Neurologic and Neuropsychological Outcomes for Treatment of Unruptured Middle Cerebral Artery Aneurysms: Standard Pterional Versus Minipterional Approach in a Retrospective Single-Center Analysis

BACKGROUND

In accordance with technique advancement and minimal invasiveness surgical approaches, the minipterional has progressively replaced the standard pterional approach for treatment of unruptured middle cerebral artery (MCA) aneurysms. Nowadays, multimodal intraoperative resources including microDoppler and microflow probes, indocyanine green videoangiography, and neurophysiologic monitoring constitute a fundamental prerequisite for increasing the safety of the clipping procedure. Our study investigated and compared in a single-center experience the effect of the evolution of a minimally invasive and multimodal approach in unruptured MCA aneurysm surgery by measuring postoperative complication rate, recovery time, and long-term neuropsychological and functional outcomes.

METHODS

One hundred and thirty-one patients who underwent surgical treatment for unruptured MCA aneurysms at our institution were evaluated retrospectively. Patients' clinical, radiologic, and surgical reports were collected. Cognitive evaluation and quality of life were assessed through validated tests in telephone interviews. Patients who met the inclusion criteria were divided into 2 groups: "PT (pterional)" and "MPT (minipterional)."

RESULTS

Ninety-two patients were included in the analysis. A significant reduction of postoperative complication rates and new-onset postoperative seizures was recorded in the MPT group (P value = 0.006). Severe cognitive deficits were lower in the MPT group, although without a clear statistical correlation.

CONCLUSIONS

Decreased complication rates, faster recovery time, and a trend toward better cognitive and functional performances were documented for the MPT group of patients. In our experience, the minipterional approach with multimodality-assisted microsurgery reduced neurologic complications and recovery time and improved long-term cognitive outcome and quality of life.

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.

Return to Work after Surgical Clipping versus Endovascular Treatment of Unruptured Intracranial Aneurysms: A Nationwide Registry-Based Study

PURPOSE

To assess return to work following the treatment of unruptured intracranial aneurysms (UIAs).

MATERIALS AND METHODS

This retrospective, nationwide registry-based study included all adult patients of working age treated for a UIA in Norway between 2008 and 2018 who had a record of sickness leave on the day of treatment. Data from The Norwegian Patient Registry and The Norwegian Labour and Welfare Administration were linked on an individual level. Daily sickness and recipiency of disability benefits, as an indirect measure of working status, from 1 year before treatment to 1 year after treatment were analyzed. Return to work after endovascular treatment and surgical clipping was compared.

RESULTS

In total, 412 patients were included. Of patients who worked 1 year before treatment, 83% returned to work 1 year after treatment. The number of days from treatment to the first day back at work in a continuous 3-month working period was lower in patients who underwent endovascular treatment than in those treated with surgical clipping (median, 69 days; 95% confidence interval [CI], 51-87; vs 201 days, 95% CI, 163-239; P < .001). Return to work was more likely in patients who underwent endovascular treatment at 3 months after treatment (hazard ratio, 3.53; 95% CI, 2.54-4.93; P < .001). There was no difference in return to work at 6 and 12 months after treatment.

CONCLUSIONS

The treatment of UIAs affects patients' postoperative working status. Patients treated endovascularly return to work earlier than those who undergo open surgery.

Quality of Life Outcomes Over Time in Patients With Unruptured Intracranial Aneurysms With and Without Preventive Occlusion: A Prospective Cohort Study

BACKGROUND AND OBJECTIVES

In counseling patients with an unruptured intracranial aneurysm (UIA), quality of life (QoL) outcomes are important for informed decision making. We evaluated QoL outcomes in patients with and without preventive aneurysm occlusion at multiple time points during the first year after UIA diagnosis and studied predictors of QoL outcomes.

METHODS

We performed a prospective cohort study in patients aged ≥18 years with a newly diagnosed UIA in 2 tertiary referral centers in the Netherlands between 2017 and 2019. Patients were sent QoL questionnaires at 7 (aneurysm occlusion) or 5 (no occlusion) moments during the first year after diagnosis. We collected baseline data on patient and aneurysm characteristics, passive coping style (Utrecht Coping List), occlusion modality, and neurologic complications. We assessed health-related QoL (HRQoL) with the EuroQol 5 dimensions (EQ-5D), emotional functioning with the Hospital Anxiety and Depression Scale (HADS), and restrictions in daily activities with the Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-P). We used a linear mixed-effects model to assess the course of QoL over time and to explore predictors of QoL outcomes.

RESULTS

Of 153 eligible patients, 99 (65%) participated, of whom 30/99 (30%) underwent preventive occlusion. Patients undergoing occlusion reported higher baseline levels of passive coping, anxiety and depression, and restrictions than patients without occlusion. During recovery after occlusion, patients reported more restrictions compared with baseline (adjusted USER-P decrease 1 month post occlusion: -12.8 [95% CI -23.8 to -1.9]). HRQoL and emotional functioning gradually improved after occlusion (EQ-5D increase at 1 year: 8.6 [95% CI 0.1-17.0] and HADS decrease at 1 year: -5.4 [95% CI -9.4 to -1.5]). In patients without occlusion, the largest HRQoL improvement occurred directly after visiting the outpatient aneurysm clinic (EQ-5D increase: 9.2 [95% CI 5.5-12.8]). At 1 year, QoL outcomes were comparable in patients with and without occlusion. Factors associated with worse QoL outcomes were a passive coping style in all patients, complications in patients with occlusion, and higher rupture risks in patients without occlusion.

DISCUSSION

After UIA diagnosis, QoL improves gradually after preventive occlusion and directly after counseling at the outpatient clinic in patients without occlusion, resulting in comparable 1-year QoL outcomes. A passive coping style is an important predictor of poor QoL outcomes in all patients with UIA.

Diagnostic yield of TOF-MRA for detecting incidental vascular lesions in patients with cognitive impairment: An observational cohort study

Objectives

The role of three-dimensional (3D) TOF-MRA in patients with cognitive impairment is not well established. We evaluated the diagnostic yield of 3D TOF-MRA for detecting incidental extra- or intracranial artery stenosis and intracranial aneurysm in this patient group.

Methods

This retrospective study included patients with cognitive impairment undergoing our brain MRI protocol from January 2013 to February 2020. The diagnostic yield of TOF-MRA for detecting incidental vascular lesions was calculated. Patients with positive TOF-MRA results were reviewed to find whether additional treatment was performed. Logistic regression analysis was conducted to identify the clinical risk factors for positive TOF-MRA findings.

Results

In total, 1,753 patients (mean age, 70.2 ± 10.6 years; 1,044 women) were included; 199 intracranial aneurysms were detected among 162 patients (9.2%, 162/1,753). A 3D TOF-MRA revealed significant artery stenoses (>50% stenosis) in 162 patients (9.2%, 162/1,753). The overall diagnostic yield of TOF-MRA was 16.8% (294/1,753). Among them, 92 patients (31.3%, 92/294) underwent either medical therapy, endovascular intervention, or surgery. In total, eighty-one patients with stenosis were prescribed with either antiplatelet medications or lipid-lowering agent. In total, fifteen patients (aneurysm: 11 patients, stenosis: 4 patients) were further treated with endovascular intervention or surgery. Thus, the “number needed to scan” was 19 for identifying one patient requiring treatment. Multivariate logistic regression analysis showed that being female (odds ratio [OR] 2.05) and old age (OR 1.04) were the independent risk factors for intracranial aneurysm; being male (OR 1.52), old age (OR 1.06), hypertension (OR 1.78), and ischemic heart disease history (OR 2.65) were the independent risk factors for significant artery stenosis.

Conclusions

Our study demonstrated the potential benefit of 3D TOF-MRA, given that it showed high diagnostic yield for detecting vascular lesions in patients with cognitive impairment and the considerable number of these lesions required further treatment. A 3D TOF-MRA may be included in the routine MR protocol for the work-up of this patient population, especially in older patients and patients with vascular risk factors.

Based on Network Pharmacology and Molecular Dynamics Simulations, Baicalein, an Active Ingredient of Yiqi Qingre Ziyin Method, Potentially Protects Patients With Atrophic Rhinitis From Cognitive Impairment

Cognition may be improved by the active ingredients of the Yiqi Qingre Ziyin method in patients with atrophic rhinitis (AR). This study aimed to identify potential targets of the Yiqi Qingre Ziyin method for the treatment of patients with cognitive impairment. Nasal mucosal tissue samples from patients with AR were subjected to proteomic assays, and differentially expressed proteins were obtained. To explore the mechanism of AR leading to mild cognitive impairment (MCI), a differential analysis of AR related differential proteins in the MCI related GSE140831 dataset was performed. Most AR-related differential proteins are also differentially expressed in peripheral blood tissues of MCI, have similar biological functions and are enriched in similar pathways. These co-expressed differential factors in AR and MCI are known as common differential proteins of AR and MCI (CDPAM). Based on the analysis and validation of the random forest, support vector machine and neural network models, CDPAM acted as a diagnostic marker for MCI risk. Cytochrome C (CYCS) was significantly upregulated in the peripheral blood of patients with MCI. The active ingredients in the Yiqi Qingre Ziqin method were obtained and targeted 137 proteins. Among these targeted proteins, CYCS belong to the CDPAM set. Molecular docking and molecular dynamics analysis revealed that baicalein, an active ingredient in the Yiqi Qingre Ziyin method, stably targeted the CYCS protein. Results of the enrichment analysis revealed that the up-regulation of CYCS expression may have a defensive effect on the cells to resist foreign stimuli. Therefore, baicalein, an active ingredient in the Yiqi Qingre Ziyin method, may prevent the development and progression of MCI by targeting the CYCS protein.

Unruptured cerebral aneurysms in elderly patients: key challenges and management

Unruptured cerebral aneurysms are increasingly identified in elderly patients as the global life expectancy continues to rise and non-invasive vascular imaging becomes more prevalent. The optimal management of unruptured aneurysms in elderly patients remains controversial. Variability in life expectancy, comorbidities and rupture risk coupled with heterogenous endovascular and surgical treatments contribute to a paucity of clear guidelines, and current management is highly individualized. Elderly patients present unique considerations including frailty, cognitive dysfunction, vasculopathy, reduced life expectancy and overall worse prognosis in case of rupture which shape the risks and likelihood of success of endovascular and microsurgical treatment. In this review, we provide a comprehensive overview of unruptured cerebral aneurysms in the elderly, with a particular focus on the natural history, key challenges associated with advanced age, management and future innovations to further refine treatment.Key MessagesThe management of unruptured cerebral aneurysms in elderly patients remains controversial.Key challenges including frailty, cognitive dysfunction, reduced life expectancy, vasculopathy and poor prognosis with aneurysm rupture add complexity to endovascular and surgical decision making not encountered with younger demographics.A thorough understanding of available treatment options, likelihood of treatment success and associated risks weighed against the risk of aneurysm rupture informs patient discussion and management.

Psychological distress after subarachnoid haemorrhage: A systematic review and meta-analysis

OBJECTIVE

Psychological distress is a common complication in patients after Subarachnoid haemorrhage (SAH) which often has significant impact on the prognosis. The objective of this study was to determine the pooled prevalence of anxiety symptoms and depressive symptoms in patients after SAH and identify relevant risk factors.

METHODS

The study adopted a systematic review and meta-analysis protocol. Multiple databases including EMBASE, Medline, PsychInfo, and Web of Science were searched for publications before 1st January 2020. Screening, data extraction, and quality assessment were undertaken following the PRISMA guidelines for preferred reporting of systematic reviews and meta-analysis. The random-effects model was used to calculate pooled prevalence rates. Meta-analysis was conducted using Comprehensive Meta-analysis software. The review protocol was registered on PROSPERO (CRD42020182594).

RESULTS

42 studies reporting anxiety symptoms and 64 studies reporting depressive symptoms were included. The pooled short term(<3 years) and long term(≥3 years) prevalence rates of anxiety symptoms were 31.4%(95% CI: 23.6%, 40.4%) and 40.4%(95% CI: 31.6%, 49.8%), respectively, whereas the pooled short term and long term prevalence rates of depressive symptoms were 25.2%(95%CI: 17.8%, 34.5%) and 35.8%(95%CI: 28.6%, 43.6%), respectively. Gender and pre-existing psychiatric conditions were identified as potential risk factors.

CONCLUSIONS

The high prevalence of anxiety symptoms and depressive symptoms after SAH highlights the need for appropriate assessment and management of psychological stress in patients after SAH. Further research is warranted to explore potential underlying mechanisms and to develop holistic interventions that incorporate understanding of both the biological and psychological impact of SAH.

Quality of life scores in patients with unruptured cerebral aneurysm: Prospective cohort study

BACKGROUND

Living with the diagnosis of an unruptured cerebral aneurysm can understandably cause distress to a patient. The goal of preventive treatment is to increase the number of years with good quality of life (QoL).

OBJECTIVE

This study aimed to measure the effect of unruptured intracranial aneurysm treatment on change in QoL scores measured by the SF36 and EQ-5D-5L.

METHODS

We prospectively collected SF36 and EQ-5D-5L survey data for patients with unruptured intracranial aneurysms at two time-points over 1 year between 2 treatment groups: observation and intervention (microsurgical and endovascular). Multivariable linear regression was used to examine treatment group differences in the mean change in scores from baseline to 1 year when adjusted for covariates.

RESULTS

92 patients were included in the observation group and 68 patients were included in the intervention group, for a total of 160 patients. The intervention group had lower SF36 total scores at baseline (p = 0.001). With multivariate linear regression models, the effect of treatment on mean change in SF36 total score from baseline to 1 year was not statistically significant (p = 0.4); similarly, there was no difference in mean change in EQ-5D-5L.

CONCLUSION

In this large prospective study, preventive aneurysm treatment was not associated with a significant change in QoL score at 1 year compared to observation as measured by the SF36 and EQ-5D-5L. Further studies are needed to explore the lower QoL scores in patients seeking treatment and its impact on management decision making.

Relationship between Deep White Matter Hyperintensities on Magnetic Resonance Imaging and Postoperative Cognitive Function Following Clipping of Unruptured Intracranial Aneurysm

To evaluate the effects on cognitive function of deep white matter hyperintensities (DWMHs) on magnetic resonance imaging (MRI) in patients treated surgically for unruptured intracranial aneurysms (UIAs). The subjects were 106 patients in whom a Wechsler adult intelligence scale-revised (WAIS-R) examination was performed 1 week before and 1 month after clipping surgery for asymptomatic UIAs. DWMH severity was evaluated on preoperative MR images by Fazekas scale, as follows: none (absence), mild (punctate foci), moderate (beginning confluence of foci), or severe (large confluent areas). A decrease of 7 or more points in intelligence quotient (IQ) postoperatively was considered deterioration. Fazekas score was none in 41 (none group), mild in 42 (mild group), moderate in 21, and severe in 2 patients (moderate/severe group). Patient characteristics, surgical factors, IQ change, and abnormal findings on postoperative MRI were compared among the groups. Although there was no statistically significant deterioration in IQ postoperatively in any group, the percentage of deteriorated patients was significantly higher in the moderate/severe group (34.8%) than in the other groups (4.9% in the none group, 7.1% in the mild group; p <0.01, p <0.05, respectively). Brain injury was observed more frequently on postoperative MR images in the moderate/severe group (17.4%) compared with the none group (2.4%; p = 0.052). The presence of moderate/severe DWMHs was an independent prognostic factor for postoperative cognitive dysfunction. In conclusion, the presence of moderate/severe DWMHs was a prognostic factor for postoperative cognitive dysfunction after surgery for UIAs.

Quality of Life of Patients with Unruptured Intracranial Aneurysms Before and After Endovascular Coiling: A HEAT Trial Secondary Study and Systematic Review of the Literature

BACKGROUND

The study of quality of life (QOL) in patients with asymptomatic diseases receiving interventional treatment provides an essential metric for the assessment of procedural benefits in the surgical patient population. In this study, we analyzed QOL data collected from patients with unruptured intracranial aneurysms (UIAs) before and after endovascular coiling in the HEAT Trial, alongside a systematic review on QOL in unruptured brain aneurysms.

METHODS

HEAT was a randomized controlled trial comparing recurrence rates in aneurysms treated with either bare platinum coils or hydrogel coils. Patients enrolled in this trial completed a short form-36 (SF-36) QOL questionnaire before treatment and at the 3- to 12- and 18- to 24-month follow-ups. The change in QOL before and after treatment was assessed. Regression analysis evaluated the effect of select baseline characteristics on QOL change.

RESULTS

A total of 270 patients were eligible for analysis. There was an increase in the role physical (P = 0.043), vitality (P = 0.022), and emotional well-being (P < 0.001) QOL components at the 18- to 24-month follow-up compared with baseline scores. Regression analysis showed that age younger than 60 and absence of serious adverse events were associated with improved social functioning and vitality. The literature review showed a mixed effect of intervention on QOL in patients with UIAs.

CONCLUSIONS

Our analysis has revealed that patients with 3- to 14-mm UIAs had improvements in some physical and emotional components of QOL at 18-24 months following aneurysm coiling in the HEAT study. The literature remains indeterminate on this issue. Further studies are needed to better understand the effects of the diagnosis of UIAs and their treatment on QOL.

Prevalence of and risk factors for anxiety and depression in Chinese patients with unruptured intracranial aneurysms treated by endovascular intervention

BACKGROUND

Studies on anxiety and depression in unruptured intracranial aneurysm (UIA) patients after treatment via endovascular intervention are rare and controversial. We aimed to explore the prevalence of anxiety and depression among Chinese patients with UIAs treated by endovascular intervention and to identify which factors contribute to the development of these symptoms.

METHODS

We performed a cross-sectional study on anxiety and depression in patients who underwent endovascular treatment for UIAs using the Hospital Anxiety and Depression Scale (HADS). The demographic, clinical and radiological data for all patients were retrospectively collected from the aneurysm database and medical records. Moreover, we utilized data from a large sample of 200 UIA patients and multivariate logistic regression analysis to investigate the risk factors for anxiety and depression in these patients. Candidate variables with P values less than 0.20 in univariate analysis were included in the multivariate logistic regression analysis.

RESULTS

Two hundred patients returned completed questionnaires in this study. Of these 200 patients, 34 (17.0%) suffered from anxiety and 31 (15.5%) suffered from depression 30.67 ± 8.6 months after being discharged. The multivariate analysis results indicated that shorter sleep times were statistically significantly associated with depression (OR = 1.62, 95% CI: 1.14 ~ 2.29, P = 0.007, Adjusted P = 0.02). .

CONCLUSION

The prevalences of anxiety and depression in UIA patients treated by endovascular intervention were 17.0 and 15.5%, respectively. Shorter sleep times were significantly associated with depression. Our findings provide evidence for the clinical and psychological management of these patients.

Effect of hemorrhagic cerebrospinal fluid drainage on cognitive function after intracranial aneurysm clipping

Objective:

The effects of repeated lumbar puncture and continuous lumbar cistern drainage on the cognitive function of patients with aneurysmal subarachnoid hemorrhage were compared and analyzed.

Methods:

Retrospective analysis was performed on 59 patients with aneurysmal subarachnoid hemorrhage treated at our Neurosurgery Department between October 2017 and October 2018. According to the hemorrhagic cerebrospinal fluid drainage mode after aneurysm clipping, the patients were divided into the following two groups: the repeated lumbar puncture drainage (Group A, n = 28) and continuous lumbar cistern drainage (Group B, n = 31). Before and 1 month after surgery, the cognitive function of the patients was scored using the Montreal Cognitive Assessment Scale. Scores of 27~30 were defined as normal, and scores of < 27 as cognitive impairment.

Results:

The incidences of cognitive impairment were 46% (13/28) and 32% (10/31) for Groups A and B, respectively, before surgery, but the difference was not significant ( P > 0.05). The incidences of cognitive impairment were 35% (10/28) and 12% (4/31) for Groups A and B, respectively, at 1 month after surgery, with significant difference ( P < 0.05).

Conclusion:

Compared with repeated lumbar puncture, continuous lumbar cistern drainage for aneurysmal subarachnoid hemorrhage significantly reduced the incidence of cognitive impairment after aneurysm clipping.

Clip-first policy versus coil-first policy for the exclusion of middle cerebral artery aneurysms

OBJECTIVE

Middle cerebral artery (MCA) aneurysms are a particular subset of intracranial aneurysms that can be excluded by clipping or coiling. A comparison of the results between these two methods is often limited by a selection bias in which wide-neck and large aneurysms are frequently treated with surgery. Here, the authors report the results of two centers using opposing policies in the management of MCA aneurysms: one center used a clip-first policy while the other used a coil-first policy, which limited the selection bias and ensured a good comparison of these two treatment modalities.

METHODS

All patients treated for either ruptured or unruptured MCA aneurysms at one of two institutions between January 2012 and December 2015 were eligible for inclusion in this study. At one center a clip-first policy was applied, whereas the other applied a coil-first policy. The authors retrospectively reviewed the medical records of these patients and compared their clinical and radiological outcomes.

RESULTS

A total of 187 aneurysms were treated during the inclusion period; 88 aneurysms were treated by coiling and 99 aneurysms by clipping. The baseline patient and radiological characteristics were similar between the two groups, but the clinical presentation of the ruptured aneurysm cohort differed slightly. In the ruptured cohort (n = 90), although patients in the coiling group had a higher rate of additional surgery, the complication rate, functional outcome, and risk of death were similar between the two treatment groups. In the unruptured cohort (n = 97), the complication rate, functional outcome, and risk of death were also similar between the two treatment groups, although the risk of discomfort related to the temporal muscle atrophy was higher in the surgical group. Overall, the rate of complete occlusion was higher in the clipping group (84.2%) than in the coiling group (31%), which led to a higher risk in the coiling group of aneurysm retreatment within the first 2 years (p = 0.04).

CONCLUSIONS

Clipping and coiling for MCA aneurysm treatment provide the same clinical outcome for ruptured and unruptured aneurysms. However, clipping provides higher short- and long-term rates of complete exclusion, which in turn decreases the risk of aneurysm retreatment. Whether this lower occlusion rate can have a clinical impact in the long-term must be further evaluated.

Meta-Analysis of Clipping versus Coiling for the Treatment of Unruptured Middle Cerebral Artery Aneurysms: Direct Comparison of Procedure-Related Complications

BACKGROUND

Endovascular coiling and surgical clipping are routinely used to treat unruptured middle cerebral artery aneurysms (MCAAs). However, the optimal treatment for unruptured MCAAs is controversial. We aimed to systematically and comprehensively compare the clinical outcomes between endovascular coiling and surgical clipping for the treatment of MCAAs.

METHOD

This meta-analysis retrieved academic articles comparing the clinical outcomes between endovascular coiling and surgical clipping for unruptured MCAAs from the Cochrane Library, Medline, PubMed, and EMBASE databases. The reference articles of the identified studies were carefully reviewed to ensure that all available articles were represented in the study. The meta-analysis was conducted in accordance with the acknowledged the prioritized reported items for systematic review and meta-analysis (PRISMA) guidelines.

RESULTS

A total of 6 studies, which enrolled a total of 789 participants, were included in our analysis. Of these 789 patients with MCAAs, 144 were assigned to an endovascular coiling group, and 645 were assigned to a surgical clipping group. Our results demonstrated that endovascular coiling was associated with a higher rate of retreatment (OR = 104.926; 95% CI: 12.931 to 851.379; P<0.001) and postoperative complications (OR = 3.157; 95% CI: 1.239 to 8.048; P= 0.016) than surgical clipping, especially for postoperative thrombus without infarction (OR = 4.905, 95% CI: 1.097 to 21.933; P = 0.037). Furthermore, surgical clipping was related to a higher rate of complete occlusion (OR = 0.349, 95% CI: 0.140 to 0.872; P = 0.024) and Glasgow Outcome Scale (GOS) ≥4 (OR = 0.250; 95% CI: 0.072 to 0.867; P= 0.029) than endovascular coiling after the operation. However, there was no significant difference in the rate of death, the proportion of patients with modified Rankin Scale (mRS)>2, infarction, or bleeding.

CONCLUSION

Although this study has inherent limitations, surgical clipping of unruptured MCAAs resulted in significantly higher complete aneurysm occlusion and GOS≥4 rates and was associated with a lower incidence of retreatment and complication, especially for postoperative thrombus without infarction. Therefore, the effect induced by surgical clipping of unruptured MCAAs remains superior to that induced by endovascular coiling; surgical clipping should be regarded as the first choice of treatment for unruptured MCAAs.

Propofol post-conditioning after temporary clipping reverses oxidative stress in aneurysm surgery

PURPOSE

Animal studies have demonstrated that propofol post-conditioning produces long-term neuroprotection in focal cerebral ischemia-reperfusion injury. However, whether propofol post-conditioning provides neuroprotection in human beings has never been explored. The aim of this study was to evaluate the role of propofol post-conditioning on oxidative stress and post-operative cognitive function following aneurysm clipping.

MATERIALS AND METHODS

Sixty patients undergoing intracranial aneurysm clipping were randomized into a propofol post-conditioning group or a sevoflurane group. Sevoflurane (0.5-2%) was used for maintenance anesthesia in both groups. In the propofol post-conditioning group, the inhaled concentration of sevoflurane was reduced after temporary clip removal to keep the bispectral index (BIS) value between 40 and 60, and propofol (Cp 1.2 µg/mL) was subsequently started. Blood samples were drawn at six time points: before induction, immediately after clip removal, at the end of the operation, 24-h post-surgery, 3 days post-surgery, and 7 days post-surgery. Oxidative stress and cognitive function were measured.

RESULTS

Between the conclusion of the operation to 7 days after surgery, propofol post-conditioning decreased the serum concentration of •OH and 8-isoprostane and increased γ-tocopherol and SOD. Reduced micronuclei and nucleoplasmic bridges were observed in the propofol post-conditioning group. Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) scores were improved by propofol post-conditioning compared to the group that received no propofol.

CONCLUSIONS

Together, our data suggest that propofol post-conditioning (Cp 1.2 µg/mL) may protect the brain from oxidative stress injury up to 7 days post-surgery after temporary parent artery clipping. Furthermore, the neuroprotection induced by propofol post-conditioning may contribute to improvement in cognitive function.

Microsurgical clipping and endovascular treatment of middle cerebral artery aneurysms in an interdisciplinary treatment concept: Comparison of long-term results

OBJECTIVE

Treatment of middle cerebral artery (MCA) aneurysms has been historically considered as the almost exclusive domain of microsurgical clipping. This retrospective single-center study assesses whether microsurgical clipping or endovascular treatment (i.e. coiling and/or stenting) for MCA aneurysms yielded better occlusion rates and clinical outcome.

METHODS

We identified patients with a minimum clinical follow-up of 12 months who had undergone MCA aneurysm repair either by clipping or by endovascular treatment between 2005 and 2015. Aneurysm occlusion rates were assessed by the Raymond-Roy Occlusion Classification (RROC) and patients' clinical outcome was measured by the modified Rankin Scale (mRS). All patients had been treated in an interdisciplinary treatment concept at a large neurovascular center; both treatment modalities were available at all times.

RESULTS

Ninety-two eligible patients with MCA aneurysms, of whom 21.7% patients were treated for subarachnoid hemorrhages, were included; 38 patients underwent endovascular therapy and 54 clipping. The median age at treatment was 53.5 years (range, 25-79 years) and the median clinical follow-up was 98.5 months (range, 18-213 months). Occlusion rates were significantly higher in the clipping cohort (RROC = 1: 96.3% vs 78.9%; p = 0.04), long-term clinical outcome was better in the endovascular treatment cohort (mRS ≤ 1: 100.0% vs 90.8%; p < 0.01). Permanent treatment-associated morbidity was seen more commonly in the clipping cohort (9.3% vs 0.0%).

CONCLUSIONS

Both treatment modalities are associated with excellent clinical and radiological outcome if applied within an interdisciplinary treatment concept. Endovascular aneurysm repair appears to be an attractive treatment alternative compared to clipping with low complication rates for well-selected patients.

Cognitive Sequelae of Unruptured and Ruptured Intracranial Aneurysms and their Treatment: Modalities for Neuropsychological Assessment

BACKGROUND

Cognitive sequelae frequently follow subarachnoid hemorrhage (SAH) and include deficits across multiple domains of executive function. This factor affects overall functional outcomes negatively, especially in younger patients. Several clinical correlates predict development and severity of cognitive dysfunction after SAH. Hypothetical mechanisms of cognitive dysfunction in the absence of radiographic lesion include cerebral hypoperfusion and blood breakdown products, resulting in perturbed interneuronal communication and network synchrony, excitotoxicity, and altered microRNA expression.

METHODS

The PubMed database was searched for articles discussing cognitive outcomes in patients with unruptured and ruptured intracranial aneurysmal disease, sequelae of treatment, and modalities for neuropsychologic testing.

RESULTS

Treatment of unruptured intracranial aneurysms, although capable of preventing SAH, comes with its own set of complications and may also affect cognitive function. Neuropsychological tests such as the Montreal Cognitive Assessment, Mini-Mental Status Examination, and others have proved useful in evaluating cognitive decline. Studies using functional neurologic imaging modalities have identified regions with altered activation patterns during various cognitive tasks. The sum of research efforts in this field has provided useful insights and an initial understanding of cognitive dysfunction after aneurysm treatment and SAH that should prove useful in guiding and rendering future investigations more fruitful.

CONCLUSIONS

Development of finer and more sensitive neuropsychological tests in evaluating the different domains of cognitive function after aneurysm treatment and SAH in general will be useful in accurately determining outcomes after ictus and comparing efficacy of different therapeutic strategies.

Minimally Invasive Transpalpebral ‘‘Eyelid’’ Approach to Unruptured Middle Cerebral Artery Aneurysms

BACKGROUND: Although recent technological advances have led to successful endovascular treatment, middle cerebral artery (MCA) aneurysms are still prone to surgery. Because minimally invasive options are limited and possess several functional and cosmetic drawbacks, a transpalpebral approach is proposed as a new alternative.

OBJECTIVES: To describe and assess surgical results of the minimally invasive transpalpebral approach in patients with MCA aneurysms.

METHODS: The data of 25 patients with unruptured MCA aneurysms from 2013 to 2016 were included in a cohort prospective database. We describe modifications of the approach and technique for MCA aneurysm clipping, in a step-by-step manner. The outcome was based on complications, procedural morbidity and mortality, and clinical and angiographic outcomes.

RESULTS: All procedures were successfully performed in a standardized way, and no major complications related to the new approach were observed. Twenty-two patients were discharged the day after surgery (88%). The majority of aneurysms were 5 to 6 mm in diameter (mean, 7 mm; range 4-21 mm). All patients underwent postoperative angiographic control, which showed no significant residual neck. A 3-mo follow-up was sufficient to show no visible scars with excellent cosmetic results. The mean duration of follow-up was 16 mo.

CONCLUSION: The transpalpebral approach comes as a minimally invasive, safe, definitive, and cosmetically adequate solution for MCA aneurysms at the present time.

Performance of language tasks in patients with ruptured aneurysm of the left hemisphere worses in the post-surgical evaluation

ABSTRACT Sub-arachnoid hemorrhage (SAH) promotes impairment of upper cortical functions. However, few information is available emphasizing changes in language after aneurismal SAH and aneurysm location influence. Objective To assess the language and verbal fluency performance in aneurismal SAH pre- and post-surgery in patients caused by an aneurysm of the anterior communicating artery (AcomA), left middle cerebral artery (L-MCA) and left posterior comunicating artery (L-PcomA). Methods Assessment in 79 patients with SAH, on two occasions: pre- and post surgical treatment. They were divided into three groups by the aneurysms’ location. Results Deterioration is detected in the performance of all patients during the post-surgical period; L-MCA aneurysm patients displayed a reduction in verbal naming and fluency; L-PcomA patients deteriorated in the written language and fluency tasks. Conclusion After the surgical procedure the patients decreased in various language tasks and these differences in performance being directly related to the location of the aneurysm.

Treatment of Unruptured Intracranial Aneurysms and Cognitive Performance: Preliminary Results of a Prospective Clinical Trial

BACKGROUND

Few studies have addressed the effect of treatment of unruptured intracranial aneurysm (UIA) on cognitive function.

OBJECTIVE

Neuropsychological assessment after UIA treatment is underreported, and prospective trials have repeatedly been demanded. In 2014, we conducted a prospective controlled study to evaluate the differences in cognitive processing caused by the treatment of anterior circulation UIAs.

PATIENTS AND METHODS

Thirty patients were enrolled until September 2015. Ten patients received endovascular aneurysm occlusion (EV), 10 patients were treated microsurgically (MS), and 10 patients with surgically treated degenerative lumbar spine disease (LD) served as control. All patients underwent extended standardized neuropsychological assessment before (t₁) and 6 weeks after treatment (t₂). Tests included verbal, visual, and visuospatial memory, psychomotor functioning, executive functioning, and its subdomains verbal fluency and cognitive flexibility. We statistically evaluated intragroup and intergroup changes.

RESULTS

Intragroup comparisons and group-rate analysis showed no significant impairment in overall neuropsychological performance, either postinterventionally or postoperatively. However, the postoperative performance in cognitive processing speed, cognitive flexibility, and executive functioning was significantly worse in the MS group than in the EV (P = 0.038) and LD group (P = 0.02). Compared with the EV group, patients with MS showed significant postoperative impairment in a subtest for auditory-verbal memory (Wechsler Memory Scale, Fourth Edition, Logical Memory II; MS vs. EV P = 0.011). The MS group trended toward posttreatment impairment in subtests for verbal fluency and semantic memory (Regensburg Word Fluency Test; MS vs. EV P = 0.083) and in auditory-verbal memory (Wechsler Memory Scale, Fourth Edition, Logical Memory II; MS vs. LD P = 0.06).

CONCLUSIONS

Our preliminary data showed no effect of anterior circulation UIA treatment on overall neuropsychological function but impaired short-term executive processing in surgically treated patients.

Unruptured intracranial aneurysm treatment effects on cognitive function: a meta-analysis

OBJECTIVE

The treatment of an unruptured intracranial aneurysm (UIA) is not free of morbidity and mortality, and the decision is made by weighing the risks of treatment complications against the risk of aneurysm rupture. This meta-analysis quantitatively analyzed the literature on the effects of UIA treatment on cognition.

METHODS

MEDLINE, Embase, and PsycInfo were systematically searched for studies that reported on the cognitive status of UIA patients before and after aneurysm treatment. The search was restricted to prospective cohort and case-control studies published between January 1, 1998, and January 1, 2013. The analyses focused on the effect of treatment on general cognitive functioning, with an emphasis on 4 specific cognitive domains: executive functions, verbal and visual memory, and visuospatial functions.

RESULTS

Eight studies, with a total of 281 patients, were included in the meta-analysis. Treatment did not affect general cognitive functioning (effect size [ES] -0.22 [95% CI -0.78 to 0.34]). Executive functions and verbal memory domains trended toward posttreatment impairment (ES -0.46 [95% CI -0.93 to 0.01] and ES -0.31 [95% CI -1.24 to 0.61]), and performance of visual memory tasks trended toward posttreatment improvement (ES 1.48 [95% CI -0.36 to 3.31]). Lastly, treatment did not significantly affect visuospatial functions (ES -0.08 [95% CI -0.30 to 0.45]).

CONCLUSIONS

The treatment of an UIA does not seem to affect long-term cognitive function. However, definitive conclusions were not possible due to the paucity of studies addressing this issue.

Call for uniform neuropsychological assessment after aneurysmal subarachnoid hemorrhage: Swiss recommendations

BACKGROUND

In a high proportion of patients with favorable outcome after aneurysmal subarachnoid hemorrhage (aSAH), neuropsychological deficits, depression, anxiety, and fatigue are responsible for the inability to return to their regular premorbid life and pursue their professional careers. These problems often remain unrecognized, as no recommendations concerning a standardized comprehensive assessment have yet found entry into clinical routines.

METHODS

To establish a nationwide standard concerning a comprehensive assessment after aSAH, representatives of all neuropsychological and neurosurgical departments of those eight Swiss centers treating acute aSAH have agreed on a common protocol. In addition, a battery of questionnaires and neuropsychological tests was selected, optimally suited to the deficits found most prevalent in aSAH patients that was available in different languages and standardized.

RESULTS

We propose a baseline inpatient neuropsychological screening using the Montreal Cognitive Assessment (MoCA) between days 14 and 28 after aSAH. In an outpatient setting at 3 and 12 months after bleeding, we recommend a neuropsychological examination, testing all relevant domains including attention, speed of information processing, executive functions, verbal and visual learning/memory, language, visuo-perceptual abilities, and premorbid intelligence. In addition, a detailed assessment capturing anxiety, depression, fatigue, symptoms of frontal lobe affection, and quality of life should be performed.

CONCLUSIONS

This standardized neuropsychological assessment will lead to a more comprehensive assessment of the patient, facilitate the detection and subsequent treatment of previously unrecognized but relevant impairments, and help to determine the incidence, characteristics, modifiable risk factors, and the clinical course of these impairments after aSAH.

Does a craniotomy for treatment of unruptured aneurysm affect cognitive function?

The surgical procedure used to treat an unruptured intracranial aneurysm (UIA) has controversial effects on cognitive function. From January 2010 through December 2012, we enrolled patients who underwent surgical clipping for a UIA. Patients were tested within one week prior to surgery and again postoperatively (6.8 ± 2.3 days) using a neuropsychological battery comprising the Mini-Mental State Examination, the Trail Making Test (TMT), the Frontal Assessment Battery (FAB), and Raven's colored progressive matrices (RCPM). Differences between preoperative and postoperative test scores for each examination were analyzed across individuals. In an additional subgroup analysis, patients were grouped according to age (< 65 or ≥ 65 years), the largest dimension of the aneurysm, the location of the aneurysm (i.e., anterior communicating artery, internal carotid artery, or middle cerebral artery) and operation duration. Paired student's t-tests were used to examine potential differences between groups. Two-tailed P-values < 0.05 were considered significant. Seventy-one patients were included in the analysis. The surgical procedure used to correct a UIA resulted in significant changes in neuropsychological scores. After the procedure, the TMT-A score declined significantly, whereas the FAB and RCPM scores were significantly improved. In the subgroup analysis, a significant deterioration in TMT-A score was observed in older patients and those with larger aneurysms, anterior communicating artery aneurysms and longer surgeries. Our findings, therefore, indicate that the surgical procedure to correct a UIA affects cognitive function. Older patients and those with large aneurysms, anterior communicating aneurysms, and long operations represent the high-risk groups.

Cognitive function, depression, anxiety and quality of life in Chinese patients with untreated unruptured intracranial aneurysms

Detected unruptured intracranial aneurysms (UIA) are becoming more common with the increased utilization of CT angiography, MR angiography and digital subtraction angiography. A proportion of patients with UIA remain untreated. We investigated to assess cognitive function, depression, anxiety and quality of life (QoL) in Chinese patients with untreated UIA. Thirty one Chinese patients with untreated UIA and 25 healthy controls were identified and matched for variables including age, sex, and living area. Cognitive function was evaluated with the Montreal Cognitive Assessment (MoCA). Depression, anxiety and QoL were screened with the Self-Rating Depression Scale, Self-Rating Anxiety Scale, and Short Form-36, respectively. Non-parametric tests were used for comparisons between groups. No patient had cognitive dysfunction at 1 month or 1 year after detection of UIA. However, a significant decrease of overall MoCA subscores was found in 30 (97%) of 31 patients 5 years after UIA discovery, suggestive of mild cognitive impairment. A significant decrease in depression and anxiety was found in patients over time. QoL in patients was reduced most prominently in psychosocial function and social activities 1 year after detection of UIA, but these improved to within normal limits at the end of the follow-up period. For Chinese patients with untreated UIA, depression, anxiety and reduced QoL may be short-term complications. Mild cognitive impairment may be a long-term complication.

Behavioral profile of unruptured intracranial aneurysms: a systematic review

Objectives

To systematically review the literature on the neuropsychological, psychosocial, and functional profiles of patients with unruptured intracranial aneurysms.

Methods

This review was limited to peer-reviewed research articles that reported cognitive, psychosocial, and/or functional profiles of patients with unruptured intracranial aneurysms. Studies were identified through Medline and PsychINFO by searching “(unruptured [intracranial OR cerebral] aneurysm) AND (cogniti* OR neuropsycholog* OR anxiety OR depression OR [quality of life] OR work OR employment OR [activities of daily living] OR [instrumental activities of daily living]).” Only articles that were published since January 1997 were considered. Reference lists of included articles were inspected for additional studies. Only articles in English were included. Case studies were excluded. Twenty-two articles were included in this review.

Results

The literature demonstrates that although treatment for unruptured intracranial aneurysms allays anxiety, it also results in an observable, though transient decline in cognition and daily functioning. Even before treatment, preliminary evidence hints that these patients are not free of such impairments.

Conclusions

The algorithm that underlies the decision to treat an unruptured intracranial aneurysm ought to add more weight to the neuropsychological, psychosocial, and functional profiles of these patients. The clinical relevance of these patients does not begin and end with their risk of rupture.

Morphology of Middle Cerebral Artery Aneurysms: Impact on Surgical Strategy and on Postoperative Outcome

The outcome of middle cerebral artery (MCA) aneurysm clipping depends on the presence of subarachnoid hemorrhage (SAH). Moreover, it is influenced by anatomical features of the aneurysm and its parent artery. We hypothesized that morphological characteristics of the aneurysm may be predictive for postoperative outcome. Therefore, we identified radiographic assessable details that predicted the surgical difficulty and the risk for new ischemia. The angiograms of 151 consecutive patients (82 presenting with SAH) were analyzed in a standardized fashion focusing on 12 defined morphological aspects. The results were correlated to intraoperative rupture and to postoperative ischemia. Aneurysms presenting with SAH were associated with irregular shape, larger maximum diameter, and larger dome-to-base distance (DBD) and were located more frequently on the M2 segment. Multivariate analysis revealed 6 independent predictors for intraoperative rupture: SAH, location on M2 segment, DBD, maximum diameter, diameter of the parent MCA, and the presence of branching vessel. Independent predictors of surgery-related ischemia were identified: SAH, irregular shape, location on M2 segment, DBD, and the neck-to-vessel ratio (NVR). In MCA aneurysms, independent predictors for the risk of rupture intraoperatively and for the postsurgical outcome were the presence of SAH, location on the M2-segment, size (DBD), and the broadness of the neck.

Middle cerebral artery aneurysms: a single-center series comparing endovascular and surgical treatment

OBJECTIVE

The optimal treatment for middle cerebral artery (MCA) aneurysms is controversial. MCA aneurysms have been considered more conducive to surgical treatment. Recent technology has led to successful endovascular treatment of MCA aneurysms. The objective of this study was to analyze the outcomes of endovascular and surgical treatment of MCA aneurysms as experienced by a single tertiary center.

METHODS

We retrospectively reviewed 90 MCA aneurysms in 84 patients treated from 2005 to 2010. They were separated into 2 groups: endovascular coiling, with 50 (59.5%) patients, and surgical clipping, with 34 (40.5%) patients. Outcome was based on complications, procedural morbidity and mortality, clinical and angiographic outcomes, and retreatment rates. Patients were further separated into ruptured and unruptured aneurysm groups.

RESULTS

Ruptured aneurysms were 10 of 50 (20%) and 9 of 34 (26.5%) patients in the endovascular and surgical groups, respectively. Procedure-related complications were 16% and 0% for the endovascular and surgical groups (P = .01), respectively. Overall rate of complete or near-complete occlusion at angiographic follow-up was 86% and 95% for the endovascular and surgical groups (P = .16), respectively. Proportion of patients with modified Rankin scale of 3 to 6 at 6 months follow-up was 10% and 5.9% for the endovascular and surgical groups (P = .5), respectively. The mean angiographic follow-up was 9.02 months (range 0 to 5.2 years). Retreatment rates were 14% and 0% for the endovascular and surgical groups, respectively (P = .01).

CONCLUSIONS

In this nonrandomized sample of 90 MCA aneurysms treated with endovascular coiling or neurosurgical clipping, we observed a similar clinical outcome based on the modified Rankin scale and angiographic occlusion. Complication and retreatment rates were higher but not significant for the endovascular group. Both treatment modalities are good alternatives and should be individualized based on aneurysm angioarchitecture and the patient's general conditions.

Neurosurgery in Oslo

Neurosurgery in Oslo, Norway, was founded by the pioneer Vilhelm Magnus in the beginning of the 20th century. Through the contributions of important surgeons such as Arne Torkildsen, Kristian Kristiansen, and Helge Nornes, Norwegian neurosurgery has developed into an active clinical and technologically oriented surgical specialty. Since the unification of neurosurgical procedures in Oslo in January 2010 into one department, it is one of the largest neurosurgical departments in Europe with more than 4500 surgeries performed per year covering all aspects of neurosurgery. The department's scientific focus is on clinical studies, in close collaboration with supportive clinical departments; through interaction with basic science stem cell groups, an increasing effort is being made in translational cellular and molecular medicine.

Cognitive Functioning and Health-Related Quality of Life 1 Year After Aneurysmal Subarachnoid Hemorrhage in Preoperative Comatose Patients (Hunt and Hess Grade V Patients)

OBJECTIVE

The objective of this study was to determine cognitive functioning and health-related quality of life 1 year after aneurysmal subarachnoid hemorrhage in preoperative comatose patients (Hunt and Hess Grade V patients).

METHODS

Patients who were comatose at hospital arrival and thereafter were investigated for 1 year using a comprehensive neuropsychological test battery and 2 HRQOL questionnaires.

RESULTS

Thirty-five of 70 patients survived the bleed, and 26 underwent neuropsychological testing. Two distinct patient groups emerged, one (n = 14) with good cognitive function, having mild deficits only, and the other (n = 12) with poor cognitive and poor motor function. Patients performing poorly were older (P = .04), had fewer years of education (P = .005) and larger preoperative ventricular scores, and were more often shunted (P = .02). There were also differences between the 2 groups in the Glasgow Outcome Scale (P = .001), the modified Rankin Scale (P = .001), and employment status. HRQOL was more reduced in patients with poor cognitive function.

CONCLUSION

A high fraction of survivors among preoperative comatose aneurysmal SAH patients (Hunt and Hess grade V) recover to good physical and cognitive function, enabling them to live a normal life.