Treatment strategies for complex intracranial aneurysms: review of a 12-year experience at the university of cincinnati

The Art of Cerebral Revascularization: An Illustrative Case Series of Bypass Techniques for Complex Intracranial Aneurysms

BACKGROUND

Complex intracranial aneurysms (CIAs) comprise a subset of lesions with defiant vascular architecture, difficult access, and prior treatment. Surgical management of CIAs is often challenging and demands an assessment on a case-by-case basis. The generational evolution of bypass surgery has offered a long-standing potential for effective cerebral revascularization. Herein, we aim to illustrate a single-center experience treating CIAs.

METHODS

The authors conducted a retrospective analysis of clinical records of patients treated with cerebral revascularization techniques at Hospital Nacional Dos de Mayo, Lima, Peru, during 2018-2022. Relevant data were collected, including patient history, aneurysm features on imaging, preoperative complications, the intraoperative course, aneurysm occlusion rates, bypass patency, neurological function, and postoperative complications.

RESULTS

Seventeen patients (70.59% female; median age: 53 years) with 17 CIAs (64.7% saccular; 76.5% ruptured) were included. The most common clinical presentation included loss of consciousness (70.6%) and headaches (58.8%). Microsurgical treatment included first-, second-, and third-generation bypass. In 47.1% of cases, an anastomosis between the superficial temporal artery and the M3 segment was predominantly used, followed by an A3-A3 bypass (29.4%), a superficial temporal artery-M2 bypass (17.6%), and an external carotid artery to M2 bypass (5.9%). The intraoperative aneurysm rupture rate was 11.8%. Postoperative complications included ischemia (40%), cerebrospinal fluid fistulas (26.7%), and pneumonia (20%). At hospital discharge, the median Glasgow Coma Scale score was 14 (range: 10-15). At the 6-month follow-up, 82.4% of patients had a modified Rankin Scale score ≤2, bypass patency was present in all cases, and the morbidity rate was 17.6%.

CONCLUSIONS

CIAs represent a spectrum of defiant vascular lesions with a poor natural history. Bypass surgery offers the potential for definitive treatment. Our case series illustrated the predominant role of cerebral revascularization of CIAs with a critical case-by-case approach to provide optimal outcomes in a limited-resource setting.

[Venous cerebral complications after microsurgery for complex aneurysms of the middle cerebral arteries]

Microsurgeries are common for complex aneurysms of the middle cerebral artery (MCA).

OBJECTIVE

To evaluate the incidence and types of venous cerebral disorders after microsurgeries for complex MCA aneurysms.

MATERIAL AND METHODS

A retrospective study included 285 patients with complex MCA aneurysms between 2009 and 2020. Pterional craniotomy and transsylvian approach were used in all cases. Aneurysm clipping was performed in 230 cases, revascularization - 27, trapping without bypass - 17, reinforcement - in 11 cases. Computed tomography within 1-3 days after surgery recognized venous cerebral disorders as heterogeneous foci of abnormal brain density with unclear boundaries. These foci were crescent-shaped as a rule and located in deep and basal parts of the frontal lobes.

RESULTS

Venous abnormalities occurred in 76 (26.7%) patients. Thirty-five (12.3%) patients had mild venous edema of the frontal lobe alone. In 35 (12.3%) patients, we found moderate disorders with focus in the frontal lobe and compression of anterior horn of the left lateral ventricle with or without hemorrhagic imbibition. Severe disorders occurred in 6 (2.1%) patients with lesion extending to the frontal, insular and temporal lobes. These lesions were accompanied by hemorrhagic imbibition, and lateral dislocation exceeded 5 mm.

CONCLUSION

Careful dissection of veins in Sylvian fissure with preservation of bridging veins is likely to reduce the risk of this complication. Cauterization of a large vein in Sylvian fissure should be followed by careful hemostasis within frontal or temporal cortex. Bleeding and cortical tension can indicate intracerebral hematoma whose likelihood is higher in patients with venous cerebral disorders.

Superficial Temporal Artery-Middle Cerebral Artery Bypass Combined with Internal Carotid Ligation in Treating Complex Internal Carotid Aneurysms. The Willis Polygon Score is an Effective Solution for Developing Countries

OBJECTIVE

Internal carotid complex aneurysms (ICCAs) management is challenging. Ligating the internal carotid artery (ICA) combined with Superficial Temporal Artery-Middle Cerebral Artery (STA-MCA) anastomosis is an effective treatment option. Balloon test occlusion (BTO) assessments for preoperative decision-making are unaffordable in developing countries. This article discusses the study of Willis polygon (WP) segments as an option and suggests a score for decision-making. Herein, we report the outcomes of a series of patients treated for ICCA aneurysms at a single institution.

METHODS

From September 2016 to December 2020, we conducted a retrospective cohort study that analyzed data from patients with ICCAs. Among them, 9 patients received treatment involving ICA ligation combined with STA-MCA anastomosis. Partial or total carotid ligation was determined by using the WP score (WPS).

RESULTS

All Patients underwent STA-MCA anastomosis, in addition to total ICA ligation in 7 patients and partial ICA ligation in 2 patients with a WPS of 7 and 5, respectively. Patients with partially ligated carotid arteries were referred to an overseas neurointerventional center 12 months after surgery. As the BTO test was negative, they underwent ICA occlusion by coiling. Postoperative clinical outcomes did not change in 8/9 patients. In 1 patient, we reported a minor parietal stroke; the patient recovered completely after 6 months. Total aneurysm exclusion by thrombosis was achieved in 7/9 patients after total ICA ligation alone and in 2/9 patients after partial ICA ligation combined with coiling.

CONCLUSIONS

Limited access to endovascular assessment techniques such as BTO poses challenges in managing ICCAs. The WPS for decision-making appears to be a simple and safe option. In addition to STA-MCA bypass surgery, total or partial ICA ligation may be proposed depending on the WPS. After 12 months, patients with low WPS who underwent partial ICA ligation combined with bypass had postoperative normal BTO.

Fast Transition from Open Surgery to Endovascular Treatment of Unruptured Anterior Communicating Artery Aneurysms-A Retrospective Analysis of 128 Patients

OBJECTIVE

Anterior communicating artery aneurysms (ACoAAs) are challenging to treat both surgically and endovascularly. In this study, we evaluate the treatment-related morbidity and clinical outcome of microsurgical clipping and endovascular treatment for a consecutive series of unruptured ACoAAs while the treatment paradigm was in transition from surgical to endovascular first.

METHODS

We retrospectively reviewed clinical and radiologic data of adult patients who underwent microsurgical clipping or endovascular treatment of an unruptured ACoAA at a high-volume academic neurovascular center (Helsinki University Hospital) during 2012-2019. During this period, a transition from microsurgical clipping to endovascular treatment took place. Regarding outcome, we focused on treatment-related complications, discharge-to-home rates, functional performance (modified Rankin Scale score), and obliteration rates.

RESULTS

Of 128 treated ACoAAs, 81 (64%) were treated surgically and 47 (36%) endovascularly. There was no difference in major complications, intracranial hemorrhagic complications or ischemic complications, discharge-to-home rates, or functional performance between the surgically and endovascularly treated patients. With time, a decrease in major complications was observed in the surgical cases (from 29% to 17%), whereas the major complication rate increased in the endovascularly patients (from 0% to 25%). Cerebral ischemia was the most frequent complication in both groups. The risk for permanent neurologic deficit remained low in both groups (9% for endovascular and 5% for surgery).

CONCLUSIONS

We did not find any major differences regarding complications and outcomes after the treatment paradigm shift from clipping to endovascular of unruptured ACoAAs. Prospective studies evaluating durability of treatments are needed to compare overall effectiveness.

Silk Vista Baby flow diverter stent for ruptured intracranial aneurysms: a retrospective observational study

PURPOSE

Flow diversion changed the approach to complex intracranial aneurysms, leading to a widespread use and a rapid technological evolution. Indeed, indications continued to expand, including ruptured intracranial aneurysms in selected cases. Recently, new devices have been designed specifically to target smaller vessels. Therefore, we conducted a multicenter study to evaluate clinical outcome, complications, and occlusion rate of patients with ruptured aneurysms treated with new generation low profile Silk Vista Baby (SVB) flow diverter stent (FD).

METHODS

We performed a retrospective observational study on consecutive patients who underwent treatment with SVB for ruptured aneurysms at 12 Italian centers. Primary end point was favorable clinical outcome rate, defined as modified ranking score (mRS) of 0-2 at the 3 months. Secondary outcomes were complication rate, aneurysm re-rupture, and complete aneurysm occlusion at last radiological follow-up.

RESULTS

Twenty-five patients were included; at 3 months' follow-up, 19 patients (79.1%) had favorable clinical outcome (mRS 0-2). Three patients (12.5%) died during follow-up. In-stent thrombosis occurred in two cases (8.3%), managed with glycoprotein IIb/IIIA and intra-stent angioplasty, without clinical consequences. In 18 (85.7%) patients, complete occlusion at 3 months was demonstrated. No rebleeding occurred during follow-up. Presentation with unfavorable World Federation of Neurosurgical Societies grading system (WFNS) and posterior circulation location were both significantly correlated with unfavorable clinical outcome (p = 0.005 and p = 0.02).

CONCLUSIONS

Our data suggests that low profile FD treatment of ruptured intracranial aneurysms located distally of the circle of Willis is feasible. New generation low profile FD may represent an alternative option in carefully selected cases.

Management of Complex Cerebral Aneurysms

BACKGROUND

Complex intracranial aneurysms (CIAs) are challenging pathologies to treat. Characteristics making an aneurysm complex include dimension, history of previous treatment, location, absence of collateral circulation, intraluminal thrombosis, and calcification of the wall. The goal of the therapeutic process is to exclude the malformation from the cerebral circulation and both endovascular and surgical treatments are valid procedures.

METHODS

Between 1990 and 2020, 170 CIAs were treated at our institution (33 ruptured, 137 unruptured). They were 3 prepetrous segment of the internal carotid artery (ICA), 14 purely intracavernous sinus, 27 intracavernous with subarachnoid extension, 60 paraclinoid, 4 ICA bifurcation, 15 anterior communicating artery, 24 middle cerebral artery, and 23 in the posterior circulation. All the patients underwent neuroradiologic examinations and images were evaluated by the neurosurgical and interventional radiologist team. Endovascular treatment was considered as the treatment of choice. Alternative treatment was surgical clipping; revascularization procedures were performed when neither endovascular treatment nor direct clipping were possible.

RESULTS

Of 170 patients, 45 underwent endovascular treatment, 77 surgical clipping, and 55 revascularization procedures. In the unruptured group, 12 patients died, 22 reported major complications, 3 had minor complications, and 101 had an uneventful postoperative course. In the ruptured group, 9 patients died, 10 had minor complications, 1 minor complication, and 13 had a complete recovery.

CONCLUSIONS

Endovascular treatment should represent the treatment of choice for CIAs. Alternative treatments include direct surgical clipping and revascularization. Overall, the correct identification of the therapeutic process guarantees a good clinical outcome.

Tailored Skull Base Approach to Management of Intracranial Aneurysms

Surgical management of intracranial aneurysms (IAs) remains one of the most challenging and dynamic tasks for neurosurgeons. The rivalry between modern time microsurgery and progress in endovascular intervention has provided a great arena for advancement and lead to redefine training concept and referral pattern. Both approaches has its own merits, risks and complications and the best outcome is achieved by case individualization and complimentary multidisciplinary approach.The recent innovation in microscopic and endoscopic tailored skull base approaches, intraoperative 3D and ICG video-angiography, design of high quality aneurysm clips, and refinement of cerebral bypass techniques enhance IAs neurosurgical management and their clinical outcome. The command of tailored skull base approaches should be part of the training curriculum of young generation of neurosurgeons to compliment the emerging treatment options of endovascular intervention.

[Thrombectomy without temporary clipping for giant partially thrombosed saccular aneurysms]

Cerebral aneurysm thrombosis is one of the factors increasing the risk of microsurgical treatment. Thrombi and calcifications within the aneurysm neck prevent adequate clipping and should be removed before the procedure. At the same time, the process of thrombectomy is difficult and time consuming that increases duration of temporary arterial clipping and risk of cerebral ischemia.

OBJECTIVE

To evaluate the results of thrombectomy without temporary arterial clipping for giant aneurysms of anterior brain circulation.

MATERIAL AND METHODS

Four patients with giant partially thrombosed saccular aneurysms underwent thrombectomy without temporary clipping followed by neck clipping. In all cases, the aneurysm was thrombosed by more than 80-90% of its baseline volume, and aneurysm neck contained parietal thrombi from all sides. Mean duration of thrombectomy from aneurysm opening to bleeding and temporary clipping of the parent artery was 82 minutes, time of temporary clipping was about 12 minutes.

RESULTS

Favorable clinical and radiological postoperative results were obtained in all patients. The authors present a scheme of surgical stages and video presentation involving the main surgical aspects of this procedure.

CONCLUSION

Thrombectomy without temporary clipping of the parent artery is an effective technique for microsurgical treatment of giant partially thrombosed saccular intracranial aneurysms. Since most thrombi are removed without bleeding, duration of temporary blood flow discontinuation in the parent artery is significantly reduced. Therefore, we decrease the risk of cerebral ischemia. This technique can be useful in microsurgical treatment of complex aneurysms of the middle cerebral and internal carotid arteries, as well as other aneurysms.

[Mathematical modeling of high-flow extra-intracranial bypass in the treatment of a complex cerebral aneurysm]

BACKGROUND

Intracranial aneurysms (IAs) pose a high risk of spontaneous subarachnoid hemorrhage. In the most complex cases, the only way to exclude the aneurysm from the circulation is to perform a high-flow extracranial-to-intracranial bypass, thus creating a new bloodstream. This avoids severe ischemic complications; however, it requires careful consideration of individual anatomy and hemodynamic parameters. Computational fluid dynamics (CFD) can be of great help in planning such a surgery by creating 3D patient-specific models of cerebral circulation.

OBJECTIVE

Assessment of the perspectivity of high-flow extracranial-to-intracranial bypass planning using computational modeling.

MATERIAL AND METHODS

In this research work, we have applied the CFD methods to a patient with a giant thrombosed IA of the internal carotid artery (ICA). Preoperative CTA images and Gamma Multivox workstation were used to create a 3D model with current geometry and three additional models: Normal anatomy (no IA), Occlusion (with ligated ICA), Virtual bypass (with bypass and ligated ICA). The postoperative data were also available. Boundary conditions were based on PC-MRI measurements. Calculation of hemodynamics was conducted with a finite element package ANSYS Workbench 19.

RESULTS

The results demonstrated an increase in the blood flow on the affected side by more than 70% after the virtual surgery and uniformity of flow distribution between the affected and contralateral sides, indicating that the treatment is likely to be efficient. Later, postoperative data confirmed that.

CONCLUSION

The study showed that virtual preoperative CFD modeling could significantly simplify and improve surgical planning.

Use of Distal Intracranial Catheters for Better Working View of Cerebral Aneurysms Hidden by Parent Artery or Its Branches: A Technical Note

A good working view is critical for safe and successful endovascular treatment of cerebral aneurysms. In a few cases, endovascular treatment of cerebral aneurysms may be challenging due to difficulty in obtaining a proper working view. In this report of 6 cases, we described the advantage of using a distal intracranial catheter (DIC) to achieve better visualization of cerebral aneurysms hidden by a parent artery or its branches. Between September 2017 and January 2021, we treated 390 aneurysms with endovascular techniques. In 6 cases in which it was difficult to obtain a proper working view, the DIC was placed distally close to the aneurysm in order to remove the parent artery projection from the working view and obtain better visualization of the aneurysm. Clinical and procedural outcomes and complications were evaluated. The position of the DIC was above the internal carotid artery siphon in the 6 cases. All aneurysms were successfully embolized. Raymond–Roy class 1 occlusion was achieved in all 4 unruptured aneurysms, while the result was class 2 in the 2 ruptured aneurysms. Placement of the DIC was atraumatic without dissections or significant catheter-induced vasospasm in all patients. Transient dysphasia was seen in 2 cases and transient aphasia in 1. Using this technique, we have found it possible to better visualize the aneurysm sac or neck and thereby treat cases we otherwise would have considered untreatable.

Giant Middle Cerebral Artery Aneurysms: A 55-Patient Series

BACKGROUND

The treatment of middle cerebral artery (MCA) giant aneurysms (GAs) represents a challenging task.

METHODS

The data for 55 patients treated for MCA GA (≥25 mm) at the N.N. Burdenko NMRCN between 2010 and 2019 were analyZed.

RESULTS

The GAs were located in the M1 segment in 11 (20%) patients, MCA bifurcation in 33 (60%), M2 in 7 (12.7%), and M3 in 4 (7.3%). There were 32 (58.2%) saccular and 23 (41.8%) fusiform GAs. MCA GAs were treated with neck clipping (50.9%), clipping with the artery lumen formation (3.6%), bypass surgeries (34.5%), wrapping (3.6%), and endovascular surgery (7.3%). A worsening of the neurologic state in the perioperative period was observed in 50.9% of patients. The complete closure of GA was achieved in 78.2%. Surgery-related mortality was 1.8%. The long-term outcome was favorable in 76.9% of patients. Surgery-related and disease-related plus treatment failures-related mortality was 9.6%.

CONCLUSIONS

Microsurgical clipping and bypass surgery are the main operative interventions for MCA GA treatment. These operations are technically complex and are followed by a relatively high percentage of complications. The main tasks that require further investigations are the introduction of new precise diagnostic methods for the collateral circulation assessment in the cortical MCA branches, the perfection of the algorithm for the bypass selection, and investigation of the long-term results of the endovascular and combined treatments. It is of major importance to thoroughly observe the patients long-term after the surgery and ensure the possibility for further angiographic studies.

Safety and effectiveness of high flow extracranial to intracranial saphenous vein bypass grafting in the treatment of complex intracranial aneurysms: a single-centre long-term retrospective study

Background

To summarize the safety and effectiveness of high flow extracranial to intracranial saphenous vein bypass grafting in the treatment of complex intracranial aneurysms.

Methods

The data of complex intracranial aneurysms patients for high flow extracranial to intracranial saphenous vein bypass grafting from January 2008 to January 2020 were retrospectively collected and analyzed. Eighty-two patients (31 men and 51 women) with 89 aneurysms underwent 82 saphenous vein bypass grafts followed by immediate parent vessel occlusion. The aneurysm was located at the internal carotid artery, middle cerebral artery, and basilar artery in 75, 11, and 3 cases, respectively.

Results

The patency rate of bypass grafting was 100, 100, 96.3 and 92.4% on intraoperation, on the first postoperative day, at discharge and 6 months follow-up, respectively. At discharge and 6 months follow-up, 3 and 6 patients had graft occlusions. The main postoperative complications were transient hemiparesis and hemianopsia. 3 patients died due to bypass complications and poor physical condition.

Conclusions

High flow extracranial to intracranial saphenous vein bypass grafting is safe and effective in the treatment of complex intracranial aneurysms and the saphenous vein can meet the requirements of brain blood supply. A high rate of graft patency and adequate cerebral blood flow can be achieved.

Highlights

A single-centre long-term retrospective study was conducted to assess the safety and effectiveness of high flow EC-IC saphenous vein bypass grafting in the treatment of complex intracranial aneurysms. The data of 82 patients from January 2008 to January 2020 were retrospectively collected and analysed.

We found the patency rate of bypass grafting was 100, 100, 96.3 and 92.4% on intraoperation, on the first postoperative day, at discharge and 6 months follow-up, respectively. At discharge and 6 months follow-up, 3 and 6 patients had graft occlusions.

Finally, we conclude that high flow extracranial to intracranial saphenous vein bypass grafting is safe and effective in the treatment of complex intracranial aneurysms and the selected blood supply vessels can meet the requirements of blood supply.

As far as we know, this study is one of the maximum number of cases in the treatment of complex intracranial aneurysms with saphenous vein bypass.

Impact of the weekend effect on outcome after microsurgical clipping of ruptured intracranial aneurysms

BACKGROUND

The "weekend effect" describes the assumption that weekend and/or on-call duty admission of emergency patients is associated with increased morbidity and mortality rates. For aneurysmal subarachnoid hemorrhage, we investigated, whether presentation out of regular working hours and microsurgical clipping at nighttime correlates with worse patient outcome.

METHODS

This is a retrospective review of consecutive patients that underwent microsurgical clipping of an acutely ruptured aneurysm at our institution between 2010 and 2019. Patients admitted during (1) regular working hours (Monday-Friday, 08:00-17:59) and (2) on-call duty and microsurgical clipping performed during (a) daytime (Monday-Sunday, 08:00-17:59) and (b) nighttime were compared regarding the following outcome parameters: operation time, treatment-related complications, vasospasm, functional outcome, and angiographic results.

RESULTS

Among 157 enrolled patients, 104 patients (66.2%) were admitted during on-call duty and 48 operations (30.6%) were performed at nighttime. Admission out of regular hours did not affect cerebral infarction (p = 0.545), mortality (p = 0.343), functional outcome (p = 0.178), and aneurysm occlusion (p = 0.689). Microsurgical clipping at nighttime carried higher odds of unfavorable outcome at discharge (OR: 2.3, 95%CI: 1.0-5.1, p = 0.039); however, there were no significant differences regarding the remaining outcome parameters. After multivariable adjustment, clipping at nighttime did not remain as independent prognosticator of short-term outcome (OR: 2.1, 95%CI: 0.7-6.2, p = 0.169).

CONCLUSIONS

Admission out of regular working hours and clipping at nighttime were not independently associated with poor outcome. The adherence to standardized treatment protocols might mitigate the "weekend effect."

Cerebrovascular bypass for ruptured aneurysms: A case series

In patients with aneurysmal subarachnoid hemorrhage (aSAH) unfavorable for endovascular or traditional open surgical techniques, surgical revascularization strategies comprise one of remaining limited options. There is nonetheless a paucity of data on the safety and efficacy of bypass in aSAH. In this study, we aimed to investigate complications and outcomes in a cohort of patients with aSAH treated with bypass. A prospective single-surgeon database of consecutive patients treated for aSAH between 2013 and 2018 was retrospectively analyzed. Complications and functional status at discharge were recorded and analyzed for the patients that underwent bypass surgery. Forty patients with aSAH were treated with bypass surgery (23 extracranial-intracranial; 17 intracranial-intracranial). All-cause perioperative mortality was 13% (6 patients). At discharge and at mean 14-month follow up, respectively, 16/40 (40%) and 16/25 (64%) of patients achieved a Glasgow Outcome Score of 4-5. All-cause, in-hospital complications occurred in 28 patients (70%), of which any ischemic complication occurred in 20 patients (50%), 7 (18%) being open surgical complications. This work represents the largest modern series of bypass for aSAH to date. In cases of aSAH unfavorable for endovascular intervention or traditional open surgical techniques, bypass remains a viable option in this complex group of patients.

Can Young Vascular Neurosurgeons Become Proficient in Microsurgical Clip Reconstruction in the Endovascular Era? A Rotterdam Cohort Spanning 2 Decades with Propensity Score Matching for Complexity

BACKGROUND

Little is known about the results of young vascular neurosurgeons who perform only microsurgical clip reconstruction in the era since the International Subarachnoid Aneurysm Trial (ISAT) or about the training and caseload required to equivocate the results of senior, more experienced colleagues. The aim of this study was to compare clinical outcomes of patients treated by young and senior vascular neurosurgeons at Erasmus MC University Medical Center Rotterdam, adjusting for case mix.

METHODS

A partially prospective and partially retrospective database was used. Hierarchical mixed models with a random intercept for surgeon were used for confounder adjustment, and propensity score matching for complexity was used to create comparable groups.

RESULTS

The study included 609 patients harboring 767 aneurysms. Most (86%) of the aneurysms had at least 1 complexity characteristic, with the majority having 3 characteristics. The most often encountered complexity characteristics were the presence of a broad neck and the presence of branches emerging from the aneurysm. Use of temporary clipping and skull base approaches was significantly higher in the young vascular neurosurgeons group (P < 0.0001). The complexity score differed significantly between senior and young vascular neurosurgeons (P < 0.001). After propensity score matching for complexity, multivariable logistic regression showed young vascular neurosurgeons to be significantly associated with better outcomes for ruptured aneurysms (propensity score weighted odds ratio 0.55 [95% confidence interval 0.35-0.88], P = 0.01).

CONCLUSIONS

In a high-volume neurovascular center where both endovascular and microsurgical treatment options are available, young vascular neurosurgeons can be trained to achieve at least the same results as their senior colleagues despite increased complexity.

Bypass and Deconstructive Technique for Hunt and Hess Grade 3-5 Aneurysmal Subarachnoid Hemorrhage Deemed Unfavorable for Endovascular Treatment: Case Series of Outcomes and Comparison with Clipping

BACKGROUND

Intracranial bypass to treat ruptured aneurysms has been well described in the literature but is largely deferred in patients with higher Hunt and Hess (H & H) grades due to complexity and length of surgery, risk of inducing vasospasm, and poor prognosis. However, there is a paucity of data and no direct comparison with more traditional open surgical techniques. This study investigated outcomes in patients with H & H grade 3-5 aneurysmal subarachnoid hemorrhage (aSAH) unfavorable for stand-alone endovascular treatment managed with bypass compared with direct surgical clipping.

METHODS

A prospective database of patients treated for aSAH with H & H grade 3-5 between 2013 and 2018 was retrospectively analyzed. Complications and functional status at discharge and latest follow-up were compared between patients who underwent bypass surgery versus direct clipping.

RESULTS

Twenty-three patients underwent revascularization, and 60 underwent clipping alone. There were no significant differences in all-cause 30-day mortality (15% vs. 16%; P = 0.97) or Glasgow Outcome Scale and modified Rankin Scale at discharge or median 8-month follow-up (P > 0.67). There was a higher overall stroke rate with revascularization (P = 0.004), specifically endovascular treatment-related stroke (P = 0.049), with no difference in surgical (P = 0.47) or vasospasm-related stroke (P = 0.53). There were no differences in overall complications, medical complications, seizures, reruptures, hydrocephalus, or perioperative death (P > 0.05).

CONCLUSIONS

Bypass is a viable option for patients presenting with higher H & H grade aSAH deemed unfavorable for stand-alone endovascular therapy. Despite obvious differences in aneurysm complexity and a higher risk of stroke, functional outcomes with revascularization can be comparable with clipping in this high-risk patient cohort.

Single Center Experience in Stent-Assisted Coiling of Complex Intracranial Aneurysms Using Low-Profile Stents : The ACCLINO® Stent Versus the ACCLINO® Flex Stent

PURPOSE

The introduction of low-profile stent systems has broadened and facilitated the treatment of complex intracranial aneurysms. This retrospective case series study was conducted to assess and compare the clinical and angiographic outcomes of patients with complex intracranial aneurysms who were treated with ACCLINO® (AS) and ACCLINO® flex stents (AFS).

METHODS

In 85 patients (female 61; male 24) a total of 95 complex intracranial aneurysms, 71 (74.7%) in the anterior circulation and 24 (25.3%) in the posterior circulation were treated. Angiographic and clinical data, aneurysm characteristics and follow-up results were analyzed.

RESULTS

The AS was used in 47 cases (49.5%) and the AFS in 48 cases (50.5%). Initial angiography after the intervention showed a complete occlusion in 52.6% (Raymond-Roy occlusion classification [RROC] 1), a neck remnant in 38.9% (RROC 2) and an incomplete occlusion in 8.4% (RROC 3). Follow-up (AS: 25.2 ± 15.4 months; AFS: 9.6 ± 8.0 months) revealed an occlusion rate of 70.5% (RROC 1), 27.4% (RROC 2) and 2.1% (RROC 3). There was no statistically significant difference between the initial (p = 0.484) and the follow-up occlusion rate (p = 0.284) when comparing the two devices. Recoiling was performed in 8 cases (8.4%). The overall complication rate was 9.5% with 5 strokes (5.3%), 2 hemorrhages (2.1%), 1 in-stent stenosis (1.1%), 1 stent occlusion (1.1%) and 2 stent thromboses (2.1%). There was no procedure-related mortality.

CONCLUSION

Using the ACCLINO® and ACCLINO® flex stent system is a feasible and effective procedure with an acceptable safety profile. Initial and follow-up angiographic results were satisfactory.

Treatment and diagnosis of cerebral aneurysms in the post-International Subarachnoid Aneurysm Trial (ISAT) era: trends and outcomes

BACKGROUND

Following publication of the International Subarachnoid Aneurysm Trial (ISAT), treatment paradigms for cerebral aneurysms (CAs) shifted from open surgical clipping to endovascular embolization as primary therapy in a majority of cases. However, comprehensive analyses evaluating more recent CA diagnosis patterns, patient populations and outcomes as a function of treatment modality remain rare.

METHODS

The National Inpatient Sample from 2004 to 2014 was reviewed. Aneurysmal subarachnoid hemorrhages (aSAHs) and unruptured intracranial aneurysms (UIAs) with a treatment of surgical clipping or endovascular therapy (EVT) were identified. Time trend series plots were created. Linear and logistic regressions were utilized to quantify treatment changes.

RESULTS

114 137 aSAHs and 122 916 UIAs were reviewed. aSAH (+732/year, p=0.014) and UIA (+2550/year, p<0.0001) discharges increased annually. The annual caseload of surgical clippings for aSAH decreased (-264/year, p=0.0002) while EVT increased (+366/year, p=0.0003). For UIAs, the annual caseload for surgical clipping remained stable but increased for EVT (+615/year, p<0.0001). The rate of incidentally diagnosed UIAs increased annually (+1987/year; p<0.0001). Inpatient mortality decreased for clipping (p<0.0001) and EVT in aSAH (p<0.0001) (2004 vs 2014-clipping 13% vs 11.7%, EVT 15.8% vs 12.7%). Mortality rates for clipped UIAs decreased over time (p<0.0001) and remained stable for EVT (2004 vs 2014-clipping 1.57% vs 0.40%, EVT 0.59% vs 0.52%).

CONCLUSION

Ruptured and unruptured CAs are increasingly being treated with EVT over clipping. Incidental unruptured aneurysm diagnoses are increasing dramatically. Mortality rates of ruptured aneurysms are improving regardless of treatment modality, whereas mortality in unruptured aneurysms is only improving for surgical clipping.

Comparative Analysis of Unruptured Cerebral Aneurysm Treatment Outcomes and Complications with the Classic versus Flex Pipeline Embolization Devices and Phenom versus Marksman Microcatheter Delivery System: The Role of Microcatheter Choice on Complication Rate

OBJECTIVE

The second-generation pipeline embolization device (PED), flex, has improved opening and resheathing ability compared to the first-generation classic PED device. A previously reported single-institutional study suggests that the PED flex devices are associated with lower rates of complications. However, there was limited discussion regarding the complication rate with respect to microcatheter choice for PED delivery and deployment. The present study aims to evaluate outcomes of aneurysm treatment with PED flex versus classic along with the Phenom microcatheter versus Marksman microcatheter.

METHODS

A retrospective, IRB-approved database of all patients who received a PED classic or PED flex device between January 2012 and July 2018 was analyzed. Microcatheter choice, patient demographics, medical comorbidities, aneurysm characteristics, treatment information, and outcome data were analyzed using univariate analyses.

RESULTS

A total of 75 PED procedures were analyzed. There was no significant difference in major complications between the PED classic and PED flex. However, those treated using the Marksman microcatheter were more likely to have a major complication (periprocedural hemorrhage or ischemic event; 16.6% vs. 0%, p = 0.0248) than those treated with the Phenom microcatheter. Within the PED flex cohort, all major complications were associated with the Marksman microcatheter (p = 0.0289).

CONCLUSIONS

The present study does not replicate significantly fewer complications with PED flex but demonstrates a significant reduction in complications with the Phenom microcatheter. Ultimately, this suggests multiple factors are involved in achieving positive outcomes and low complication rates in PED treated unruptured cerebral aneurysms.

Warning headache correlates survival rate in aneurysmal subarachnoid hemorrhage

Background

Severe headaches, projectile vomiting, focal neurological deficits and early onset seizure are regarded as early warning symptoms of subarachnoid hemorrhage (SAH). Earlier diagnosis based on such warning symptoms theoretically would improve the clinical prognosis. However, it is still not clear whether the prognosis is correlated with early warning symptoms. Here, we reviewed warning symptoms and other predictive factors in the emergency room (ER) setting and examined their correlations with mortality.

Methods

Ninety saccular aneurysmal SAH cases were reviewed in a single medical center between January 2011 and December 2013. We examined differences in mortality rate related to warning symptoms, SAH scales, onset-to-ER time, hydrocephalus, and aneurysm size, location, and complexity. Logistic regression analyses were performed to determine the correlations of warning symptoms and other predictive factors with mortality. Receiver operating characteristic (ROC) curve analysis was used to calculate the area the under curve (AUC) of SAH mortality prediction tools.

Results

Warning headache, projectile vomiting, the Hunt and Hess scale, Fisher scale, World Federation of Neurological Surgeons (WFNS) grading scale, and modified WFNS (m-WFNS) scale, body mass index, aneurysm complexity and hydrocephalus were significantly different between the survivors and the decedents. The warning headache and WFNS grade were strongly correlated with mortality. The rate of prognostic prediction improved from 90.4% to 94.6% when warning headache was additionally evaluated.

Conclusions

With growing healthcare costs and recognition of the value of palliative care, early identification via warning headache and a detailed clinical history review is necessary for cases of aSAH.

Use of a Polytetrafluoroethylene-Coated Vascular Plug for Focal Intracranial Parent Vessel Sacrifice for Fusiform Aneurysm Treatment

BACKGROUND

Fusiform intracranial aneurysms are challenging due to the circumferential nature of the disease. Endovascular parent vessel sacrifice with coils may be a treatment option, but typically requires a long vessel segment to induce complete cessation of flow.

OBJECTIVE

We evaluate early clinical experience with the intracranial use of the microvascular plug (MVP; Medtronic, Dublin, Ireland) device and to compare to previous coil-only techniques for vertebral artery sacrifice for fusiform vertebral aneurysm.

METHODS

We reviewed patients treated with the MVP for intracranial aneurysms at our institution. As a case-control study, we located 6 control patients who underwent coiling alone for vertebral artery sacrifice. The number of implants, fluoroscopy time, and procedural charges were compared using unpaired t -tests.

RESULTS

Twelve patients underwent vessel sacrifices with MVP. Eight were for vertebral artery dissecting aneurysms. Comparing only vertebral aneurysms, the mean implants was 7 in the MVP group (n = 8) and 19.5 in the coiling group (n = 6; P = .0015). Mean fluoroscopy time was 17.62 min in the MVP group compared to 24.2 min in the coiling group ( P = .07). Procedural costs were less in the MVP group ($19 667.38) compared to coiling ($44 909.50, P = .05). There were no technical failures and no cases with persistent flow in the parent vessel at the end of the procedure.

CONCLUSION

The MVP is a cost-effective device for focal intracranial vessel occlusion in select patients. This is an important tool for cerebrovascular surgeons, particularly in cases of ruptured dissecting vertebral aneurysms.

Bypass Surgery for Complex Internal Carotid Artery Aneurysms: 39 Consecutive Patients

OBJECTIVE

Bypass surgery is a special technique used to treat complex internal carotid artery (ICA) aneurysms. The aim of this retrospective study is to provide a comprehensive description of treatment and outcome of complex ICA aneurysms at different ICA segments (cavernous, supraclinoid, ICA bifurcation) treated with bypass procedures.

METHODS

We identified 39 consecutive patients with 41 complex ICA aneurysms that were treated with 44 bypass procedures between 1998 and 2016. We divided the aneurysms into 3 anatomic subgroups to review our treatment strategy. All the imaging studies and medical records were reviewed for relevant information.

RESULTS

The aneurysm occlusion (n = 34, 83%) or flow modification (n = 5, 12%) was achieved in 39 aneurysms (95%). The long-term bypass patency rate was 68% (n = 30). Minor postoperative ischemia or hemorrhage was commonly seen (n = 20, 51%), but large-scale strokes were rare (n = 1, 3%). Preoperative dysfunction of extraocular muscles (cranial nerves III, IV, and VI) showed low-to-moderate improvement rates (20%-50%). Preoperative vision disturbance (cranial nerve II) improved seldom (22%). At the latest follow-up (mean; 51 months) 29 patients (74%) were independent (modified Rankin Scale ≤2).

CONCLUSIONS

Bypass surgery for complex ICA aneurysms is a feasible treatment method with an acceptable risk profile. Patients should be informed of the uncertainty related to improvement of pretreatment cranial nerve dysfunctions.

Endovascular treatment of complex intracranial aneurysms

PURPOSE

Complex intracranial aneurysms (CIA) are heterogenous group of intracranial vascular malformations. Due to its giant size, difficult location, broad neck, branches arising from the aneurysm, wall structure, calcification, presence of intraluminal thrombus or previous treatments it requires more careful approach. The aim of this study was to evaluate endovascular treatment results of CIA in our Department.

MATERIAL AND METHODS

In order to differentiate CIA from all the aneurysms, treated endovascularly in years 2008-2014, authors proposed their own qualification criteria. Additionally, subgroup of patients with CIA with simultaneous subarachnoid haemorrhage (SAH) was divided. Clinical outcomes of patients were assessed with Glasgow Outcome Scale (GOS), while radiological outcomes were assessed with Montreal Scale. Aneurysm localization, incidence of aborted procedures, intraoperative complications were also evaluated.

RESULTS

Internal carotid artery was the most common localization in both CIA and non-complex (nCIA) groups. Incidence of aborted procedures was significantly higher in CIA group than in nCIA (25% vs. 7%; p < 0.01). CIA group had worse Montreal scores then nCIA group (1.90 vs. 1.49; p < 0.01). Clinical outcome in GOS scale in patients with SAH and CIA was significantly worse than in SAH and nCIA (2.86 vs. 4.06; p = 0.04).

CONCLUSIONS

To conclude, proposed criteria of CIA should be taken into consideration during diagnosis and qualification to invasive treatment. Classifying aneurysm as CIA is related to greater possibility of aborting endovascular procedure due to technical difficulties.

Bypass Surgery for Complex Intracranial Aneurysms: 15 Years of Experience at a Single Institution and Review of Pertinent Literature

BACKGROUND

Bypass surgery is a treatment option for complex intracranial aneurysms.

OBJECTIVE

To determine the utility of bypass surgery for the treatment of complex intracranial aneurysms and to review the literature on this topic.

METHODS

Sixty-two patients were included in this retrospective study. Unruptured aneurysms were dominant (80.6%), and the internal carotid artery was the most common location of the aneurysm (56.4%), followed by the middle cerebral artery (21.0%). The mean maximal diameter of the aneurysms was 20.5 ± 11.4 mm. The clinical and angiographic states were evaluated preoperatively, immediately after surgery (within 3 days) and at the last follow-up. The mean angiographic and clinical follow-up duration was 34.2 ± 38.9 and 46.5 ± 42.5 months, respectively.

RESULTS

Sixty-one patients (98.3%) underwent extracranial–intracranial bypass, and 1 underwent intracranial–intracranial bypass. At the last follow-up angiography, 58 aneurysms (93.5%) were completely obliterated and 4 were incompletely obliterated, with a graft patency of 90.3%. Surgical mortality was 0 and permanent morbidity was 8.1%. A good clinical outcome (Karnofsky Performance Scale ≥ 70 and modified Rankin Scale score ≤ 2) was achieved in 91.9% of patients (n = 57).

CONCLUSION

With a proper selection of bypass type, bypass-associated treatment can be a good alternative for patients with complex intracranial aneurysms when conventional microsurgical clipping or endovascular intervention is not feasible.

Treatment of complex intracranial aneurysm: Case report of the simultaneous use of endovascular and microsurgical techniques

Background:

The surgical treatment of complex intracranial aneurysms (CIAs) represents a significant challenge to the skill and expertise of the neurosurgeon. The natural history of complex cerebrovascular lesions is especially unfavorable because of the pressure effect on adjacent areas, the risk of embolism in the presence of intraluminal thrombi, and the possibility of hemorrhage through leakage or rupture of the aneurysm. The surgical strategy must be customized for each case in order to maximize the treatment effectiveness and the safety of the patient.

Case Description:

A 68-year-old woman presented with a 10-month history of atypical headaches but no other neurological symptoms. Computed tomography scan and digital subtraction angiography revealed an unruptured saccular aneurysm on the M1 segment of the right middle cerebral artery. The lesion was 21 mm in length in its largest diameter and with an undefined neck (extensive involvement of the walls of the afferent vessel). Craniotomy was performed in order to expose the lesion and allow microsurgical dissection of the neck of the aneurysm and its adjacent structures. A balloon catheter was navigated via the internal carotid artery to a position alongside the aneurysm neck. With the balloon fully inflated, the aneurysm was punctured and drained, and a guide clip was located at the neck of the aneurysm. Additional clips were applied using a similar procedure to ensure the exclusion of the aneurysm.

Conclusion:

The patient recovered without complications and complete occlusion of the CIA was confirmed on follow-up angiography. A modified Rankin score of 0 was attributed to the patient 6 months after treatment. A multidisciplinary perspective is important in planning and executing the treatment of CIAs.

Use of a flow-diverting stent for ruptured dissecting aneurysm treatment in a patient with sickle cell disease

INTRODUCTION

Sickle cell disease (SCD) is a clinical phenotype that presents a unique challenge to the interventionalist, particularly when stent therapy is contemplated. Homozygous individuals are likely at increased risk for thromboembolic complications. There are no formal guidelines regarding antiplatelet therapy in the short or long term for intracranial stent use in SCD. The authors describe the novel use of a pipeline embolization device (PED) to treat a ruptured dissecting bilobed/fusiform vertebral artery V4 aneurysm in an SCD patient complicated by tortuous proximal anatomy and the anterior spinal artery arising from the diseased segment. Considerations regarding antiplatelet therapy in this scenario are discussed.

CASE REPORT

A 50-year-old woman with homozygous recessive SCD was transported to the emergency department and presented with diffuse subarachnoid hemorrhage. CT angiography demonstrated a left-sided 3 × 5 mm fusiform bi-lobulated presumed dissecting vertebral artery aneurysm, immediately distal to the origin of the posterior inferior cerebellar artery (PICA). A PED was deployed within the V4 segment across the aneurysm. Post-treatment angiography showed patency of the parent artery, and patency of the "jailed" anterior spinal artery and of the PICA.

DISCUSSION

Selecting a treatment method in SCD patients with a ruptured intracranial aneurysm is challenging and there are no clinical trials comparing treatment methods in this population. The authors demonstrate that flow diversion is feasible in SCD, which has not been described in the literature. Additionally, the case stresses the peri- and post-procedural management of SCD, as well as long-term considerations with a flow-diverting stent in place.