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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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Choi HZ, Kim SU, Huh J, Lee HG, Kim MK, Kim DS, Huh CW. Comparison of treatment outcomes and complications of coil embolization in elderly and very elderly patients with cerebral aneurysms: a propensity score matching analysis. Acta Neurochir (Wien) 2023; 165:3361-3369. [PMID: 37728829 DOI: 10.1007/s00701-023-05793-2] [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: 07/04/2023] [Accepted: 08/31/2023] [Indexed: 09/21/2023]
Abstract
PURPOSE This single center study aims to compare the treatment outcomes and procedure-related complications of coil embolization in elderly patients (60-79 years) and very elderly patients (aged 80 years or older) with cerebral aneurysms. METHODS Data was collected from 504 elderly patients aged 60 years or older who underwent coil embolization for intracranial aneurysms from 2018 to 2021. The study evaluated patient-related and anatomical factors and assessed various outcomes, comparing results between groups using statistical analysis and propensity score matching. RESULTS A total of 503 cerebral aneurysms were analyzed from individuals aged 60-79 years (n = 472) and those aged 80 years or older (n = 31). The majority of the aneurysms were unruptured with an average size of 3.5 mm in height and 3.4 mm in width. The patients were compared using 1:1 propensity score matching, and no significant differences were found in factors other than age and aortic elongation. Logistic analysis revealed that being over 80 years old and having a severe aortic arch elongation were identified as risk factors for procedure-related events in both total and unruptured cases. CONCLUSIONS The study compared coil embolization treatment for cerebral aneurysms in patients aged 60-79 and over 80, finding no significant difference in treatment outcomes except for procedure-related events. Procedure-related events were associated with severe aortic arch elongation and being over 80 years old. Coil embolization can be considered safe and effective for patients over 80, but further trials are needed for accurate conclusions.
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Affiliation(s)
- Han-Zo Choi
- Department of emergency medicine, Kyung Hee University Hospital at Gangdong, Seoul, South Korea
| | - Sang-Uk Kim
- Department of Neurosurgery, Myong-Ji St. Mary's Hospital, 156, Dorimro, Youngdungpo-gu, Seoul, 07417, Republic of Korea.
| | - Joon Huh
- Department of Neurosurgery, Myong-Ji St. Mary's Hospital, 156, Dorimro, Youngdungpo-gu, Seoul, 07417, Republic of Korea
| | - Hyun-Goo Lee
- Department of Neurosurgery, Myong-Ji St. Mary's Hospital, 156, Dorimro, Youngdungpo-gu, Seoul, 07417, Republic of Korea
| | - Mi-Kyung Kim
- Department of Neurosurgery, Myong-Ji St. Mary's Hospital, 156, Dorimro, Youngdungpo-gu, Seoul, 07417, Republic of Korea
| | - Dal-Soo Kim
- Department of Neurosurgery, Myong-Ji St. Mary's Hospital, 156, Dorimro, Youngdungpo-gu, Seoul, 07417, Republic of Korea
| | - Choon-Woong Huh
- Department of Neurosurgery, Myong-Ji St. Mary's Hospital, 156, Dorimro, Youngdungpo-gu, Seoul, 07417, Republic of Korea
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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: 0] [Impact Index Per Article: 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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Increased Risk of Aortic Dissection with Perlecan Deficiency. Int J Mol Sci 2021; 23:ijms23010315. [PMID: 35008739 PMCID: PMC8745340 DOI: 10.3390/ijms23010315] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 12/24/2021] [Accepted: 12/25/2021] [Indexed: 12/22/2022] Open
Abstract
Perlecan (HSPG2), a basement membrane-type heparan sulfate proteoglycan, has been implicated in the development of aortic tissue. However, its role in the development and maintenance of the aortic wall remains unknown. Perlecan-deficient mice (Hspg2−/−-Tg: Perl KO) have been found to show a high frequency (15–35%) of aortic dissection (AD). Herein, an analysis of the aortic wall of Perl KO mice revealed that perlecan deficiency caused thinner and partially torn elastic lamina. Compared to the control aortic tissue, perlecan-deficient aortic tissue showed a significant decrease in desmosine content and an increase in soluble tropoelastin levels, implying the presence of immature elastic fibers in Perl KO mice. Furthermore, the reduced expression of the smooth muscle cell contractile proteins actin and myosin in perlecan-deficient aortic tissue may explain the risk of AD. This study showed that a deficiency in perlecan, which is localized along the elastic lamina and at the interface between elastin and fibrillin-1, increased the risk of AD, largely due to the immaturity of extracellular matrix in the aortic tissue. Overall, we proposed a new model of AD that considers the deficiency of extracellular molecule perlecan as a risk factor.
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Lee SH, Lee SU, Kwon OK, Bang JS, Ban SP, Kim T, Kim YD, Byoun HS, Oh CW. Clinical Outcomes of Clipping and Coiling in Elderly Patients with Unruptured Cerebral Aneurysms: a National Cohort Study in Korea. J Korean Med Sci 2021; 36:e178. [PMID: 34227262 PMCID: PMC8258241 DOI: 10.3346/jkms.2021.36.e178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 06/06/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND We aimed to analyze outcomes of clipping and coiling in treating unruptured intracranial aneurysms (UIAs) in elderly patients and to identify the age at which perioperative risk increases based on national cohort data in South Korea. METHODS The incidence of perioperative intracranial hemorrhage (ICRH), perioperative cerebral infarction (CI), mortality, and moderate to severe disability data of the patients who underwent coiling or clipping for UIAs were retrieved. Estimated breakpoint (EBP) was calculated to identify the age at which the risk of treatment increases. RESULTS A total of 38,207 patients were treated for UIAs. Among these, 22,093 (57.8%) patients underwent coiling and 16,114 (42.2%) patients underwent clipping. The incidence of ICRH, requiring a secondary operation, within 3 months in patients ≥ 65 years that underwent coiling and clipping was 1.13% and 4.81%, respectively, and that of both groups assessed were significantly higher in patients ≥ 75 years (coiling, P = 0.013, relative risk (RR) 1.81; clipping, P = 0.015) than younger patients. The incidence of CI within 3 months in patients aged ≥ 65 was 13.90% and 9.19% in the coiling and clipping groups, respectively. The incidence of CI after coiling in patients aged ≥ 75 years (P < 0.001, RR 1.96) and after clipping in patients aged ≥ 70 years (P < 0.001, RR 1.76) was significantly higher than that in younger patients. The mortality rates within 1 year in patients with perioperative ICRH or CI were 2.41% and 3.39% for coiling and clipping groups, respectively, in patients ≥ 65. These rates increased significantly at age 70 in the coiling group and at age 75 for the clipping group (P = 0.012 and P < 0.001, respectively). CONCLUSION The risk of treatment increases with age, and this risk increases dramatically in patients aged ≥ 70 years. Therefore, the treatment decisions in patients aged ≥ 70 years should be made with utmost care.
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Affiliation(s)
- Sang Hyo Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Si Un Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea.
| | - O Ki Kwon
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Seung Bang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Pil Ban
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Tackeun Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Young Deok Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyoung Soo Byoun
- Department of Neurosurgery, Chungnam University Sejong Hospital, Sejong, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea.
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Rutledge C, Raper DMS, Jonzzon S, Raygor KP, Pereira MP, Winkler EA, Zhang L, Lawton MT, Abla AA. Sensitivity of the Unruptured Intracranial Aneurysm Treatment Score (UIATS) in the Elderly: Retrospective Analysis of Ruptured Aneurysms. World Neurosurg 2021; 152:e673-e677. [PMID: 34129975 DOI: 10.1016/j.wneu.2021.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 06/06/2021] [Accepted: 06/07/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND/PURPOSE The prevalence of intracranial aneurysms, as well as the incidence of subarachnoid hemorrhage (SAH), increase with age, and the elderly have poor outcomes after SAH. Age is a key factor in the unruptured intracranial aneurysm treatment score (UIATS),but the sensitivity of the UIATS model in detecting risk of SAH among the elderly is unknown. METHODS We retrospectively analyzed 153 consecutive cases of ruptured aneurysms between 2012 and 2018. We used Fisher's exact test, analysis of variance, and multivariate logistic regression to compare outcomes between those >65 years of age and those younger. We then applied the UIATS model and evaluated the sensitivity of the model as a predictor of SAH in the elderly compared with younger patients. RESULTS Elderly patients made up 32% (n = 49 of 153) of our cohort. They had significantly higher in-hospital mortality (19 of 49, 39%) than younger patients (14 of 104, 13%) (P < 0.01). In a multivariate logistic regression, controlling for Hunt-Hess grade and comorbidities, age >65 years remained a significant predictor of unfavorable outcome at discharge (P = 0.03). The UIATS model had low sensitivity in the elderly compared with younger patients: 63% (59 of 136) of younger patients would have been recommended aneurysm repair had their aneurysm been detected unruptured, compared with only 12% (5 of 42) of elderly patients >65 years (P < 0.01). CONCLUSIONS Elderly patients >65 years in age have far worse outcomes after SAH. The sensitivity of the UIATS model for detecting those at risk of SAH was significantly lower in elderly patients. The UIATS model may lead to undertreatment of elderly patients at risk of SAH.
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Affiliation(s)
- Caleb Rutledge
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Daniel M S Raper
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Soren Jonzzon
- School of Medicine, University of California, San Francisco, California, USA
| | - Kunal P Raygor
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | | | - Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Li Zhang
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Michael T Lawton
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, California, USA.
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Arimura K, Iihara K, Satow T, Nishimura A, Tokunaga S, Sakai N. Safety and Feasibility of Neuroendovascular Therapy for Elderly Patients: Analysis of Japanese Registry of Neuroendovascular Therapy 3. Neurol Med Chir (Tokyo) 2019; 59:305-312. [PMID: 31130572 PMCID: PMC6694018 DOI: 10.2176/nmc.oa.2018-0325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Japan has a rapidly aging population and the application of neuroendovascular therapy (NET) for cerebrovascular diseases among elderly patients has increased, but feasibility and safety of NET for elderly patients are still debated. Therefore, this study aimed to elucidate feasibility and safety of NET by analyzing the Japanese nationwide database, the Japanese Registry of Neuroendovascular Therapy 3 (JR-NET 3). In total, 35,972 patients in the JR-NET 3 were analyzed retrospectively. “Elderly patients” were defined as those aged ≥75 years. Approximately one-quarter of patients who received NET were elderly patients. The proportion of patients with modified Rankin Scale (mRS) 0–2 before treatment and 30 days after NET was significantly low across all diseases in the elderly patients. Technical success rates were generally high across all procedures, but complication rate was significantly higher among elderly patients; ischemic complications were significantly higher with NET for unruptured aneurysms (UA) and carotid artery stenosis (CAS). Multivariate analysis revealed that mRS 0–2 before treatment [odds ratio (OR): 0.56, 95% confidence interval (CI): 0.34–0.94, P = 0.03], middle cerebral artery aneurysm (OR: 0.33, 95% CI: 0.12–0.92, P = 0.04), and complete obliteration (OR: 0.66, 95% CI: 0.44–0.97, P = 0.03) were associated with ischemic complications with NET for UA. Moreover, mRS 0–2 before treatment (OR: 0.55, 95% CI: 0.36–0.86, P < 0.01), high intensity with time-of-flight magnetic resonance angiography (OR: 1.55, 95% CI: 1.03–2.32, P = 0.04), open-cell stent (OR: 2.20, 95% CI: 1.50–3.22, P <0.01) were associated with ischemic complications with NET for CAS. Taken together, our findings indicate that cautious and precise selection of patients suitable for NET is necessary.
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Affiliation(s)
- Koichi Arimura
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University
| | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University
| | - Tetsu Satow
- Department of Neurosurgery, National Cerebral and Cardiovascular Center
| | - Ataru Nishimura
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University
| | - So Tokunaga
- Department of Neurosurgery, Kyushu Rosai Hospital
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital
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Li L, Zhang X, Feng Z, Zhao R, Hong B, Xu Y, Huang Q, Liu J. Risk Factors for Intraprocedural Rupture in the Endovascular Treatment of Unruptured Intracranial Aneurysms: A Single-Center Experience with 1232 Procedures. World Neurosurg 2019; 123:e9-e14. [DOI: 10.1016/j.wneu.2018.09.164] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 09/20/2018] [Accepted: 09/21/2018] [Indexed: 10/28/2022]
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Algra AM, Lindgren A, Vergouwen MDI, Greving JP, van der Schaaf IC, van Doormaal TPC, Rinkel GJE. Procedural Clinical Complications, Case-Fatality Risks, and Risk Factors in Endovascular and Neurosurgical Treatment of Unruptured Intracranial Aneurysms: A Systematic Review and Meta-analysis. JAMA Neurol 2019; 76:282-293. [PMID: 30592482 PMCID: PMC6439725 DOI: 10.1001/jamaneurol.2018.4165] [Citation(s) in RCA: 117] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 11/02/2018] [Indexed: 01/16/2023]
Abstract
Importance The risk of procedural clinical complications and the case-fatality rate (CFR) from preventive treatment of unruptured intracranial aneurysms varies between studies and may depend on treatment modality and risk factors. Objective To assess current procedural clinical 30-day complications and the CFR from endovascular treatment (EVT) and neurosurgical treatment (NST) of unruptured intracranial aneurysms and risk factors of clinical complications. Data Sources We searched PubMed, Excerpta Medica Database, and the Cochrane Database for studies published between January 1, 2011, and January 1, 2017. Study Selection Studies reporting on clinical complications, the CFR, and risk factors, including 50 patients or more undergoing EVT or NST for saccular unruptured intracranial aneurysms after January 1, 2000, were eligible. Data Extraction and Synthesis Per treatment modality, we analyzed clinical complication risk and the CFR with mixed-effects logistic regression models for dichotomous data. For studies reporting data on complication risk factors, we obtained risk ratios (RRs) or odds ratios (ORs) with 95% CIs and pooled risk estimates with weighted random-effects models. Main Outcomes and Measures Clinical complications within 30 days and the CFR. Results We included 114 studies (106 433 patients with 108 263 aneurysms). For EVT (74 studies), the pooled clinical complication risk was 4.96% (95% CI, 4.00%-6.12%), and the CFR was 0.30% (95% CI, 0.20%-0.40%). Factors associated with complications from EVT were female sex (pooled OR, 1.06 [95% CI, 1.01-1.11]), diabetes (OR, 1.81 [95% CI, 1.05-3.13]), hyperlipidemia (OR, 1.76 [95% CI, 1.3-2.37]), cardiac comorbidity (OR, 2.27 [95% CI, 1.53-3.37]), wide aneurysm neck (>4 mm or dome-to-neck ratio >1.5; OR, 1.71 [95% CI, 1.38-2.11]), posterior circulation aneurysm (OR, 1.42 [95% CI, 1.15-1.74]), stent-assisted coiling (OR, 1.82 [95% CI, 1.16-2.85]), and stenting (OR, 3.43 [95% CI, 1.45-8.09]). For NST (54 studies), the pooled complication risk was 8.34% (95% CI, 6.25%-11.10%) and the CFR was 0.10% (95% CI, 0.00%-0.20%). Factors associated with complications from NST were age (OR per year increase, 1.02 [95% CI, 1.01-1.02]), female sex (OR, 0.43 [95% CI, 0.32-0.85]), coagulopathy (OR, 2.14 [95% CI, 1.13-4.06]), use of anticoagulation (OR, 6.36 [95% CI, 2.55-15.85]), smoking (OR, 1.95 [95% CI, 1.36-2.79]), hypertension (OR, 1.45 [95% CI, 1.03-2.03]), diabetes (OR, 2.38 [95% CI, 1.54-3.67]), congestive heart failure (OR, 2.71 [95% CI, 1.57-4.69]), posterior aneurysm location (OR, 7.25 [95% CI, 3.70-14.20]), and aneurysm calcification (OR, 2.89 [95% CI, 1.35-6.18]). Conclusions and Relevance This study identifies risk factors for procedural complications. Large data sets with individual patient data are needed to develop and validate prediction scores for absolute complication risks and CFRs from EVT and NST modalities.
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Affiliation(s)
- Annemijn M. Algra
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Antti Lindgren
- Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Kuopio, Finland
- Department of Neurosurgery, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Mervyn D. I. Vergouwen
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Jacoba P. Greving
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Irene C. van der Schaaf
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Tristan P. C. van Doormaal
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Gabriel J. E. Rinkel
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Unruptured intracranial aneurysms in patients over 80 years: natural history and management implications. Acta Neurochir (Wien) 2018; 160:1773-1777. [PMID: 29982888 DOI: 10.1007/s00701-018-3590-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 06/07/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE Patients over the age of 80 years when diagnosed with an unruptured intracranial aneurysm (UIA) pose unique decision-making challenges due to shortened life-expectancy and increased risk of treatment. Thus, we investigated the risk of rupture and survival of a consecutive series of patients who were diagnosed with an UIA after the age of 80 years. METHODS Data of consecutive patients with an UIA were reviewed, and patients were included in our study if they were first evaluated for a UIA by the senior author during their ninth decade of life. Outcomes were aneurysm rupture and overall survival after diagnosis. Survival was estimated from a Kaplan-Meier survival curve. Incidence of risk factors was compared to a population of patients less than 65 years who were seen by the senior author over the same time period. RESULTS Eighty-three patients who were over 80 years when diagnosed with a UIA were included in this study. In our population, there is a risk of rupture of 3.2% per patient-year. One-, three-, and five-year survival rates for our population were estimated to be 92, 64, and 35%, respectively. When compared to patients under 65 years diagnosed with a UIA, "over 80" patients had a significantly higher incidence of hypertension, and a significantly lower incidence of smoking history and familial aneurysm history. CONCLUSIONS In our study population, UIAs greater than 7 mm carry a non-negligible risk of rupture of 3.2% per patient-year, and further studies investigating the risk-to-benefit ratio of treatment in this population are warranted.
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Mori K, Wada K, Otani N, Tomiyama A, Toyooka T, Fujii K, Kumagai K, Takeuchi S, Tomura S, Yamamoto T, Nakao Y, Arai H. Validation of effectiveness of keyhole clipping in nonfrail elderly patients with unruptured intracranial aneurysms. J Neurosurg 2017; 127:1307-1314. [DOI: 10.3171/2016.9.jns161634] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVEAdvanced age is known to be associated with a poor prognosis after surgical clipping of unruptured intracranial aneurysms (UIAs). Keyhole clipping techniques have been introduced for less invasive treatment of UIAs. In this study, the authors compared the complications and clinical and radiological outcomes after keyhole clipping between nonfrail elderly patients (≥ 70 years) and nonelderly patients.METHODSKeyhole clipping (either supraorbital or pterional) was performed to treat 260 cases of relatively small (≤ 10 mm) anterior circulation UIAs. There were 62 cases in the nonfrail elderly group (mean age 72.9 ± 2.6 years [± SD]) and 198 cases in the nonelderly group (mean age 59.5 ± 7.6 years). The authors evaluated mortality and morbidity (modified Rankin Scale score > 2 or Mini–Mental State Examination [MMSE] score < 24) at 3 months and 1 year after the operation, the general cognitive function by MMSE at 3 months and 1 year, anxiety and depression by the Beck Depression Inventory (BDI) and Hamilton Rating Scale for Depression (HAM-D) at 3 months, and radiological abnormalities and recurrence at 1 year.RESULTSBasic characteristics including comorbidities, frailty, and BDI and HAM-D scores were not significantly different between the 2 groups, whereas the MMSE score was slightly but significantly lower in the elderly group. Aneurysm location, largest diameter, type of keyhole surgery, neck clipping rate, and hospitalization period were not significantly different between the 2 groups. The incidence of chronic subdural hematoma was not significantly higher in the elderly group than in the nonelderly group (8.1% vs 4.5%, p = 0.332); rates of other complications including stroke and epilepsy were not significantly different. Lacunar infarction occurred in 3.2% of the elderly group and 3.0% of the nonelderly group. No patient in the elderly group required re-treatment or demonstrated recurrence of clipped aneurysms. The MMSE score at 3 months significantly improved in the nonelderly group but did not change in the elderly group. The BDI and HAM-D scores at 3 months were significantly improved in both groups. No patient died in either group. The morbidity at 3 months and 1 year in the elderly group (1.6% and 4.8%, respectively) was not significantly different from that in the nonelderly group (2.0% and 1.5%, respectively).CONCLUSIONSKeyhole clipping for nonfrail elderly patients with relatively small anterior circulation UIAs did not significantly increase the complication, mortality, or morbidity rate; hospitalization period; or aneurysm recurrence compared with nonelderly patients, and it was associated with improvement in anxiety and depression. Keyhole clipping to treat UIAs in the nonfrail elderly is an effective and long-lasting treatment.
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Affiliation(s)
- Kentaro Mori
- 1Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama
| | - Kojiro Wada
- 1Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama
| | - Naoki Otani
- 1Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama
| | - Arata Tomiyama
- 1Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama
| | - Terushige Toyooka
- 1Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama
| | - Kazuya Fujii
- 1Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama
| | - Kosuke Kumagai
- 1Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama
| | - Satoru Takeuchi
- 1Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama
| | - Satoshi Tomura
- 1Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama
| | - Takuji Yamamoto
- 2Department of Neurosurgery, Juntendo University, Shizuoka Hospital, Izunokuni, Shizuoka; and
| | - Yasuaki Nakao
- 2Department of Neurosurgery, Juntendo University, Shizuoka Hospital, Izunokuni, Shizuoka; and
| | - Hajime Arai
- 3Department of Neurosurgery, Juntendo University, Tokyo, Japan
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