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Versyck G, van Loon J, Lemmens R, Demeestere J, Bonne L, Peluso JP, De Vleeschouwer S. An overview of decision-making in cerebrovascular treatment strategies: Part I - unruptured aneurysms. BRAIN & SPINE 2024; 4:103331. [PMID: 39309547 PMCID: PMC11416541 DOI: 10.1016/j.bas.2024.103331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 08/28/2024] [Accepted: 09/04/2024] [Indexed: 09/25/2024]
Abstract
Introduction Unruptured intracranial aneurysm treatment has evolved over the last two centuries, starting from the introduction of aneurysm ligation and clipping, up until the inception of endovascular treatment and further advancements in both fields. Research question The wide variety of aneurysm presentations and possible treatment modalities, complicates the understanding of decision-making for the treatment of a given aneurysm. The goal of this article is to provide an overview of the best available evidence concerning unruptured intracranial aneurysm decision-making and identify insights and hiatuses, as well as providing a scaffold to surpass the subjectiveness of decision-making. Materials and methods A literature review was performed for the most impactful articles on decision-making in unruptured intracranial aneurysm treatment, to provide an overview on current practice. Results Two groups of decision-altering factors were identified; patient-related and aneurysm-related factors. A summary is presented of the general evidence, and the influence of age, aneurysmal mass-effect, as well as size, morphological aspects and specific anatomical locations on decision-making. Discussion and conclusion Decision-making for an unruptured intracranial aneurysm often comes down to combining these different patient- and aneurysm-related factors. In this paper, an evidence-based overview is provided into these different factors which alter management of unruptured saccular aneurysms.
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Affiliation(s)
- Georges Versyck
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - Johannes van Loon
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
- Neuro-vascular Unit, University Hospitals Leuven, Leuven Brain Institute (LBI), Belgium
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
- Neuro-vascular Unit, University Hospitals Leuven, Leuven Brain Institute (LBI), Belgium
| | - Jelle Demeestere
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
- Neuro-vascular Unit, University Hospitals Leuven, Leuven Brain Institute (LBI), Belgium
| | - Lawrence Bonne
- Department of Interventional Radiology, University Hospitals Leuven, Leuven, Belgium
- Neuro-vascular Unit, University Hospitals Leuven, Leuven Brain Institute (LBI), Belgium
| | - Jo P. Peluso
- Department of Interventional Radiology, University Hospitals Leuven, Leuven, Belgium
- Neuro-vascular Unit, University Hospitals Leuven, Leuven Brain Institute (LBI), Belgium
| | - Steven De Vleeschouwer
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
- Neuro-vascular Unit, University Hospitals Leuven, Leuven Brain Institute (LBI), Belgium
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Brandel MG, Plonsker JH, Rennert RC, Produturi G, Saripella M, Wali AR, McCann C, Ravindra VM, Santiago-Dieppa DR, Pannell JS, Steinberg JA, Khalessi AA, Levy ML. Treatment of pediatric intracranial aneurysms: institutional case series and systematic literature review. Childs Nerv Syst 2024; 40:2419-2429. [PMID: 38635071 PMCID: PMC11269470 DOI: 10.1007/s00381-024-06384-x] [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: 03/18/2024] [Accepted: 03/27/2024] [Indexed: 04/19/2024]
Abstract
INTRODUCTION Pediatric intracranial aneurysms (IAs) are rare and have distinct clinical profiles compared to adult IAs. They differ in location, size, morphology, presentation, and treatment strategies. We present our experience with pediatric IAs over an 18-year period using surgical and endovascular treatments and review the literature to identify commonalities in epidemiology, treatment, and outcomes. METHODS We identified all patients < 20 years old who underwent treatment for IAs at our institution between 2005 and 2020. Medical records and imaging were examined for demographic, clinical, and operative data. A systematic review was performed to identify studies reporting primary outcomes of surgical and endovascular treatment of pediatric IAs. Demographic information, aneurysm characteristics, treatment strategies, and outcomes were collected. RESULTS Thirty-three patients underwent treatment for 37 aneurysms over 18 years. The mean age was 11.4 years, ranging from one month to 19 years. There were 21 males (63.6%) and 12 females (36.4%), yielding a male: female ratio of 1.75:1. Twenty-six (70.3%) aneurysms arose from the anterior circulation and 11 (29.7%) arose from the posterior circulation. Aneurysmal rupture occurred in 19 (57.5%) patients, of which 8 (24.2%) were categorized as Hunt-Hess grades IV or V. Aneurysm recurrence or rerupture occurred in five (15.2%) patients, and 5 patients (15.2%) died due to sequelae of their aneurysms. Twenty-one patients (63.6%) had a good outcome (modified Rankin Scale score 0-2) on last follow up. The systematic literature review yielded 48 studies which included 1,482 total aneurysms (611 with endovascular treatment; 656 treated surgically; 215 treated conservatively). Mean aneurysm recurrence rates in the literature were 12.7% and 3.9% for endovascular and surgical treatment, respectively. CONCLUSIONS Our study provides data on the natural history and longitudinal outcomes for children treated for IAs at a single institution, in addition to our treatment strategies for various aneurysmal morphologies. Despite the high proportion of patients presenting with rupture, good functional outcomes can be achieved for most patients.
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Affiliation(s)
- Michael G Brandel
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, USA
| | - Jillian H Plonsker
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, USA
| | - Robert C Rennert
- Department of Neurosurgery, University of Utah, 175 North Medical Drive East, Salt Lake City, CA, USA
| | - Gautam Produturi
- School of Medicine, University of California, San Diego, CA, USA
| | - Megana Saripella
- School of Medicine, University of California, San Diego, CA, USA
| | - Arvin R Wali
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, USA
| | - Carson McCann
- School of Medicine, University of California, San Diego, CA, USA
| | - Vijay M Ravindra
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, USA
| | - David R Santiago-Dieppa
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, USA
| | - J Scott Pannell
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, USA
| | - Jeffrey A Steinberg
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, USA
| | - Alexander A Khalessi
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, USA
| | - Michael L Levy
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, USA.
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Brunasso L, Di Bonaventura R, Sturiale CL, Albanese A. Letter to the Editor Regarding "The Nightmare of Aneurysm Surgery: Intraoperative Rupture". World Neurosurg 2024; 185:485-486. [PMID: 38741318 DOI: 10.1016/j.wneu.2024.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 02/05/2024] [Indexed: 05/16/2024]
Affiliation(s)
- Lara Brunasso
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, University of Palermo, Palermo, Italy.
| | - Rina Di Bonaventura
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | | | - Alessio Albanese
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy; Institute of Neurosurgery, Catholic University of the Sacred Heart, Rome, Italy
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Pineda-Castillo SA, Jones ER, Laurence KA, Thoendel LR, Cabaniss TL, Zhao YD, Bohnstedt BN, Lee CH. Systematic Review and Meta-Analysis of Endovascular Therapy Effectiveness for Unruptured Saccular Intracranial Aneurysms. STROKE (HOBOKEN, N.J.) 2024; 4:e001118. [PMID: 38846323 PMCID: PMC11152505 DOI: 10.1161/svin.123.001118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 11/13/2023] [Indexed: 06/09/2024]
Abstract
Background Currently, endovascular treatment of intracranial aneurysms (ICAs) is limited by low complete occlusion rates. The advent of novel endovascular technology has expanded the applicability of endovascular therapy; however, the superiority of novel embolic devices over the traditional Guglielmi detachable coils (GDCs) is still debated. We performed a systematic review of literature that reported Raymond-Roy occlusion classification (RROC) rates of modern endovascular devices to determine their immediate and follow-up occlusion effectiveness for the treatment of unruptured saccular ICAs. Methods A search was conducted using electronic databases (PUBMED, Cochrane, ClinicalTrials.gov, Web of Science). We retrieved studies published between 2000-2022 reporting immediate and follow-up RROC rates of subjects treated with different endovascular ICA therapies. We extracted demographic information of the treated patients and their reported angiographic RROC rates. Results A total of 80 studies from 15 countries were included for data extraction. RROC rates determined from angiogram were obtained for 21,331 patients (72.5% females, pooled mean age: 58.2 (95% CI: 56.8-59.6), harboring 22,791 aneurysms. The most frequent aneurysm locations were the internal carotid artery (46.4%, 95% CI: 41.9%-50.9%), the anterior communicating artery (26.4%, 95% CI: 22.5%-30.8%), the middle cerebral artery (24.5%, 95% CI:19.2%-30.8%) and the basilar tip (14.4%, 95% CI:11.3%-18.3%). The complete occlusion probability (RROC-I) was analyzed for GDCs, the Woven EndoBridge (WEB), and flow diverters. The RROC-I rate was the highest in balloon-assisted coiling (73.9%, 95% CI: 65.0%-81.2%) and the lowest in the WEB (27.8%, 95% CI:13.2%-49.2%). The follow-up RROC-I probability was homogenous in all analyzed devices. Conclusions We observed that the coil-based endovascular therapy provides acceptable rates of complete occlusion, and these rates are improved in balloon-assisted coils. Out of the analyzed devices, the WEB exhibited the shortest time to achieve >90% probability of follow-up complete occlusion (~18 months). Overall, the GDCs remain the gold standard for endovascular treatment of unruptured saccular aneurysms.
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Affiliation(s)
- Sergio A. Pineda-Castillo
- Biomechanics and Biomaterials Design Laboratory, School of Aerospace and Mechanical Engineering, The University of Oklahoma, Norman, OK, USA
| | - Evan R. Jones
- Biomechanics and Biomaterials Design Laboratory, School of Aerospace and Mechanical Engineering, The University of Oklahoma, Norman, OK, USA
| | - Keely A. Laurence
- Biomechanics and Biomaterials Design Laboratory, School of Aerospace and Mechanical Engineering, The University of Oklahoma, Norman, OK, USA
| | - Lauren R. Thoendel
- Biomechanics and Biomaterials Design Laboratory, School of Aerospace and Mechanical Engineering, The University of Oklahoma, Norman, OK, USA
| | - Tanner L. Cabaniss
- Biomechanics and Biomaterials Design Laboratory, School of Aerospace and Mechanical Engineering, The University of Oklahoma, Norman, OK, USA
| | - Yan D. Zhao
- Department of Biostatistics and Epidemiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Bradley N. Bohnstedt
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Chung-Hao Lee
- Biomechanics and Biomaterials Design Laboratory, School of Aerospace and Mechanical Engineering, The University of Oklahoma, Norman, OK, USA
- Department of Bioengineering, University of California Riverside, Riverside, CA, USA
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Peng L, Qin H, Liu J, Wu N, Wang X, Han L, Ding X. Neurosurgical clipping versus endovascular coiling for patients with ruptured anterior circulation aneurysms: A systematic review and meta-analysis. Neurosurg Rev 2024; 47:68. [PMID: 38267600 DOI: 10.1007/s10143-024-02304-4] [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: 11/17/2023] [Revised: 12/28/2023] [Accepted: 01/16/2024] [Indexed: 01/26/2024]
Abstract
To compare the safety and efficacy of clipping and coiling in patients with ruptured anterior circulation aneurysms. A systematic search of four databases (PubMed, Web of Science, Cochrane Library, and Embase) was conducted to identify comparative articles on endovascular coiling and surgical clipping in patients with ruptured anterior circulation aneurysms. Meta-analyses were conducted using random-effects models. Nineteen studies, including 1983 patients, were included. The meta-analysis showed that neurosurgical clipping was associated with a lower incidence of retreatment (OR:0.28, 95% CI (0.11, 0.70), P = 0.006) than endovascular coiling, which seemed to be a result of incomplete occlusion (OR:0.22, 95% CI (0.11, 0.45), P < 0.001). Neurosurgical clipping was associated with lower mortality (OR:0.45, 95% CI (0.25, 0.82), P = 0.009) at short-term follow-up than endovascular coiling. However, neurosurgical clipping showed a higher incidence of ischemic infarction (OR:2.28, 95% CI (1.44, 3.63), P < 0.001) and a longer length of stay (LOS) (WMD:6.12, 95% CI (4.19, 8.04), P < 0.001) after surgery than endovascular coiling. Furthermore, the pooled results showed no statistically significant differences between the two groups regarding poor outcome, long-term mortality, rebleeding, vasospasm, and hydrocephalus. Evidence from this systematic review illustrates that neurosurgical clipping may be superior to endovascular coiling for ruptured anterior circulation aneurysms. Large-scale RCTs should be conducted to verify these outcomes and provide results according to patient status.
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Affiliation(s)
- Liangsheng Peng
- Department of Neurosurgery, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Hao Qin
- Department of Neurosurgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030032, China
| | - Jiahao Liu
- Department of Neurosurgery, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Nuojun Wu
- Department of Internal Medicine, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Xiaolong Wang
- Department of Neurosurgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030032, China
| | - Li Han
- Department of Neurosurgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030032, China
| | - Xinmin Ding
- Department of Neurosurgery, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China.
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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Pettersson SD, Khorasanizadeh M, Maglinger B, Garcia A, Wang SJ, Taussky P, Ogilvy CS. Trends in the Age of Patients Treated for Unruptured Intracranial Aneurysms from 1990 to 2020. World Neurosurg 2023; 178:233-240.e13. [PMID: 37562685 DOI: 10.1016/j.wneu.2023.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND The decision for treatment for unruptured intracranial aneurysms (UIAs) is often difficult. Innovation in endovascular devices have improved the benefit-to-risk profile especially for elderly patients; however, the treatment guidelines from the past decade often recommend conservative management. It is unknown how these changes have affected the overall age of the patients selected for treatment. Herein, we aimed to study potential changes in the average age of the patients that are being treated over time. METHODS A systematic search of the literature was performed to identify all studies describing the age of the UIAs that were treated by any modality. Scatter diagrams with trend lines were used to plot the age of the patients treated over time and assess the presence of a potential significant trend via statistical correlation tests. RESULTS A total of 280 studies including 83,437 UIAs treated between 1987 and 2021 met all eligibility criteria and were entered in the analysis. Mean age of the patients was 55.5 years, and 70.7% were female. There was a significant increasing trend in the age of the treated patients over time (Spearman r: 0.250; P < 0.001), with a 1-year increase in the average age of the treated patients every 5 years since 1987. CONCLUSIONS The present study indicates that based on the treated UIA patient data published in the literature, older UIAs are being treated over time. This trend is likely driven by safer treatments while suggesting that re-evaluation of certain UIA treatment decision scores may be of great interest.
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Affiliation(s)
- Samuel D Pettersson
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - MirHojjat Khorasanizadeh
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Benton Maglinger
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Alfonso Garcia
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - S Jennifer Wang
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Philipp Taussky
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
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Li G, Chen S, Han J, Pan W, Ji P. Comparative study on the clinical outcomes and prognosis of endovascular embolization and craniotomy clipping for the treatment of cerebral aneurysms. Pak J Med Sci 2023; 39:1296-1300. [PMID: 37680810 PMCID: PMC10480711 DOI: 10.12669/pjms.39.5.7401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 11/28/2022] [Accepted: 05/25/2023] [Indexed: 09/09/2023] Open
Abstract
Objective To investigate the safety and outcomes of endovascular embolization and craniotomy clipping in the treatment of cerebral aneurysms. Methods We collected the clinical data of 106 patients with cerebral aneurysm who underwent surgical treatment (endovascular embolization, Group-A, n=55; craniotomy clipping, Group-B, n=51) in the First People's Hospital of Yichang from January 2020 to May 2021. We compared surgical treatment indexes, treatment costs, neurological function before and after the treatment, incidence of postoperative complications and the prognosis after one-year follow-up between the two groups. Results Endovascular embolization (Group-A) was associated with a shorter mean operation time and hospital stay, a lower mean intraoperative bleeding amount, and a higher mean treatment cost than craniotomy clipping (Group-B) (P<0.05). Compared with the pre-operative neurological function scores, the scores of both groups decreased after the surgery, and the mean post-operative score of Group-A was significantly lower than that of Group-B (P<0.05). Compared with Group-B , patients in Group-A had a lower overall complication rate (P < 0.05. Higher proportion of patients in Group-A had a good prognosis (P < 0.05). Conclusion Endovascular embolization for the treatment of cerebral aneurysms is safe as it can shorten the operation time and hospital stay, reduce the incidence of neurological injury and complications, and have a favorable prognosis. However, the treatment is more expensive. Endovascular embolization can be selected for the treatment of cerebral aneurysms when economic conditions allow it.
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Affiliation(s)
- Gang Li
- Gang Li, Department of Neurosurgery, The First People’s Hospital of Yichang, People’s Hospital of Three Gorges University, Yichang 443000, Hubei Province, P.R. China
| | - Shaojun Chen
- Shaojun Chen, Department of Neurosurgery, The First People’s Hospital of Yichang, People’s Hospital of Three Gorges University, Yichang 443000, Hubei Province, P.R. China
| | - Jing Han
- Jing Han, Department of Neurosurgery, The First People’s Hospital of Yichang, People’s Hospital of Three Gorges University, Yichang 443000, Hubei Province, P.R. China
| | - Wanxi Pan
- Wanxi Pan, Department of Neurosurgery, The First People’s Hospital of Yichang, People’s Hospital of Three Gorges University, Yichang 443000, Hubei Province, P.R. China
| | - Ping Ji
- Ping Ji, The People’s Hospital of China Three Gorges University, The First People’s Hospital Of Yichang, Hubei Province, 443000, P.R. China
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Rossmann T, Veldeman M, Nurminen V, Huhtakangas J, Niemelä M, Lehecka M. 3D Exoscopes are Noninferior to Operating Microscopes in Aneurysm Surgery: Comparative Single-Surgeon Series of 52 Consecutive Cases. World Neurosurg 2023; 170:e200-e213. [PMID: 36334715 DOI: 10.1016/j.wneu.2022.10.106] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The literature on exoscope use in cerebrovascular neurosurgery is scarce, mainly comprising small case series and focused on visualization quality and ergonomics. As these devices become widely used, direct comparison to the operating microscope regarding efficacy and patient safety is necessary. METHODS Fifty-two consecutive clipping procedures, performed by 1 senior vascular neurosurgeon, were analyzed. Either an operating microscope with a mouth switch (25 cases with 27 aneurysms; 13 ruptured) or a three-dimensional exoscope with a foot switch (27 cases with 34 aneurysms; 6 ruptured) were used. Durations of major surgical stages, number of device adjustments, numbers of clip repositionings and clips implanted were extracted from surgical videos. Demographic data, imaging characteristics, clinical course and outcomes were extracted from digital patient records. RESULTS Duration of surgery and different stages did not differ between devices, except for final site inspection. The number of device adjustments was higher with the exoscope. With progressive experience in exoscope use, the number of device adjustments increased significantly, whereas surgery duration remained unchanged. Favorable outcome (modified Rankin Scale score 0-2) was observed in 80% and 88% of patients in the microscope and exoscope groups, respectively. Ischemic events were found in 2 patients in each group; no other complications occurred. CONCLUSIONS In aneurysm clipping, three-dimensional exoscopes are noninferior to operating microscopes in terms of surgery duration, safety, and outcomes, based on our limited series. Progressive experience enables the surgeon to perform significantly more device adjustments within the same amount of surgical time.
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Affiliation(s)
- Tobias Rossmann
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland; Department of Neurosurgery, Neuromed Campus, Kepler University Hospital, Linz, Austria.
| | - Michael Veldeman
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland; Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Ville Nurminen
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Justiina Huhtakangas
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Mika Niemelä
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Martin Lehecka
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
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Krueger EM, Farhat H. Elective Endovascular Treatment of Unruptured Intracranial Aneurysms. Cureus 2022; 14:e27515. [PMID: 36060362 PMCID: PMC9424830 DOI: 10.7759/cureus.27515] [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] [Accepted: 07/30/2022] [Indexed: 11/05/2022] Open
Abstract
Background Elective endovascular treatment (EVT) of unruptured intracranial aneurysms (UIA) is a commonly used treatment modality. However, the appropriate post-procedure management is not well-defined. Methods This was a single-center, retrospective review of all adults undergoing EVT of UIA performed between January 1, 2010, and March 31, 2020. Patients with any current intracranial hemorrhage or clinical symptoms severe enough to warrant emergent intervention were excluded. Results Sixty-seven UIA were treated on 58 patients. The mean dome diameter was 6.6 mm (2-20, ±3.9), the most common parent vessel was the internal carotid artery (43.2%, 29/67), and sole flow diverter stents were the most common device used (46.2%, 31/67). Post-treatment, 43.2% (29/67) patients went to the neurocritical care unit (NCCU). The mean NCCU length of stay (LOS) was 1.07 days (range 1-4, ±0.5), and 96.6% (28/29) only spent one day in the NCCU.
There were no (0%, 0/67) anesthesia-related procedural complications. One (1.5%, 1/67) intra-procedural complication was an aneurysm rupture during attempted coiling. There were five (7.4%, 5/67) post-procedural complications: two (3.0%, 2/67) groin hematomas, two (3.0%, 2/67) permanent neurologic events (left lower extremity hypoesthesia and left upper extremity hemiparesis), and one (1.5%, 1/67) temporary neurologic event (aphasia). Post-procedural complications were associated with longer hospital LOS (p=0.02), but not with longer NCCU LOS. No acute management changes occurred for the five patients that developed post-procedural complications. There were no (0%, 0/67) 30-day readmissions. Conclusion The overall incidence of post-procedure complications was low. In the future, a possible viable way to reduce hospital costs may involve utilizing a hospital unit that could closely monitor patients but only for a short period of time post-procedure.
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10
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Nussbaum ES, Touchette JC, Madison MT, Goddard JK, Lassig JP, Meyers ME, Torok CM, Carroll JJ, Lowary J, Janjua T, Nussbaum LA. Procedural complications in patients undergoing microsurgical treatment of unruptured intracranial aneurysms: a single-center experience with 1923 aneurysms. Acta Neurochir (Wien) 2022; 164:525-535. [PMID: 34562151 DOI: 10.1007/s00701-021-04996-9] [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: 01/27/2021] [Accepted: 08/27/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND With the growing use of endovascular therapy (EVT) to manage unruptured intracranial aneurysms (IAs), detailed information regarding periprocedural complication rates of microsurgical clipping and EVT becomes increasingly important in determining the optimal treatment for individual cases. We report the complication rates associated with open microsurgery in a large series of unruptured IAs and highlight the importance of maintaining surgical skill in the EVT era. METHODS We reviewed all cases of unruptured IAs treated with open microsurgery by a single neurosurgeon between July 1997 and June 2019. We analyzed surgical complications, deaths, and patient-reported outcomes. RESULTS A total of 1923 unruptured IAs in 1750 patients (mean age 44 [range: 6-84], 62.0% [1085/1750] female) were treated surgically during the study period. Of the aneurysms treated, 84.9% (1632/1923) were small, 11.1% (213/1923) were large, and 4.1% (78/1923) were giant. Aneurysm locations included the middle cerebral artery (44.2% [850/1923]), internal carotid artery (29.1% [560/1923]), anterior cerebral artery (21.0% [404/1923]), and vertebrobasilar system (5.7% [109/1923]). The overall mortality rate was 0.3% (5/1750). Surgical complications occurred in 7.4% (129/1750) of patients, but only 0.4% (7/1750) experienced permanent disability. The majority of patients were able to return to their preoperative lifestyles with no modifications (95.9% [1678/1750]). CONCLUSIONS At a high-volume, multidisciplinary center, open microsurgery in carefully selected patients with unruptured IAs yields favorable clinical outcomes with low complication rates. The improvement of EVT techniques and the ability to refer cases for EVT when a high complication rate with open microsurgery was expected have contributed to an overall decrease in surgical complication rates. These results may serve as a useful point of reference for physicians involved in treatment decision-making for patients with unruptured IAs.
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Patient-Reported Outcome for Endovascular Treatment versus Microsurgical Clipping in Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2021; 155:e695-e703. [PMID: 34500096 DOI: 10.1016/j.wneu.2021.08.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 08/26/2021] [Accepted: 08/27/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Aneurysmal subarachnoid hemorrhage has a high mortality with significant impact on quality of life despite effective management strategies including endovascular treatment and/or microsurgical clipping. Although the modalities have undergone clinical comparison, they have not been evaluated on patient-reported outcomes (PROs). This study compared endovascular versus microsurgical treatment using a PRO measure. METHODS We conducted a cross-sectional telephonic survey of adult patients conducted at Hamad General Hospital, Doha, Qatar between 2017 and 2019. Candidate study participants were identified from procedure logs and hospital electronic health records for endovascular treatment (N = 32) versus microsurgical clipping (N = 32) of cerebral aneurysm. The primary outcome measure was the short version of the Stroke-Specific Quality of Life (SS-QoL) measure. The secondary outcome measure was the screened clinician-reported modified Rankin Scale (mRS) for all screened patients (n = 137). Mean scores were compared for the 2 treatment groups. RESULTS The SS-QoL mean score was 4.23 (standard deviation ± 0.77) in endovascular treatment and 4.19 ± 0.19 in surgical clipping (P = 0.90). In exploratory analysis, mean physical domain score was 3.17 ± 0.60 versus 2.98 ± 0.66 in endovascular treatment and surgical clipping groups, respectively. Mean psychosocial domain scores were 4.43 ± 0.85 versus 4.18 ± 0.0.92, respectively. In multivariable analysis, none of the clinical variables were significantly related to SS-QoL except vasospasm irrespective of intervention received. In secondary outcome analysis, modified Rankin Scale score was higher for endovascular treatment (P = 0.04). CONCLUSIONS Published evidence has supported clinical benefits of endovascular treatment for cerebral aneurysm treatment, but this study did not find any difference in PROs. Future studies of treatments should include PRO to identify potential differences from the patient's perspective.
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SDF-1α/CXCR4 Pathway Mediates Hemodynamics-Induced Formation of Intracranial Aneurysm by Modulating the Phenotypic Transformation of Vascular Smooth Muscle Cells. Transl Stroke Res 2021; 13:276-286. [PMID: 34173205 DOI: 10.1007/s12975-021-00925-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 05/29/2021] [Accepted: 06/02/2021] [Indexed: 10/21/2022]
Abstract
The objective of this study is to explore the role of the SDF-1α/CXCR4 pathway in the development of intracranial aneurysm (IA) induced by hemodynamic forces. We collected 12 IA and six superficial temporal artery samples for high-throughput sequencing, hematoxylin and eosin staining, and immunohistochemistry to examine vascular remodeling and determine the expression of the components of the SDF-1α/CXCR4 pathway, structural proteins (α-SMA and calponin) of vascular smooth muscle cells (VSMCs), and inflammatory factors (MMP-2 and TNF-α). Computational fluid dynamics (CFD) was used for hemodynamic analysis. Mouse IA model and dynamic co-culture model were established to explore the mechanism through which the SDF-1α/CXCR4 pathway regulates the phenotypic transformation of VSMCs in vivo and in vitro. We detected a significant elevation of SDF-1α and CXCR4 in IA, which was accompanied by vascular remodeling in the aneurysm wall (i.e., the upregulation of inflammatory factors, MMP-2 and TNF-α, and the downregulation of contractile markers, α-SMA and calponin). In addition, hemodynamic analysis revealed that compared with unruptured aneurysms, ruptured aneurysms were associated with lower wall shear stress and higher MMP-2 expression. In vivo and in vitro experiments showed that abnormal hemodynamics could activate the SDF-1α/CXCR4, P38, and JNK signaling pathways to induce the phenotypic transformation of VSMCs, leading to IA formation. Hemodynamics can induce the phenotypic transformation of VSMCs and cause IA by activating the SDF-1α/CXCR4 signaling pathway.
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Koo AB, Elsamadicy AA, Lin IH, David WB, Sujijantarat N, Santarosa C, Cord BJ, Zetchi A, Hebert R, Bahrassa F, Malhotra A, Matouk CC. Predictors of Extended Length of Stay Following Treatment of Unruptured Adult Cerebral Aneurysms: A Study of The National Inpatient Sample. J Stroke Cerebrovasc Dis 2020; 29:105230. [PMID: 33066916 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105230] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/26/2020] [Accepted: 07/30/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND In an unprecedented era of soaring healthcare costs, payers and providers alike have started to place increased importance on measuring the quality of surgical procedures as a surrogate for operative success. One metric used is the length of hospital stay (LOS) during index admission. For the treatment of unruptured cerebral aneurysms, the determinants of extended length of stay are relatively unknown. The aim of this study was to identify the patient- and hospital-level factors associated with extended LOS following treatment for unruptured cerebral aneurysms. METHODS The National Inpatient Sample years 2010 - 2014 was queried. Adults (≥18 years) with unruptured aneurysms undergoing either clipping or coiling were selected using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Extended LOS was defined as greater than 75th percentile for the entire cohort (>5 days). Weighted patient demographics, comorbidities, complications, LOS, disposition and total cost were recorded. Multivariate logistic regression was used to determine the odds ratio for risk-adjusted extended LOS. The primary outcome was the degree which patient comorbidities or postoperative complications correlated with extended LOS. RESULTS A total of 46,880 patients were identified for which 9,774 (20.8%) patients had extended LOS (Normal LOS: 37,106; Extended LOS: 9,774). Patients in the extended LOS cohort presented with a greater number of comorbidities compared to the normal LOS cohort. A greater proportion of the normal LOS cohort was coiled (Normal LOS: 63.0% vs. Extended LOS: 33.5%, P<0.001), while more patients in the extended LOS cohort were clipped (Normal LOS: 37.0% vs. Extended LOS: 66.5%, P<0.001). The overall complication rate was higher in the extended LOS cohort (Normal LOS: 7.3% vs. Extended LOS: 43.8%, P<0.001). On average, the extended LOS cohort incurred a total cost nearly twice as large (Normal LOS: $26,050 ± 13,430 vs. Extended LOS: $52,195 ± 37,252, P<0.001) and had more patients encounter non-routine discharges (Normal LOS: 8.5% vs. Extended LOS: 52.5%, P<0.001) compared to the normal LOS cohort. On weighted multivariate logistic regression, multiple patient-specific factors were associated with extended LOS. These included demographics, preadmission comorbidities, choice of procedure, and inpatient complications. The odds ratio for extended LOS was 5.14 (95% CI, 4.30 - 6.14) for patients with 1 complication and 19.58 (95% CI, 15.75 - 24.34) for patients with > 1 complication. CONCLUSIONS Our study demonstrates that extended LOS after treatment of unruptured aneurysms is influenced by a number of patient-level factors including demographics, preadmission comorbidities, type of aneurysm treatment (open surgical versus endovascular), and, importantly, inpatient complications. A better understanding of these independent predictors of prolonged length of hospital stay may help to improve patient outcomes and decrease overall healthcare costs.
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Affiliation(s)
- Andrew B Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | | | - I-Hsin Lin
- Yale Center for Analytical Sciences, New Haven, CT
| | - Wyatt B David
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | | | - Corrado Santarosa
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Branden J Cord
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Akli Zetchi
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Ryan Hebert
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Farhad Bahrassa
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Ajay Malhotra
- Department of Radiology & Biomedical Imaging, Yale University School of Medicine, New Haven, CT
| | - Charles C Matouk
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT; Department of Radiology & Biomedical Imaging, Yale University School of Medicine, New Haven, CT.
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