Long-term outcomes of treatment for unruptured intracranial aneurysms in South Korea: clipping versus coiling

Influence of size ratio on retreatment after coil embolization for unruptured bifurcation aneurysms

Background

Aneurysm size is considered a risk factor for aneurysm rupture, and even small aneurysms may rupture, especially bifurcation aneurysms (BAs), which are occasionally detected. Therefore, we aimed to investigate the predictors of retreatment after coil embolization for unruptured BAs, with a particular focus on the absolute and relative size of the aneurysm (size ratio [SR]).

Methods

To evaluate the predictors of retreatment, patients were divided into two groups: those with and those without retreatment. Patient characteristics and radiographic assessments were compared between the groups. SR was defined as the ratio of the maximum aneurysm diameter and the average diameter of the parent artery.

Results

Overall, 181 unruptured BAs in 176 patients were investigated. The mean age of the patients was 63.8 ± 9.6 years. The mean aneurysm size and SR were 7.18 ± 2.94 mm and 2.49 ± 1.32, respectively. Further, 12 aneurysms with retreatment (6.6 %) and 169 aneurysms without retreatment were compared. In univariate analysis, SR was significantly higher in the group with retreatment (P = 0.02), but aneurysm size was not significantly different between the groups (P = 0.09). Multivariable analysis revealed that SR > 2.6 was a significant predictor of retreatment (P = 0.03; odds ratio: 10.41; 95 % confidence interval: 2.1-51.73).

Conclusions

This study showed that SR influences retreatment after coil embolization for unruptured BAs. Therefore, if the aneurysm size and parent artery diameter were small, as in cases with a large SR, meticulous follow-up after coil embolization is required to detect recurrence and recanalization.

The Safety and Efficacy of eCLIPs for Treatment of Wide-Necked Bifurcation Aneurysms: A Systematic Review and Meta-Analysis

BACKGROUND

Wide-necked bifurcation aneurysms (WNBAs) are challenging intracranial aneurysms. Several device and treatment approaches have been proposed for the treatment of WNBAs. The endovascular clip system (eCLIPs) is a newly developed endovascular device with flow diverter and flow disruptor features. This study aims to investigate the safety and efficacy of the eCLIPs for treatment of patients with WNBAs.

METHODS

This is a systematic review and meta-analysis study conducted in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. The electronic databases of PubMed, Embase, Scopus, and Web of Science were systematically reviewed from inception to June 19, 2023. The rate of complete and near-complete occlusion, successful device implantation, and serious adverse events were pooled using STATA, version 17.

RESULTS

A total of 5 studies with 110 patients with WNBAs were systematically investigated. Our findings show that the immediate successful implantation rate of eCLIPs was 0.93 (95% confidence interval [CI], 0.88-0.97). Moreover, the immediate postoperative complete occlusion rate was 0.34 (95% CI, 0.10-0.58), and the immediate postoperative near-complete occlusion rate was 0.35 (95% CI, 0.24-0.45). Also, the near-complete occlusion rate at the latest follow-up was 0.3 (95% CI, 0.16-0.44). The serious adverse event rate was 0.14 (95% CI, 0.05-0.22). Stroke was also reported in 2 studies, with 1 study reporting 1 patient who experienced stroke within the first 24 hours and 1 study reporting no patients with stroke.

CONCLUSIONS

Our findings document that the eCLIPs is a safe and effective device for treating patients with WNBAs and associated with favorable outcomes.

Clipping and coiling of intracranial aneurysms in the elderly patients: clinical features and treatment outcomes

Objective

In recent years, more and more cases of intracranial aneurysms (IAs) have been found in elderly patients, and neurosurgical interventions have increased, but there is still no consensus on the best treatment strategy for elderly patients. In elderly patients, endovascular coiling (EC) is more popular than surgical clipping (SC) due to its advantages of less trauma and faster recovery. However, SC has made great progress in recent years, significantly improving the prognosis of elderly patients. Therefore, it is necessary to further explore the effects of different treatment modalities on clinical prognosis, hospital stay, and hospital cost of elderly IA patients, and select the most appropriate treatment modalities.

Methods

The authors retrospectively analyzed 767 patients with intracranial aneurysms admitted to the facility between August 2017 and December 2022. Prognostic risk factors and multivariate logistic regression were analyzed for elderly patients treated with EC or SC. The area under the receiver operating characteristic (ROC) curve was used to calculate the predictive power of each independent predictor between the treatment groups.

Results

Our study included 767 patients with aneurysms, of whom 348 (45.4%) were elderly, 176 (22.9%) underwent endovascular coiling, and 172 (22.4%) underwent microsurgical clipping. A comparison of elderly patients treated with EC and SC showed a higher prevalence of hypertension in the EC group (P = 0.011) and a higher Hunt-Hess score on admission in the SC group (P = 0.010). Patients in the EC group had shorter hospital stays but higher costs (P = 0.000 and P = 0.000, respectively). Patients treated with SC had a higher incidence of postoperative cerebral infarction and poor prognosis (P = 0.002 and P = 0.008, respectively). Through multi-factor logistic analysis, it was found that age (OR 1.209, 95% CI 1.047-1.397, P = 0.010), length of stay (LOS) (OR 1.160, 95 CI% 1.041-1.289, P = 0.007), and complications (OR 31.873, 95 CI% 11.677-320.701, P = 0.000) was an independent risk factor for poor prognosis in elderly patients with EC. In elderly patients treated with SC, age (OR 1.105, 95% CI 1.010-1.209, P = 0.029) was an independent risk factor for poor prognosis.

Conclusion

EC and SC interventions in elderly adults carry higher risks compared to non-older adults, and people should consider these risks and costs when making a decision between intervention and conservative treatment. In elderly patients who received EC or SC treatments, EC showed an advantage in improving outcomes in elderly patients although it increased the economic cost of the patient's hospitalization.

How does the recurrence-related morphology characteristics of the Pcom aneurysms correlated with hemodynamics?

Introduction

Posterior communicating artery (Pcom) aneurysm has unique morphological characteristics and a high recurrence risk after coil embolization. This study aimed to evaluate the relationship between the recurrence-related morphology characteristics and hemodynamics.

Method

A total of 20 patients with 22 Pcom aneurysms from 2019 to 2022 were retrospectively enrolled. The recurrence-related morphology parameters were measured. The hemodynamic parameters were simulated based on finite element analysis and computational fluid dynamics. The hemodynamic differences before and after treatment caused by different morphological features and the correlation between these parameters were analyzed.

Result

Significant greater postoperative inflow rate at the neck (Qinflow), relative Qinflow, inflow concentration index (ICI), and residual flow volume (RFV) were reported in the aneurysms with wide neck (>4 mm). Significant greater postoperative RFV were reported in the aneurysms with large size (>7 mm). Significant greater postoperative Qinflow, relative Qinflow, and ICI were reported in the aneurysms located on the larteral side of the curve. The bending angle of the internal carotid artery at the initiation of Pcom (αICA@PCOM) and neck diameter had moderate positive correlations with Qinflow, relative Qinflow, ICI, and RFV.

Conclusion

The morphological factors, including aneurysm size, neck diameter, and αICA@PCOM, are correlated with the recurrence-inducing hemodynamic characteristics even after fully packing. This provides a theoretical basis for evaluating the risk of aneurysm recurrence and a reference for selecting a surgical plan.

Trends in the Age of Patients Treated for Unruptured Intracranial Aneurysms from 1990 to 2020

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.

Risk Factors for Cerebral Infarction After Microsurgical Clipping of Hunt-Hess Grade 0-2 Single Intracranial Aneurysm: A Retrospective Study

OBJECTIVE

The study aimed to explore risk factors for cerebral infarction after microsurgical clipping in patients with Hunt-Hess grade 0-2 single intracranial aneurysms.

METHODS

A total of 137 patients with Hunt-Hess grade 0-2 single intracranial aneurysms treated with microsurgical clipping between March 2017 and December 2020 were retrospectively enrolled. Patients were divided into 2 groups on the basis of the occurrence of cerebral infarction after surgery.

RESULTS

Of 137 enrolled patients, 14 (10.22%) showed cerebral infarction symptoms after surgery. Univariate analysis indicated that ruptured aneurysm status, aneurysm rupture during surgery, history of transient ischemic attack (TIA)/stroke, aneurysm size ≥7 mm, temporary clipping, intraoperative systolic hypotension (IOH), and occurrences of intraoperative motor-evoked potentials change were significantly related to postoperative cerebral infarction (PCI). However, using multivariate regression, only history of TIA/stroke (odds ratio = 0.124; 95% confidence interval [CI] = 0.021-0.748, P = 0.023) and IOH (odds ratio = 0.032; 95% CI = 0.005-0.210, P < 0.001) were independent predictors for PCI. Receiver operating characteristic curve analysis showed that the critical duration of temporary clipping and IOH that minimized the risk of PCI was 5.5 minutes and 7.5 minutes, respectively.

CONCLUSIONS

Our study identified history of TIA/stroke and IOH as independent risk factors for cerebral infarction after microsurgical clipping.

European Stroke Organisation (ESO) guidelines on management of unruptured intracranial aneurysms

Unruptured intracranial aneurysms (UIA) occur in around 3% of the population. Important management questions concern if and how to perform preventive UIA occlusion; if, how and when to perform follow up imaging and non-interventional means to reduce the risk of rupture. Using the Standard Operational Procedure of ESO we prepared guidelines according to GRADE methodology. Since no completed randomised trials exist, we used interim analyses of trials, and meta-analyses of observational and case-control studies to provide recommendations to guide UIA management. All recommendations were based on very low evidence. We suggest preventive occlusion if the estimated 5-year rupture risk exceeds the risk of preventive treatment. In general, we cannot recommend endovascular over microsurgical treatment, but suggest flow diverting stents as option only when there are no other low-risk options for UIA repair. To detect UIA recurrence we suggest radiological follow up after occlusion. In patients who are initially observed, we suggest radiological monitoring to detect future UIA growth, smoking cessation, treatment of hypertension, but not treatment with statins or acetylsalicylic acid with the indication to reduce the risk of aneurysm rupture. Additionally, we formulated 15 expert-consensus statements. All experts suggest to assess UIA patients within a multidisciplinary setting (neurosurgery, neuroradiology and neurology) at centres consulting >100 UIA patients per year, to use a shared decision-making process based on the team recommendation and patient preferences, and to repair UIA only in centres performing the proposed treatment in >30 patients with (ruptured or unruptured) aneurysms per year per neurosurgeon or neurointerventionalist. These UIA guidelines provide contemporary recommendations and consensus statement on important aspects of UIA management until more robust data come available.

Aneurysm treatment with the Woven EndoBridge (WEB) device in the combined population of two prospective, multicenter series: 5-year follow-up

BACKGROUND

Evaluating a new endovascular treatment for intracranial aneurysms must not only demonstrate short-term safety and efficacy, but also evaluate longer-term outcomes (eg, delayed complications, anatomical results, retreatment). The current analysis reports the 5-year clinical and anatomical results of Woven EndoBridge (WEB) treatment in two European combined trial populations (WEBCAST (WEB Clinical Assessment of Intrasaccular Aneurysm Therapy) and WEBCAST-2).

METHODS

All adverse events occurring between the procedure and 5-year follow-up were independently evaluated by an expert. Aneurysm occlusion was evaluated by an independent core laboratory using a three-grade scale: complete occlusion, neck remnant, and aneurysm remnant. In cases where data were not available at 5-year follow-up, the last observation carry forward (LOCF) method was used.

RESULTS

The safety and efficacy populations comprised 100 patients and 95 aneurysms, respectively. No adverse event related to the device occurred after the procedure during the 5-year follow-up period. Mortality at 5 years was 7.0% (7/100 patients) including mortality related to the WEB (0/100, 0.0%), the procedure (1/100, 1.0%), and another condition (6/100, 6.0%). At 5 years, complete aneurysm occlusion was observed in 49/95 (51.6%) aneurysms, neck remnant in 25/95 (26.3%), and aneurysm remnant in 21/95 (22.1%). Retreatment rate at 5 years was 11.6% (11/95 aneurysms).

CONCLUSIONS

This analysis conducted in a population of patients with wide-neck bifurcation aneurysms confirms WEB's safety profile. Additional evidence demonstrates good stability of aneurysm occlusion with adequate occlusion (complete occlusion or neck remnant) at 5 years in 77.9% of aneurysms with a low retreatment rate (11.6%).

CLINICAL TRIAL REGISTRATION

WEBCAST and WEBCAST-2: Unique identifier: NCT01778322.

Higher oscillatory shear index is related to aneurysm recanalization after coil embolization in posterior communicating artery aneurysms

BACKGROUND

The recurrence rate of posterior communicating artery (Pcom) aneurysms after endovascular treatment (EVT) is higher than that for aneurysms located in other sites. However, it is still unclear what mechanisms are responsible for the recanalization of cerebral aneurysms. In this investigation, we compared hemodynamic factors related with recanalization of Pcom aneurysms treated by endoluminal coiling using computational fluid dynamics (CFD) with high-resolution three-dimensional digital subtraction angiography images.

METHODS

Twenty patients were enrolled. A double-sinogram acquisition was performed with and without contrast injection after coil embolization to get true blood vessel lumen by relatively complementing the first sinogram with the second. Adaptive Cartesian meshing was performed to produce vascular wall objects for CFD simulation. The boundary condition for inlet (ICA) was set for dynamic velocity according to the cardiac cycle (0.8 s). Hemodynamic parameters were recorded at two specific points (branching point of Pcom and residual sac). The peak pressure, peak WSS, and oscillatory shear index (OSI) were recorded and analyzed.

RESULTS

The median age was 61.0 years, and 18 patients (90%) were female. During a median follow-up of 12 months, seven (35%) treated aneurysms showed recanalization. The median aneurysm volume was significantly higher, and aneurysm height and neck sizes were significantly longer in the recanalization group than those in the stable group. At the branching point of the Pcom, the peak pressure, peak WSS, or OSI did not significantly differ between the two groups. The only statistically significant hemodynamic parameter related with recanalization was the OSI at the aneurysm point. Multivariate logistic regression showed that with an increase of 0.01 OSI at the aneurysm point, the odds ratio for the aneurysm recanalization was 1.19.

CONCLUSIONS

A higher OSI is related with recanalization after coil embolization for a Pcom aneurysm.

Intravenous Fluid Selection for Unruptured Intracranial Aneurysm Clipping : Balanced Crystalloid versus Normal Saline

OBJECTIVE

While balanced crystalloid (BC) could be a relevant fluid regimen with buffer system compared with normal saline (NS), there have been no studies on the optimal fluid for surgery of an unruptured intracranial aneurysm (UIA). This study aimed to compare the effects of fluid regimens between NS and BC on the metabolic and clinical outcomes of patients who underwent surgery for UIA.

METHODS

This study was designed as a propensity score matched retrospective comparative study and included adult patients who underwent UIA clipping. Patient groups were categorized as NS and BC groups based on the types of pre-operative fluid and the amount of fluid administered during surgery. The primary outcomes were defined as electrolyte imbalance and acidosis immediately after surgery. The secondary outcomes were the length of stay in the intensive care unit (ICU) and duration from the end of the operation to extubation.

RESULTS

A total of 586 patients were enrolled in this study, with each of 293 patients assigned to the NS and BC groups, respectively. Immediately after surgery, serum chloride levels were significantly higher in the NS group. Compared to the NS group, the BC group had lower incidence rates of acidemia (6.5% vs. 11.6%, p=0.043) and metabolic acidosis (0.7% vs. 4.4%, p=0.007). As compared to NS group, BC group had significantly shorter duration from the end of the operation to extubation (250±824 vs. 122±372 minutes, p=0.016) and length of stay in ICU (1.37±1.11 vs. 1.12±0.61 days, p=0.001). Throughout multivariable analysis, use of BC was found to be significant factor for favorable post-operative results.

CONCLUSION

This study showed that the patients who received BC during UIA clipping had lower incidence of metabolic acidosis, earlier extubation and shorter ICU stay compared to those who received NS. Therefore, using BC as a peri-operative fluid can be recommended for patients who undergo surgery for UIA.

Delayed Bleeding of Unruptured Intracranial Aneurysms After Coil Embolization: A Retrospective Case Series

OBJECTIVE

Delayed bleeding of unruptured intracranial aneurysms (UIAs) after coil embolization is rare; this study aimed to analyze the occurrence of delayed bleeding of UIAs after coil embolization.

METHODS

We retrospectively analyzed patients with UIAs after coil embolization between January 2002 and December 2018 and assessed the features of UIAs with delayed bleeding after coil embolization.

RESULTS

Analysis included 307 patients with 335 UIAs. Mean follow-up was 7.1 ± 4.9 years, and total follow-up was 2365 aneurysm-years. There were 271 (80.9%) aneurysms located in the anterior circulation and 64 (19.1%) aneurysms located in the posterior circulation. Significant differences were observed between the 2 groups in terms of maximum size of the aneurysm (P < 0.01), width of the aneurysm neck (P < 0.01), and number of retreatment cases (P < 0.01). During the follow-up period, delayed bleeding occurred in 4 aneurysms (annual bleeding rate of 0.17%); all were located in the posterior circulation. The original size was not relatively large (mean 8.6 ± 2.4 mm). All aneurysms bled within 5 years (mean 35 ± 9.6 months) after the initial treatment. Two were de novo aneurysms that developed adjacent to the coiled aneurysms and were not detected on follow-up magnetic resonance angiography.

CONCLUSIONS

Cautious follow-up of UIAs with digital subtraction angiography is important, articularly within the first 5 years after the procedure. If there are changes in the anatomic outcomes, short-term reassessment or additional treatment should be actively considered, particularly for aneurysms in the posterior circulation.

Long-term outcomes of endovascular simple coiling versus neurosurgical clipping of unruptured intracranial aneurysms: A systematic review and meta-analysis

BACKGROUND

Previous studies on ruptured intracranial aneurysms have shown favourable long-term outcomes of patients undergoing endovascular coiling compared to neurosurgical clipping. We aimed to evaluate if these results also apply to patients with unruptured intracranial aneurysms (UIAs).

METHODS

Embase, PubMed, and Cochrane Library were systematically searched for all studies reporting long-term (≥3 years) follow-up after coiling or clipping of UIAs. Thirteen studies involving 16,622 coiled patients and 13,606 clipped patients were included. Short-term outcome was defined as death ≤30 days after treatment. Long-term outcomes (>3 years) included all-cause mortality, morbidity (defined as modified Rankin Score 3-5 or Glasgow Outcome Score 2-3), cerebrovascular accident, intracerebral haemorrhage, additional repairs, and lost to follow-up. We calculated relative risk (RR), incidence and mortality rates (IR and MR), together with incidence and mortality rate ratio (IRR and MRR).

RESULTS

Patients treated with simple coiling had lower short-term mortality than clipped patients (RR = 0.62 (95%CI 0.42-0.91)), but this difference disappeared after long-term follow-up ((MRR) = 0.89 (95%CI: 0.78-1.02). Coiled patients had higher retreatment rates than clipped patients (IRR = 1.70 (95%CI 1.50-1.93)).

CONCLUSIONS

This systematic review and meta-analysis reports benefits and drawbacks of simple coiling versus neurosurgical clipping of UIAs. Future studies with longer follow-up time should account for differences in coiling techniques and confounding factors such as size and location of UIAs.

The potential biomarkers for the formation and development of intracranial aneurysm

This study is aimed to understand the pathogenesis of intracranial aneurysm (IA), which has a risk of rupture and is the primary cause of subarachnoid hemorrhage. From Gene Expression Omnibus (GEO) database, GSE75436 was extracted (15 IA tissues and 15 superficial temporal artery tissues). The differentially expressed genes (DEGs) was conducted through limma package, which followed by the enrichment analysis. Combining STRING database, protein-protein interaction (PPI) network was constructed. The modules in PPI network were performed utilizing molecular complex detection (MCODE) algorithm. With Cytoscape software, the transcription factor-miRNA-target regulatory network was constructed. Finally, microarray dataset GSE54083 was downloaded (13 IA tissues and 10 superficial temporal artery tissues) for the verification test. A total of 1332 DEGs were screened in IA tissues compared with superficial temporal artery tissues. Besides, the up-regulated TNF, IL10, IL1B, and CTSS, as well as down-regulated IL6 were included in the top 20 nodes in the PPI networks. Furthermore, in the module A of up-regulated PPI network, TNF, IL10, IL1B, and VCAM1 were interact with each other. In the regulatory network, miR-29A/B/C targeted up-regulated genes. Besides, VCAM1 was implicated in the pathway of leukocyte transendothelial migration. In the verification analysis, between GSE75436 and GSE54083, there were 444 up-regulated and 543 down-regulated co-existence DEGs and 11 co-existence genes involved the Leukocyte transendothelial migration pathway. VCAM1, TNF, CTSS, IL10, IL1B, IL6, and miR-29A/B/C might be the potential biomarkers for the formation and development of IA.

Rebleeding and bleeding in the year following intracranial aneurysm coiling: analysis of a large prospective multicenter cohort of 1140 patients-Analysis of Recanalization after Endovascular Treatment of Intracranial Aneurysm (ARETA) Study

BACKGROUND

Endovascular treatment is the first line therapy for the management of ruptured and unruptured intracranial aneurysms, but delayed aneurysm rupture leading to bleeding/rebleeding can occur subsequently. ARETA (Analysis of Recanalization after Endovascular Treatment of intracranial Aneurysm) is a prospective, multicenter study conducted to analyze aneurysm recanalization. We analyzed delayed bleeding and rebleeding in this large cohort.

METHODS

16 neurointerventional departments prospectively enrolled patients treated for ruptured and unruptured aneurysms between December 2013 and May 2015 (ClinicalTrials.gov: NCT01942512). Participant demographics, aneurysm characteristics and endovascular techniques were recorded. Data were analyzed from participants with ruptured or unruptured aneurysms treated by coiling or balloon-assisted coiling. Rates of bleeding and rebleeding were analyzed and associated factors were studied using univariable and multivariable analyses.

RESULTS

The bleeding rate was 0.0% in patients with unruptured aneurysms and 1.0% (95% CI 0.3% to 1.7%) in patients with ruptured aneurysms. In multivariate analysis, two factors were associated with rebleeding occurrence: incomplete aneurysm occlusion after initial treatment (2.0% in incomplete aneurysm occlusion vs 0.2% in complete aneurysm occlusion, OR 10.2, 95% CI 1.2 to 83.3; p=0.03) and dome-to-neck ratio (1.5±0.5 with rebleeding vs 2.2±0.9 without rebleeding, OR 0.2, 95% CI 0.04 to 0.8; p=0.03). Modalities of management of aneurysm rebleeding as well as clinical outcomes are described.

CONCLUSIONS

Aneurysm coiling affords good protection against bleeding (for unruptured aneurysms) and rebleeding (for ruptured aneurysms) at 1 year with rates of 0.0% and 1.0%, respectively. Aneurysm occlusion and dome-to-neck ratio are the two factors that appear to play a role in the occurrence of rebleeding.

Prediction of Intracranial Aneurysm Risk using Machine Learning

An efficient method for identifying subjects at high risk of an intracranial aneurysm (IA) is warranted to provide adequate radiological screening guidelines and effectively allocate medical resources. We developed a model for pre-diagnosis IA prediction using a national claims database and health examination records. Data from the National Health Screening Program in Korea were utilized as input for several machine learning algorithms: logistic regression (LR), random forest (RF), scalable tree boosting system (XGB), and deep neural networks (DNN). Algorithm performance was evaluated through the area under the receiver operating characteristic curve (AUROC) using different test data from that employed for model training. Five risk groups were classified in ascending order of risk using model prediction probabilities. Incidence rate ratios between the lowest- and highest-risk groups were then compared. The XGB model produced the best IA risk prediction (AUROC of 0.765) and predicted the lowest IA incidence (3.20) in the lowest-risk group, whereas the RF model predicted the highest IA incidence (161.34) in the highest-risk group. The incidence rate ratios between the lowest- and highest-risk groups were 49.85, 35.85, 34.90, and 30.26 for the XGB, LR, DNN, and RF models, respectively. The developed prediction model can aid future IA screening strategies.

Endovascular coiling versus surgical clipping for the treatment of unruptured cerebral aneurysms: Direct comparison of procedure-related complications

BACKGROUND

Endovascular coiling and surgical clipping are routinely used to treat unruptured cerebral aneurysms (UCAs). However, the evidence to support the efficacy of these approaches is limited. We aimed to analyze the efficacy of endovascular coiling compared with surgical clipping in patients with UCAs.

METHOD

A systematic search of 4 databases was conducted to identify comparative articles involving endovascular coiling and surgical clipping in patients with UCAs. We conducted a meta-analysis using the random-effects model when I> 50%. Otherwise, a meta-analysis using the fixed-effects model was performed.

RESULTS

Our results showed that endovascular coiling was associated with a shorter length of stay (WMD: -4.14, 95% CI: (-5.75, -2.531), P < .001) and a lower incidence of short-term complications compared with surgical clipping (OR: 0.518; 95% CI (0.433, 0.621); P < .001), which seems to be a result of ischemia complications (OR: 0.423; 95% CI (0.317, 0.564); P < .001). However, surgical clipping showed a higher rate of complete occlusion after surgery, in both short-term (OR: 0.179, 95% CI (0.064, 0.499), P = .001) and 1-year follow-ups (OR: 0.307, 95% CI (0.146, 0.646), P = .002), and a lower rate of short-term retreatment (OR: 0.307, 95% CI (0.146, 0.646), P = .002). Meanwhile, there was no significant difference in postoperative death, bleeding, and modified Rankin Scale (mRS) > 2 between the 2 groups.

CONCLUSIONS

The latest evidence illustrates that surgical clipping resulted in lower retreatment rates and was associated with a higher incidence of complete occlusion, while endovascular coiling was associated with shorter LOS and a lower rate of complications, especially ischemia.

Surgical and Endovascular Comprehensive Treatment Outcomes of Unruptured Intracranial Aneurysms: Reduction of Treatment Bias

BACKGROUND

Determining the risks of treatment of unruptured intracranial aneurysms is critical in the decision-making process of management. Most studies have reported the results for endovascular or surgical management. Our objective was to better delineate the risk estimates for unruptured intracranial aneurysms treated with surgical or endovascular techniques in a comprehensive fashion, according to the patients' risk profiles.

METHODS

Data were gathered from 553 patients with 658 unruptured intracranial aneurysms treated at a single institution from 2014 to 2017. The decision to treat was determined by a projected morbidity that was lower than the natural history rupture risk. Data on aneurysm size, location, patient age, and outcome at the last clinical visit (modified Rankin scale scores) were collected and analyzed retrospectively.

RESULTS

The mean patient age was 59 years, and the mean lesion size was 7.3 mm. Microsurgical clipping was used in 251 lesions (38.2%), endovascular coiling in 70 (10.6%), stent-assisted coiling in 89 (13.5%), and a pipeline embolization device in 248 (37.7%). Complications from the procedures or during hospital admission occurred 66 lesions (10% of the total). Of these 66 complications, 28 (4.32% of the total) were non-neurological, treated, and resolved without permanent morbidity. Neurologic complications occurred in 38 procedures (5.7% of the total). Of these, 7 (1%) resulted in a permanent poor outcome (modified Rankin scale score, 3-6).

CONCLUSION

Aneurysmal obliteration using endovascular and surgical approaches in a comprehensive fashion has low treatment risks for unruptured aneurysms. The nomograms generated are useful in the discussion with patients and families regarding the risks of total institutional treatment of unruptured aneurysms.

A Phantom Menace to Medical Personnel During Endovascular Treatment of Cerebral Aneurysms: Real-Time Measurement of Radiation Exposure During Procedures

BACKGROUND

The number of endovascular treatment procedures performed for cerebral aneurysms has markedly increased. However, little is known about the annual effective radiation dose to medical staff in neurointervention fields. We performed a retrospective observational study to investigate the real-time radiation dose to surgeons, nurses, anesthesiologists, and radiologic technologists during endovascular treatment of intracranial aneurysms.

METHODS

We measured the real-time radiation doses for 2 weeks using standard and reinforced protection, during which 28 procedures were performed, including 23 coil embolizations for unruptured intracranial aneurysms. Four procedures were excluded because of an inadequately equipped sensor, which resulted in inappropriate data collection. The procedure time was defined from intubation to extubation. Five RaySafe i2 detectors were installed at the chest level of the operator, attending nurse, radiologic technologist, and anesthesiologist and just inside the front door of the hybrid operating room.

RESULTS

The median doses per session with standard protection to the operator, attending nurse, anesthesiologist, and radiologic technologist were 11.16, 2.60, 4.76, and 1.93 μSv, respectively. The dose to the operator, attending nurse, and anesthesiologist had decreased to 6.63, 0.39, and 1.52 μSv under reinforced protection, respectively. However, the session dose for the radiologic technologist had increased to 3.12 μSv.

CONCLUSIONS

We confirmed the differences in the amount of radiation exposure for different roles. An additional lead screen, which provided more effective protection on the operator side, was proved effective for attenuating radiation exposure during endovascular treatment. All personnel involved in the hybrid operating room were exposed to acceptable effective doses.