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Senol YC, Orscelik A, Bilgin C, Kobeissi H, Ghozy S, Arul S, Kallmes DF, Kadirvel R. Pipeline versus non-pipeline flow diverter treatment for M1 aneurysms: A systematic review and meta-analysis. Neuroradiol J 2024:19714009241260805. [PMID: 39033417 DOI: 10.1177/19714009241260805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024] Open
Abstract
BACKGROUND The flow diversion treatment of aneurysms located distal to the Circle of Willis has recently increased in frequency. We conducted a systematic review and meta-analysis of the clinical and radiological outcomes of flow diverter (FD) embolization in treating M1 aneurysms. METHODS PubMed, Web of Science, Ovid Medline, Ovid Embase, and Scopus were searched up to May 2024 using the Nested Knowledge platform. We included studies assessing the long-term clinical and radiological outcomes for M1 aneurysms. Results of FDs classified as Pipeline Embolization Devices (PED) versus other types of FDs. Angiographic occlusion rates, ischemic and hemorrhagic complications, and favorable clinic outcomes were included. All data were analyzed using R software version 4.2.2. RESULTS Thirteen studies with 112 total patients (58 patients for PED and 54 patients for other FD devices) were included in our meta-analysis. The overall adequate (complete + near-complete) occlusion rates were 85.1%. The complete occlusion rate was higher with PED than with other FD devices (72.9% PED and 41.6% for non-PED FDs, respectively, p-value <.01). The ischemic complications were 9.9% and 9.0% for the PED and non-PED groups, respectively (p-value = .89). The overall modified Rankin Scale 0-2 was 100% for the non-PED and 97.1% for the PED group (p-value = .51). In-stent stenosis rate was 7.5% for PED devices compared to 2.6% in the non-PED group (p-value = .35). CONCLUSIONS This relatively small meta-analysis showed high rates of adequate and complete occlusion in FD treatment of M1 segment aneurysms, with favorable safety profiles. PEDs were associated with higher rates of complete aneurysm occlusion compared to other types of FDs.
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Affiliation(s)
- Yigit Can Senol
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Cem Bilgin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Santhosh Arul
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
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Devalckeneer A, Lu T, Bourgeois P, Maurage CA, Loiez C, Grolez GP, Morales O, Menovsky T, Aboukaïs R, Delhem N. Oral bacterial genic expression detection in aneurysm wall of a French population sample - preliminary monocentric study. Neurosurg Rev 2024; 47:325. [PMID: 39001998 DOI: 10.1007/s10143-024-02548-0] [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: 05/14/2024] [Revised: 06/18/2024] [Accepted: 07/02/2024] [Indexed: 07/15/2024]
Abstract
INTRODUCTION The etiology of brain aneurysms remains poorly understood. Finnish research suggests that oral bacteria might contribute to the development and rupture of brain aneurysms. Previous studies by our team have not confirmed these findings, likely due to methodological differences. We aimed to replicate the Finnish study with a French population, using the same primers and comparing the results to internal controls. METHODS We used RT-qPCR to retrospectively analyze the expression of oral bacterial genes in eight patients. During surgical procedures, four tissue types were consistently sampled from each patient: the aneurysmal wall, the superficial temporal artery (STA), the middle meningeal artery (MMA), and the dura mater (DM). Results were expressed as fold differences employing the 2-∆∆Ct method, and statistical analyses were performed accordingly. RESULTS Our cohort included eight patients, evenly split into ruptured and unruptured groups. The sex distribution was balanced (4 females, 4 males). We observed DNA expression from oral bacteria in all sampled tissues; however, there were no significant differences between the ruptured and unruptured groups. CONCLUSION We detected oral bacterial gene expression in the aneurysmal wall, STA, MMA, and DM in a sample of French patients. Although limited by the small sample size, our results suggest a potential role for bacterial involvement in vascular invasiveness related to bacteremia. These findings do not definitively link oral bacteria to the pathogenesis of aneurysm development and rupture.
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Affiliation(s)
- Antoine Devalckeneer
- Department of Neurosurgery, Lille University Hospital, Rue E. Laine, Hôpital Nord, Lille cedex, 59037, France.
- Lille University, INSERM, CHU Lille, U1189-ONCO-THAI-Image Assisted Laser Therapy for Oncology, Lille, F-59000, France.
| | - Tuong Lu
- Department of Neurosurgery, Lille University Hospital, Rue E. Laine, Hôpital Nord, Lille cedex, 59037, France
| | - Philippe Bourgeois
- Department of Neurosurgery, Lille University Hospital, Rue E. Laine, Hôpital Nord, Lille cedex, 59037, France
| | | | - Caroline Loiez
- Department of Microbiology, Lille University Hospital, Hôpital Nord, France
| | - Guillaume Paul Grolez
- Lille University, INSERM, CHU Lille, U1189-ONCO-THAI-Image Assisted Laser Therapy for Oncology, Lille, F-59000, France
| | - Olivier Morales
- Lille University, INSERM, CHU Lille, U1189-ONCO-THAI-Image Assisted Laser Therapy for Oncology, Lille, F-59000, France
- University Lille, CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity Plasticity and Resistance to Therapies, Lille, F-59000, France
| | - Thomas Menovsky
- Department of Microbiology, Lille University Hospital, Hôpital Nord, France
- Department of Neurosurgery, Antwerpen University Hospital, Antwerp, Belgium
| | - Rabih Aboukaïs
- Department of Neurosurgery, Lille University Hospital, Rue E. Laine, Hôpital Nord, Lille cedex, 59037, France
- Lille University, INSERM, CHU Lille, U1189-ONCO-THAI-Image Assisted Laser Therapy for Oncology, Lille, F-59000, France
| | - Nadira Delhem
- Lille University, INSERM, CHU Lille, U1189-ONCO-THAI-Image Assisted Laser Therapy for Oncology, Lille, F-59000, France
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Wu Q, Yao J, Qi J, Bi Y, Chen A, Yang Z, Ai C, Chen L, Zhang B, Xu S, Li Z, Shi H, Wu P. Microsurgical clipping versus endovascular therapy for treating patients with middle cerebral artery aneurysms presenting with neurological ischemic symptoms. Neurosurg Rev 2024; 47:318. [PMID: 38995460 DOI: 10.1007/s10143-024-02559-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 05/05/2024] [Accepted: 07/07/2024] [Indexed: 07/13/2024]
Abstract
Studies comparing different treatment methods in patients with middle cerebral artery (MCA) aneurysms in different subgroups of onset symptoms are lacking. It is necessary to explore the safety and efficacy of open surgical treatment and endovascular therapy in patients with MCA aneurysms in a specific population. This study aimed to compare microsurgical clipping versus endovascular therapy regarding complication rates and outcomes in patients with MCA aneurysms presenting with neurological ischemic symptoms. This was a retrospective cohort study in which 9656 patients with intracranial aneurysms were screened between January 2014 and July 2022. Further, 130 eligible patients were enrolled. The primary outcome was the incidence of serious adverse events (SAEs) within 30 days of treatment, whereas secondary outcomes included postprocedural target vessel-related stroke, disabling stroke or death, mortality, and aneurysm occlusion rate. Among the 130 included patients, 45 were treated with endovascular therapy and 85 with microsurgical clipping. The primary outcome of the incidence of SAEs within 30 days of treatment was significantly higher in the clipping group [clipping: 23.5%(20/85) vs endovascular: 8.9%(4/45), adjusted OR:4.05, 95% CI:1.20-13.70; P = 0.024]. The incidence of any neurological complications related to the treatment was significantly higher in the clipping group [clipping:32.9%(28/85) vs endovascular:15.6%(7/45); adjusted OR:3.49, 95%CI:1.18-10.26; P = 0.023]. Postprocedural target vessel-related stroke, disabling stroke or death, mortality rate, and complete occlusion rate did not differ significantly between the two groups. Endovascular therapy seemed to be safer in treating patients with MCA aneurysms presenting with neurological ischemic symptoms compared with microsurgical clipping, with a significantly lower incidence of SAEs within 30 days of treatment and any neurological complications related to the treatment during follow-up.
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Affiliation(s)
- Qiaowei Wu
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng Road No.23, Harbin, 150000, Heilongjiang, China
| | - Jinbiao Yao
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng Road No.23, Harbin, 150000, Heilongjiang, China
| | - Jingtao Qi
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng Road No.23, Harbin, 150000, Heilongjiang, China
| | - Yuange Bi
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Aixia Chen
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng Road No.23, Harbin, 150000, Heilongjiang, China
| | - Zhonghui Yang
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng Road No.23, Harbin, 150000, Heilongjiang, China
| | - Changsi Ai
- Department of Neurosurgery, Hongda Hospital of Jiamusi University, Jiamusi, Heilongjiang, China
| | - Lining Chen
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng Road No.23, Harbin, 150000, Heilongjiang, China
| | - Bohan Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng Road No.23, Harbin, 150000, Heilongjiang, China
| | - Shancai Xu
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng Road No.23, Harbin, 150000, Heilongjiang, China
| | - Zhentao Li
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng Road No.23, Harbin, 150000, Heilongjiang, China
| | - Huaizhang Shi
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng Road No.23, Harbin, 150000, Heilongjiang, China.
| | - Pei Wu
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng Road No.23, Harbin, 150000, Heilongjiang, China.
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Ribeiro L, Devalckeneer A, Bretzner M, Bourgeois P, Lejeune JP, Aboukais R. Impact of preaneurysmal M 1 length in unruptured middle cerebral artery aneurysm: mid-term outcome and single-center experience. Neurochirurgie 2024; 70:101569. [PMID: 38749316 DOI: 10.1016/j.neuchi.2024.101569] [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: 03/08/2024] [Revised: 04/06/2024] [Accepted: 04/30/2024] [Indexed: 07/20/2024]
Abstract
OBJECTIVE This study was design to investigate the surgical and functional outcome based on the preaneurysmal M1 length for unruptured MCA aneurysm. METHODS Among 250 consecutive patients with unruptured aneurysms operated in our institution between 2015 and 2017, 72 were MCA aneurysms. Risk factors for IR (i.e., intraoperative rupture) were investigated including age, sex, preaneurysmal M1 length, maximal MCA aneurysm diameter, neck size, aneurysm shape, sphenoid ridge proximation sign. Outcome was measured at discharge, 1 yr and last follow-up. Outcome was compared according to the preaneurysmal M1 length. RESULTS Among 68 patients included, five patients (7.3%) suffered IR. Mean maximal diameter of MCA aneurysm (7.9 mm ± 3.4 vs. 4.5 ± 1.8; p = 0.01) was significantly associated with IR risk. Mean M1 length seemed to be shorter in the IR group although not statistically significant (16.2 mm ± 5.1 vs. 11.5 mm ± 4.8; p = 0.053). Mid-term outcome was favorable for all patients at last follow-up but was worsen in case of short preaneurysmal M1 segment (10.7 mm ± 4.8 vs. 16.4 mm ± 5.3, p = 0.02). Complete aneurysm occlusion was achieved for sixty-nine patients (95.5%) with 6.9% of early postoperative complications. CONCLUSIONS The microsurgical treatment of unruptured MCA aneurysm was associated with favorable mid-term outcome in all patients and high rates of complete occlusion. Aneurysm size was significantly associated with the intraoperative rupture risk for unruptured MCA aneurysm and patients with a short preaneurysmal M1 segment seemed to have a greater risk of intraoperative rupture although not statistically significant. Short preaneurysmal M1 patients had worsen mid-term outcome.
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Affiliation(s)
- Lucas Ribeiro
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France.
| | - Antoine Devalckeneer
- Department of Neurosurgery, Roger Salengro Hospital, Lille University Medical Center, Lille, France; Univ. Lille, INSERM, CHU Lille, U1189-ONCO-THAI-Image Assisted Laser Therapy for Oncology, F-59000, Lille, France
| | - Martin Bretzner
- Department of Neuroradiology, Roger Salengro Hospital, Lille University Medical Center, Lille, France
| | - Philippe Bourgeois
- Department of Neurosurgery, Roger Salengro Hospital, Lille University Medical Center, Lille, France
| | - Jean-Paul Lejeune
- Department of Neurosurgery, Roger Salengro Hospital, Lille University Medical Center, Lille, France; Univ. Lille, INSERM, CHU Lille, U1189-ONCO-THAI-Image Assisted Laser Therapy for Oncology, F-59000, Lille, France
| | - Rabih Aboukais
- Department of Neurosurgery, Roger Salengro Hospital, Lille University Medical Center, Lille, France; Univ. Lille, INSERM, CHU Lille, U1189-ONCO-THAI-Image Assisted Laser Therapy for Oncology, F-59000, Lille, France
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Arrese I, García-García S, Cepeda S, Sarabia R. Integrating endovascular techniques into established open neurosurgery practice: a temporal analysis of treatment evolution in a dual-trained neurosurgical unit. NEUROCIRUGIA (ENGLISH EDITION) 2024:S2529-8496(24)00035-2. [PMID: 38945298 DOI: 10.1016/j.neucie.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 05/15/2024] [Accepted: 06/19/2024] [Indexed: 07/02/2024]
Abstract
OBJETIVE In Europe, units with Dual-trained Neurovascular Surgeons (DTNS) skilled in both open neurosurgery (ON) and endovascular neurosurgery (EN) are scarce. For instance, in Spain, our unit is unique within the public health system, where all neurovascular procedures are carried out by DTNS. Our study aims to evaluate the evolution in treating ruptured intracranial aneurysms (rICAs) and assess the impact of this evolution on clinical outcomes. METHODS A retrospective cohort study was performed on rICAs treated in our unit from October 2012 to June 2023. We reviewed clinical and radiological data to analyze the evolution of ON and EN over time, as well as their impact on patient outcomes. Univariate, multivariate, and mixed-effects models were utilized to discern temporal changes. RESULTS The modified Fisher Scale (mFS) and the modified World Federation of Neurological Surgeons scale (mWFNS) showed strong correlation with the outcome at 6 months outcomes, both with p < 0.00001. However, the surgical intervention method, ON versus EN, did not significantly affect outcomes (p > 0.85). In adjusted multivariate logistic regression, mFS (-1.579, p: 0.011) and mWFNS (-0.872, p < 0.001) maintained their significance. rICAs location was significant when comparing ON to EN p = 0.0001. A significant temporal trend favored the selection of EN p = 0.0058). Mixed-effects time series modeling indicated that while patient characteristics and rICA specifics did not predict treatment choice, the year of treatment was significantly correlated (0.161, p = 0.002). Logistic regression with interaction terms for time and treatment type did not produce significant results. CONCLUSION Our findings suggest that despite an increased adoption of EN techniques, there has been no change in patient outcomes. Even with the rise of EN, our unit continues to perform ON for a higher proportion of rICAs than most national hospitals. We propose that a "dual approach" offers advantages in a patient individualized treatment decision protocol in the European context.
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Affiliation(s)
- Ignacio Arrese
- Unit of Vascular Neurosurgery, Hospital Universitario Río Hortega, Valladolid, Spain.
| | - Sergio García-García
- Unit of Vascular Neurosurgery, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Santiago Cepeda
- Unit of Vascular Neurosurgery, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Rosario Sarabia
- Unit of Vascular Neurosurgery, Hospital Universitario Río Hortega, Valladolid, Spain
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Sternbach S, Nguyen VN, Sizdahkhani S, Abedi A, Rennert RC, Atai NA, Khahera AS, Carey JN, Russin JJ. Open Surgical Treatment of Middle Cerebral Artery Aneurysms: A Single-Center Series in the Endovascular Era. World Neurosurg 2024; 184:e577-e585. [PMID: 38336208 DOI: 10.1016/j.wneu.2024.01.172] [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: 12/09/2023] [Revised: 01/31/2024] [Accepted: 01/31/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVE We review the outcomes of open surgical treatment of middle cerebral artery aneurysms (MCAAs) at a single center, focusing on aneurysm obliteration rates and functional outcomes at the most recent follow-up. These findings can be used for future comparisons of surgical outcomes with MCAAs. METHODS We retrospectively reviewed cases from a prospectively maintained database of patients receiving open surgical treatment for ruptured or unruptured MCAAs between July 2014 and December 2022. We utilized patients' modified Rankin Scale (mRS) score and Glasgow Outcome Scale score as functional outcome measures. Means, standard deviations, medians, and interquartile ranges were calculated, and a student's t test or its nonparametric equivalent was used to compare subgroups. RESULTS One hundred fifty patients (114 women, 76%; mean age 55.0 ± 14.7 years) with a total of 156 MCAAs comprised 152 cases; 85 (56%) ruptured and 71 (46%) unruptured. Bypass was performed in 34 cases (22.4%); 18 ruptured (51.4%) and 16 unruptured (48.6%). Intraoperative rupture occurred in 5 (5%) ruptured and 1 (2%) unruptured cases. Onwe hundred forty-five patients (95.4%) had aneurysm obliteration with initial surgery, with 98.4% of patients having complete occlusion at 40.2± 65.5 weeks of follow-up. Intrahospital mortality occurred in 7 (6.9%) ruptured versus 1 (2.0%) unruptured case. Fifty-two (51.5%) of the ruptured compared to 43 (86%) unruptured patients were discharged home, with the remaining patients requiring inpatient rehabilitation or long-term hospitalization. The ruptured group had a mean hospital stay of 18.4 ± 10.5 days versus. 5.7 ± 6.0 days for unruptured. Length of stay, discharge mRS/ Glasgow Outcome Scale, and mRS at 4-6 weeks favored unruptured cases (P < 0.0001-0.0336). Mean change in mRS from presentation to last follow-up favored ruptured cases (-0.7 ± 1.2 vs. -0.04 ± 1.2, P = 0.0215). CONCLUSIONS Open surgery remains a safe and definitive treatment option for MCAAs in the endovascular era.
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Affiliation(s)
- Sarah Sternbach
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Vincent N Nguyen
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Saman Sizdahkhani
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Aidin Abedi
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA; Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Robert C Rennert
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Nadia A Atai
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA; Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Anadjeet S Khahera
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Joseph N Carey
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jonathan J Russin
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA; Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
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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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Zhang Z, Liu JY, Xing HS, Ma JY, Li AJ. Microsurgical clipping and endovascular intervention for middle cerebral artery aneurysm: A meta-analysis. Medicine (Baltimore) 2023; 102:e34956. [PMID: 37653731 PMCID: PMC10470800 DOI: 10.1097/md.0000000000034956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 07/12/2023] [Accepted: 08/04/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND The purpose of this study is to compare the prognosis and effective rate of interventional embolization and surgical clipping in the treatment of middle cerebral artery aneurysms, to provide evidence-based basis for the selection of clinical treatment. METHODS By searching PubMed, Cochrane library, Medline, Embase and other databases, we collected the related studies interventional embolization and surgical clipping in the treatment of middle cerebral artery aneurysms, whether it was a randomized controlled trial or not. According to the relevant inclusion and exclusion criteria, 2 researchers independently screened and extracted the relevant data. Quality of life, residual neck and recurrence rate, incidence of ischemic cerebral infarction, intracranial infection rate, incidence of vasospasm and rebleeding rate were measured. Revman5.4 software was used for Meta-analysis. RESULTS There were 3658 patients included in 30 literatures, including 1478 patients treated with interventional embolization and 2180 patients treated with surgical clipping. The rate of low quality of life (odds ratio [OR] = 1.68, 95% confidence interval [CI]: 1.36-2.07, P < .00001) and intracranial infection rate (OR = 8.79,95% CI: 4.47-17.27, P < .00001) in the interventional embolization group were lower than those in the surgical clipping group. The postoperative rebleeding rate (OR = 0.46, 95% CI: 0.29-0.73, P = .0009), residual neck and recurrence rate (OR = 0.32, 95% CI: 0.24-0.43, P < .00001) in the interventional embolization group were higher than those in the surgical clipping group. The heterogeneity of residual neck and recurrence rate were high, so subgroup analysis was performed. We divide them into short-term group (OR = 0.68, 95% CI: 0.40-1.13, P = .13) and long-term group (OR = 0.23, 95% CI: 0.16-0.33, P < .00001). The results showed that the residual neck and recurrence rate in the interventional embolization group were higher than those in the surgical clipping group. There was no significant difference in the incidence of cerebral vasospasm (OR = 1.09, 95% CI: 0.64-1.86, P = .74) and ischemic stroke (OR = 0.87, 95% CI: 0.63-1.19, P = .37) between the 2 treatments. CONCLUSION According to the current clinical research evidence, compared with interventional embolization in the treatment of middle cerebral artery aneurysms, the quality of life of patients after clipping is lower, the incidence of intracranial infection is higher, but the residual neck, and recurrence rate are reduced. The risk of rebleeding is also reduced. There was no significant difference in the incidence of vasospasm and ischemic stroke between the 2 groups.
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Affiliation(s)
- Zheng Zhang
- School of Clinical Medicine, Weifang Medical University, Weifang, China
| | - Jing Yi Liu
- Plastic Surgery Institute, Weifang Medical University, Weifang, Weifang City, Shandong Province, China
| | - Hong Shun Xing
- Department of Neurosurgery, Weifang People’s Hospital Affiliated to Weifang Medical University, Weifang, China
| | - Jin Yuan Ma
- Department of Neurosurgery, The Affiliated Hospital of Qing Dao Binhai University, Qingdao, China
| | - Ai Jun Li
- Department of Neurosurgery, The Affiliated Hospital of Qing Dao Binhai University, Qingdao, China
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Arrese I, Sarabia R. Appreciation and Concerns Regarding the Published Study "CURES". AJNR Am J Neuroradiol 2023; 44:E35. [PMID: 37500284 PMCID: PMC10411835 DOI: 10.3174/ajnr.a7925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Affiliation(s)
- I Arrese
- Unit of Vascular NeurosurgeryHospital Universitario Río HortegaValladolid, Spain
| | - R Sarabia
- Unit of Vascular NeurosurgeryHospital Universitario Río HortegaValladolid, Spain
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Metayer T, Dumot C, Bernard F, Le Reste PJ, Bernat AL, Cebula H, Mallereau CH, Peltier C, le Guerinel C, Vivien D, Piotin M, Emery E, Gillard V, Leclerc A, Magro E, Proust F, Pelissou-Guyotat I, Derrey S, Aldea S, Barbier C, Borha A, Nadin L, Briant AR, Gaberel T. Clipping Versus Coiling for Ruptured MCA Aneurysms Associated with Intracerebral Hematoma Requiring Surgical Evacuation. Neurocrit Care 2023; 39:162-171. [PMID: 36991178 DOI: 10.1007/s12028-023-01702-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/14/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND Ruptured middle cerebral artery aneurysm (MCAa) can lead to intracerebral hematoma, and surgical evacuation can be performed in these cases. MCAa can be treated by clipping or before by endovascular therapy (EVT). Our objective was to compare the impact on the functional outcome of MCAa in patients with intracerebral hematoma requiring evacuation. METHODS This is a multicenter, retrospective, cohort study with nine French neurosurgical units from January 1, 2013, to December 31, 2020. All participants were adult patients who required evacuation of an intracerebral hematoma. We looked for risk factors for poor outcomes by comparing the baseline characteristics and treatments performed by using the 6-month modified Rankin scale score. Poor outcomes were defined by an modified Rankin scale score of 3-6. RESULTS A total of 162 patients were included. A total of 129 (79.6%) patients were treated by microsurgery, and 33 (20.4%) patients were treated by EVT. In multivariate analysis, factors associated with poor outcomes included hematoma volume, realization of a decompressive craniectomy, occurrence of procedure-related symptomatic cerebral ischemia, occurrence of delayed cerebral ischemia, and EVT. In the propensity score matching analysis (n = 33 per group), poor outcomes were observed in 30% of the patients in the clipping group versus 76% in the EVT group (P < 0.001). These differences may have been related to a longer delay between hospital admission and hematoma evacuation in the EVT group. CONCLUSIONS In the specific subgroup of ruptured MCAa with intracerebral hematoma that requires surgical evacuation, clipping with concomitant hematoma evacuation could provide better functional outcomes than EVT followed by surgical evacuation.
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Affiliation(s)
- Thomas Metayer
- Department of Neurosurgery, University Hospital of Caen, Caen, France.
- Physiopathology and Imaging of Neurological Disorders, Institut Blood and Brain @ Caen-Normandie, Institut National de la Santé et de la Recherche Médicale, University of Caen Normandy, Cyceron, France.
- Service de Neurochirurgie, CHU de Caen, Avenue de la Côte de Nacre, 14000, Caen, France.
| | - Chloe Dumot
- Department of Neurosurgery, Hospices Civils de Lyon, Lyon, France
| | - Florian Bernard
- Department of Neurosurgery, University Hospital of Angers, Angers, France
| | | | - Anne-Laure Bernat
- Department of Neurosurgery, Lariboisière Hospital, University of Paris Diderot, Paris, France
| | - Helene Cebula
- Department of Neurosurgery, University Hospital of Strasbourg, Strasbourg, France
| | | | - Charles Peltier
- Department of Neurosurgery, University Hospital of Brest, Brest, France
| | | | - Denis Vivien
- Physiopathology and Imaging of Neurological Disorders, Institut Blood and Brain @ Caen-Normandie, Institut National de la Santé et de la Recherche Médicale, University of Caen Normandy, Cyceron, France
| | - Michel Piotin
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - Evelyne Emery
- Department of Neurosurgery, University Hospital of Caen, Caen, France
- Physiopathology and Imaging of Neurological Disorders, Institut Blood and Brain @ Caen-Normandie, Institut National de la Santé et de la Recherche Médicale, University of Caen Normandy, Cyceron, France
| | - Vianney Gillard
- Department of Neuroradiology, University Hospital of Rouen, Rouen, France
| | - Arthur Leclerc
- Department of Neurosurgery, University Hospital of Caen, Caen, France
| | - Elsa Magro
- Department of Neurosurgery, University Hospital of Brest, Brest, France
| | - Francois Proust
- Department of Neurosurgery, University Hospital of Strasbourg, Strasbourg, France
| | | | - Stephane Derrey
- Department of Neuroradiology, University Hospital of Rouen, Rouen, France
| | - Sorin Aldea
- Department of Neurosurgery, Rothschild Foundation Hospital, Paris, France
| | - Charlotte Barbier
- Department of Neuroradiology, University Hospital of Caen, Caen, France
| | - Alin Borha
- Department of Neurosurgery, University Hospital of Caen, Caen, France
- Physiopathology and Imaging of Neurological Disorders, Institut Blood and Brain @ Caen-Normandie, Institut National de la Santé et de la Recherche Médicale, University of Caen Normandy, Cyceron, France
| | - Lawrence Nadin
- Biostatistics and Clinical Research Unit, University Hospital of Caen Normandy, Caen, France
| | - Anais R Briant
- Biostatistics and Clinical Research Unit, University Hospital of Caen Normandy, Caen, France
| | - Thomas Gaberel
- Department of Neurosurgery, University Hospital of Caen, Caen, France
- Physiopathology and Imaging of Neurological Disorders, Institut Blood and Brain @ Caen-Normandie, Institut National de la Santé et de la Recherche Médicale, University of Caen Normandy, Cyceron, France
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11
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Boisseau W, Darsaut TE, Fahed R, Findlay JM, Bourcier R, Charbonnier G, Smajda S, Ognard J, Roy D, Gariel F, Carlson AP, Shotar E, Ciccio G, Marnat G, Sporns PB, Gaberel T, Jecko V, Weill A, Biondi A, Boulouis G, Bras AL, Aldea S, Passeri T, Boissonneau S, Bougaci N, Gentric JC, Diestro JDB, Omar AT, Al-Jehani HM, Hage GE, Volders D, Kaderali Z, Tsogkas I, Magro E, Holay Q, Zehr J, Iancu D, Raymond J. Surgical or Endovascular Treatment of MCA Aneurysms: An Agreement Study. AJNR Am J Neuroradiol 2022; 43:1437-1444. [PMID: 36137654 PMCID: PMC9575541 DOI: 10.3174/ajnr.a7648] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/28/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE MCA aneurysms are still commonly clipped surgically despite the recent development of a number of endovascular tools and techniques. We measured clinical uncertainty by studying the reliability of decisions made for patients with middle cerebral artery (MCA) aneurysms. MATERIALS AND METHODS A portfolio of 60 MCA aneurysms was presented to surgical and endovascular specialists who were asked whether they considered surgery or endovascular treatment to be an option, whether they would consider recruitment of the patient in a randomized trial, and whether they would provide their final management recommendation. Agreement was studied using κ statistics. Intrarater reliability was assessed with the same, permuted portfolio of cases of MCA aneurysm sent to the same specialists 1 month later. RESULTS Surgical management was the preferred option for neurosurgeons (n = 844/1320; [64%] responses/22 raters), while endovascular treatment was more commonly chosen by interventional neuroradiologists (1149/1500 [76.6%] responses/25 raters). Interrater agreement was only "slight" for all cases and all judges (κ = 0.094; 95% CI, 0.068-0.130). Agreement was no better within specialties or with more experience. On delayed requestioning, 11 of 35 raters (31%) disagreed with themselves on at least 20% of cases. Surgical management and endovascular treatment were always judged to be a treatment option, for all patients. Trial participation was offered to patients 65% of the time. CONCLUSIONS Individual clinicians did not agree regarding the best management of patients with MCA aneurysms. A randomized trial comparing endovascular with surgical management of patients with MCA aneurysms is in order.
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Affiliation(s)
- W Boisseau
- From the Department of Radiology (W.B., D.R., A.W., D.I., J.R.), Division of Neuroradiology
| | - T E Darsaut
- Department of Surgery (T.E.D., J.M.F.), Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - R Fahed
- Department of Medicine (R.F.), Division of Neurology, The Ottawa Hospital, Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada
| | - J M Findlay
- Department of Surgery (T.E.D., J.M.F.), Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - R Bourcier
- Department of Neuroradiology (R.B.), University Hospital of Nantes, Nantes, France
| | - G Charbonnier
- Departments of Interventional Neuroradiology (G. Charbonnier, A.B.)
| | - S Smajda
- Departments of Interventional Neuroradiology (S.S.)
| | - J Ognard
- Department of Interventional Neuroradiology (J.O., J.C.G.), Hôpital de la Cavale Blanche, Brest, Bretagne, France
| | - D Roy
- From the Department of Radiology (W.B., D.R., A.W., D.I., J.R.), Division of Neuroradiology
| | - F Gariel
- Departments of Neuroradiology (F.G., G.M.)
| | - A P Carlson
- Department of Neurosurgery (A.P.C.), University of New Mexico Hospital, Albuquerque, New Mexico
| | - E Shotar
- Department of Neuroradiology (E.S.), Groupe Hospitalier de Pitié Salpêtrière, Paris, France
| | - G Ciccio
- Department of Interventional Neuroradiology (G. Ciccio), Centre Hospitalier de Bastia, Bastia, Corse, France
| | - G Marnat
- Departments of Neuroradiology (F.G., G.M.)
| | - P B Sporns
- Department of Neuroradiology (P.B.S., I.T.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
- Department of Diagnostic and Interventional Neuroradiology (P.B.S.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - T Gaberel
- Department of Neurosurgery (T.G.), University Hospital of Caen, Caen, France
| | - V Jecko
- Neurosurgery (V.J.), University Hospital of Bordeaux, Bordeaux, France
| | - A Weill
- From the Department of Radiology (W.B., D.R., A.W., D.I., J.R.), Division of Neuroradiology
| | - A Biondi
- Departments of Interventional Neuroradiology (G. Charbonnier, A.B.)
| | - G Boulouis
- Department of Neuroradiology (G.B.), University Hospital of Tours, Tours, Indre et Loire, France
| | - A L Bras
- Department of Radiology (A.L.B.), Groupement Hospitaliser Bretagne Atlantique-Hôpital Chubert, Vannes, Bretagne, France
| | - S Aldea
- Neurosurgery (S.A.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
| | - T Passeri
- Department of Neurosurgery (T.P.), Lariboisière Hospital, Assistance Publique Hôpitaux de Paris, University of Paris, Paris, France
| | - S Boissonneau
- Department of Neurosurgery (S.B.), La Timone Hospital
- L'Institut National de la Santé et de la Recherche Médicale (S.B.), Institut de Neurosciences des Systèmes, Aix Marseille University, Marseille, France
| | - N Bougaci
- Neurosurgery (N.B.), Besançon University Hospital, Besançon, France
| | - J C Gentric
- Department of Interventional Neuroradiology (J.O., J.C.G.), Hôpital de la Cavale Blanche, Brest, Bretagne, France
| | - J D B Diestro
- Division of Diagnostic and Therapeutic Neuroradiology (J.D.B.D.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - A T Omar
- Division of Neurosurgery (A.T.O.), Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - H M Al-Jehani
- Department of Neurosurgery, Radiology and Critical Care Medicine (H.M.A.-J.), King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University, Alkhobar, Saudi Arabia
| | - G El Hage
- Department of Neurosurgery (G.E.H.), Centre Hospitalier de l'Université de Montréal,Montreal, Québec, Canada
| | - D Volders
- Department of Radiology (D.V.), Dalhousie University, Halifax, Nova Scotia, Canada
| | - Z Kaderali
- Division of Neurosurgery (Z.K.), GB1-Health Sciences Centre, Winnipeg, Manitoba, Canada
| | - I Tsogkas
- Department of Neuroradiology (P.B.S., I.T.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - E Magro
- Department of Neurosurgery (E.M.), Centre Hospitalier Universitaire Cavale Blanche, UBO L'Institut National de la Santé et de la Recherche Médicale, LaTIM UMR 1101, Brest, France
| | - Q Holay
- Department of Radiology (Q.H.), Hôpital d'Instruction des Armées Saint-Anne, Toulon, France
| | - J Zehr
- Department of Mathematics and Statistics (J.Z.), Pavillon André-Aisenstadt,Montreal, Québec, Canada
| | - D Iancu
- From the Department of Radiology (W.B., D.R., A.W., D.I., J.R.), Division of Neuroradiology
| | - J Raymond
- From the Department of Radiology (W.B., D.R., A.W., D.I., J.R.), Division of Neuroradiology
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Woven EndoBridge in Wide-Neck Bifurcation Aneurysms: Digital Subtraction Angiography at 3-Year Follow-Up. J Clin Med 2022; 11:jcm11102879. [PMID: 35629006 PMCID: PMC9143363 DOI: 10.3390/jcm11102879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/30/2022] [Accepted: 05/12/2022] [Indexed: 02/06/2023] Open
Abstract
Introduction: The Woven EndoBridge (WEB) device is a self-expanding intrasaccular braided-wire device for the treatment of wide-neck bifurcation aneurysms (WNBAs). Even though this device has an excellent safety profile and a low risk of rebleeding, little is known about its long-term effects. Material and Methods: All patients treated with WEB due to ruptured WNBAs were subjected to follow-up digital subtraction angiography (DSA) at 2 and 3 years after device deployment. The degree of residual neck was assessed through BOSS, Lubicz, and WEBCAST scales. Data on modified Rankin scale (mRS), bleeding events, and ischemic events occurring during this time period were collected as well. Lastly, overall and procedure-related mortality rates were calculated. Results: A total of 21 patients were treated between 1 January 2016, and 31 December 2018. DSA demonstrated a patency grade of 57.1% and 61.1% at 2 and 3 years, respectively. The overall 2-year mortality rate due to causes unrelated to the aneurysm was 14.3%. None of the patients were retreated between the 2- and the 3-year follow-up. No rebleeding or stroke events occurred during the follow-up. Conclusions: WEB-treated ruptured aneurysms showed an excellent degree of stability over time. The overall mortality rate—unrelated to the procedure–observed in our sample was higher than what reported in the literature, a possible bias associated with the COVID-19 pandemic.
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13
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Nia AM, Lall RR, Kan P, Srinivasan VM. Trends and Outcomes of Endovascular Embolization and Surgical Clipping for Ruptured Intracranial Aneurysms: A Propensity-Matched Study of 1332 Patients in the United States. World Neurosurg 2022; 161:e674-e681. [PMID: 35218963 PMCID: PMC9081193 DOI: 10.1016/j.wneu.2022.02.077] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe recent trends in treatment and outcomes of endovascular coil embolization and microsurgical clipping treatment strategies for ruptured intracranial aneurysms. METHODS Using International Classification of Diseases, Tenth Revision, codes, 1332 propensity-matched patients >18 years old who underwent coiling or clipping were identified. Patient demographics, baseline characteristics, comorbidities, and clinical outcomes were evaluated within 1 year postoperatively. Pooled and individual studies of the International Classification of Diseases codes investigated differences in clinical outcomes owing to aneurysm location. Outcomes were mortality, intensive care, surgical complications, hydrocephalus, and vasospasm. RESULTS After propensity matching for baseline characteristics and comorbidities, 666 patients were included in the coiling and clipping cohorts. There was no significant difference in 1-year mortality between cohorts. However, incidence of intensive care, surgical/medical complications, and vasospasm was significantly lower in the pooled coiling cohort (P = 0.02, P = 0.03, and P = 0.014) compared with the clipping cohort within 1 year postoperatively. Additionally, individual International Classification of Diseases code analysis revealed that coiling of anterior communicating artery aneurysms was associated with significantly fewer surgical/medical complications and hydrocephalus (P = 0.0008 and P = 0.015) and coiling of posterior communicating artery aneurysms was associated with substantially less vasospasm treatment (P = 0.034) compared with the respective clipping cohorts. CONCLUSIONS Analysis revealed no difference in 1-year mortality between coiling and clipping. Clinical outcomes, including intensive care, surgical complications, and vasospasm, favored coiling regardless of aneurysm location. Patients with coiling of anterior communicating artery aneurysms had significantly less hydrocephalus and patients with coiling of posterior communicating artery aneurysms had substantially less vasospasm treatment within 1 year compared with the clipping cohort.
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Affiliation(s)
- Anna M Nia
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA.
| | - Rishi R Lall
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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14
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Srinivasan VM, Farhadi DS, Shlobin NA, Cole TS, Graffeo CS, Lawton MT. Clinical Trials of Microsurgery for Cerebral Aneurysms: Past and Future. World Neurosurg 2022; 161:354-366. [PMID: 35505555 DOI: 10.1016/j.wneu.2021.11.087] [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: 08/30/2021] [Revised: 11/19/2021] [Accepted: 11/20/2021] [Indexed: 10/18/2022]
Abstract
BACKGROUND New findings and research regarding the microsurgical treatment of intracerebral aneurysms (IAs) continue to advance even in the era of endovascular therapies. Research in the past 2 decades has continued to revolve around the question of whether open surgery or endovascular treatment is preferable. The answer remains both complex and in flux. OBJECTIVE This review focuses on microsurgery, reflects on the research decisions of previous landmark studies, and proposes future study designs that may further our understanding of IAs and how best to treat them. RESULTS The future of IA research may include a combination of pragmatic trials, artificial intelligence integrated tools, and mining of large data sets, in addition to the publication of high-quality single-center studies. CONCLUSIONS The future will likely emphasize testing innovative techniques, looking at granular patient data, and considering every patient encounter as a potential source of knowledge, creating a system in which data are updated daily because each patient interaction contributes to answering important research questions.
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Affiliation(s)
- Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Dara S Farhadi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Nathan A Shlobin
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Christopher S Graffeo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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15
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Sriamornrattanakul K, Akharathammachote N, Wongsuriyanan S. Early Exposure of the Dorsal Surface of M1 Segment via the Distal Transsylvian Approach for Clipping of Anteroinferior-Projecting Middle Cerebral Artery Bifurcation Aneurysms. Asian J Neurosurg 2022; 17:23-30. [PMID: 35873836 PMCID: PMC9298598 DOI: 10.1055/s-0042-1749177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Abstract
Background Middle cerebral artery bifurcation (MCAB) aneurysms are common intracranial aneurysms. Anteroinferior-projecting MCAB aneurysms, with M1 segment usually embedded into the deep part of the Sylvian fissure, cause some surgical challenges. The distal transsylvian approach (DTSA) allows M1 exposure from the dorsal surface for proximal control in the early step. Therefore, this study aimed to demonstrate the efficacy and safety of DTSA for clipping anteroinferior-projecting MCAB aneurysms.
Methods Among 97 patients with MCA aneurysms, 13 with anteroinferior-projecting MCAB aneurysms who underwent aneurysm clipping via the DTSA between June 2018 and January 2021 were retrospectively evaluated for the aneurysm obliteration rate, surgical complications, and outcomes.
Results Ten patients (76.9%) had ruptured MCAB aneurysms and three (23.1%) had incidentally discovered unruptured MCAB aneurysms. Favorable outcome was achieved in 100% of patients with good grade. The complete aneurysm obliteration rate was 100% without intraoperative lenticulostriate artery injury. Twelve (92.3%) patients had early identified distal M1 segment for proximal control, and one (7.7%) patient had premature rupture of aneurysm that achieved favorable outcome at 3 months postoperatively. Difficult M1 exposure and premature rupture occurred in the patient with MCAB located above the Sylvian fissure line. Permanent postoperative neurological deficit was detected in one patient due to severe vasospasm.
Conclusion DTSA, which simplify the early exposure of the dorsal surface of distal M1, is safe and effective for clipping anteroinferior-projecting MCAB aneurysms without extensive Sylvian fissure dissection. High-positioned MCAB requires careful dissection of the aneurysm neck with consideration of tentative clipping preparation.
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Affiliation(s)
- Kitiporn Sriamornrattanakul
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Nasaeng Akharathammachote
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Somkiat Wongsuriyanan
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
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16
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Darsaut TE, Keough MB, Boisseau W, Findlay JM, Bojanowski MW, Chaalala C, Iancu D, Weill A, Roy D, Estrade L, Lejeune JP, Januel AC, Carlson AP, Sauvageau E, Al-Jehani H, Orlov K, Aldea S, Piotin M, Gaberel T, Gevry G, Raymond J. Middle Cerebral Artery Aneurysm Trial (MCAAT): A randomized care trial comparing surgical and endovascular management of MCA aneurysm patients. World Neurosurg 2021; 160:e49-e54. [PMID: 34971833 DOI: 10.1016/j.wneu.2021.12.083] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Whether the best management of middle cerebral artery (MCA) aneurysm patients is surgical or endovascular remains uncertain, with little evidence to guide decision-making. A randomized care trial offering MCA aneurysm patients a 50% chance of surgical and a 50% chance of endovascular management may optimize outcomes in the presence of uncertainty. METHODS The Middle Cerebral Artery Aneurysm Trial (MCAAT) is an investigator-initiated, multi-center, parallel group, prospective, 1:1 randomized controlled clinical trial. All adult patients with MCA aneurysms, ruptured or unruptured, amenable to surgical and endovascular treatment can be included. The composite primary outcome is 'Treatment Success': i) occlusion or exclusion of the aneurysm using the allocated treatment modality; ii) no intracranial hemorrhage during follow-up; iii) no retreatment of the target aneurysm during follow-up, iv) no residual aneurysm on angiographic follow-up and v) independence (mRS <3) at 1 year. The trial tests two versions of the same hypothesis (one for ruptured and one for unruptured MCA aneurysm patients): Surgical management will lead to a 15% absolute increase in the proportion of patients reaching Treatment Success from 55% to 70% (ruptured) or from 75% to 90% (unruptured aneurysm patients) compared to endovascular treatment (any method). In this pragmatic trial, outcome evaluations are by treating physicians, except for 1 year angiographic results which will be core lab assessed. The trial will be monitored by an independent data safety monitoring committee to assure safety of participants. MCAAT is registered at clinicaltrials.gov: NCT05161377. CONCLUSION Patients with MCA aneurysms can be optimally managed within a care trial protocol.
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Affiliation(s)
- Tim E Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Canada
| | - Michael B Keough
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Canada
| | - William Boisseau
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - J Max Findlay
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Canada
| | - Michel W Bojanowski
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Chiraz Chaalala
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Daniela Iancu
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Alain Weill
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Daniel Roy
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Laurent Estrade
- Department of Interventional Neuroradiology, CHU de Lille, Hôpital Salengro, Lille, France
| | - Jean-Paul Lejeune
- Department of Neurosurgery, CHU de Lille, Hôpital Salengro, Lille, France
| | - Anne-Christine Januel
- Department of Interventional Neuroradiology, CHU de Toulouse, Hôpital Purpan, Toulouse, France
| | - Andrew P Carlson
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Health, Jacksonville, Florida, USA
| | - Hosam Al-Jehani
- Department of Neurosurgery and Radiology, King Fahad University Hospital, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia
| | - Kirill Orlov
- Endovascular Neurosurgery Research Center, Federal Center of Brain Research and Neurotechnologies of the Federal Medical Biological Agency of Russia, Moscow, Russia
| | - Sorin Aldea
- Department of Neurosurgery, Rothschild Foundation Hospital, Paris, France
| | - Michel Piotin
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | | | - Guylaine Gevry
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Jean Raymond
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
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