department of Neurosurgery, The First Affiliated Hospital, Nanchang University, Jiangxi, China
| | - Zheng Hao
- Department of Neurosurgery, The First Affiliated Hospital, Nanchang University, Jiangxi, China
| | - Zheng Liu
- Department of Neurosurgery, The First Affiliated Hospital, Nanchang University, Jiangxi, China
| | - Mei-hua Li
- Department of Neurosurgery, The First Affiliated Hospital, Nanchang University, Jiangxi, China
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Walter J, Unterberg AW, Zweckberger K. Lethal Ultra-Early Subarachnoid Hemorrhage Due to Rupture of De Novo Aneurysm 5 Months After Primary Aneurysmatic Subarachnoid Hemorrhage. World Neurosurg 2018; 113:316-319. [PMID: 29482004 DOI: 10.1016/j.wneu.2018.02.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 02/14/2018] [Accepted: 02/15/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Approximately 1% of all patients surviving rupture of a cerebral aneurysm suffer from a second aneurysmatic subarachnoid hemorrhage later in their lives, 61% of which are caused by rupture of a de novo aneurysm. Latency between bleedings is usually many years, and younger patients tend to achieve better outcomes from a second subarachnoid hemorrhage. CASE DESCRIPTION We report an unusual case of lethal ultra-early rupture of a de novo aneurysm of the anterior communicating artery only 5 months after the initial subarachnoid hemorrhage and complete coiling in a young, healthy male patient. CONCLUSION Despite complete aneurysm obliteration, young age, and good recovery, patients may be subjected to secondary subarachnoid hemorrhages from de novo aneurysms after only a few months of the initial bleeding. Early-control magnetic resonance angiography might hence be advisable.
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Affiliation(s)
- Johannes Walter
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Andreas W Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Klaus Zweckberger
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany.
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