1
|
Carvalho V, Moreira M, Vilarinho A, Cerejo A, Vaz R, Silva PA. Selection bias in patients proposed for neurosurgical versus endovascular treatment of aneurysms of the posterior communicating artery. Interv Neuroradiol 2022; 28:675-681. [PMID: 34787020 PMCID: PMC9706261 DOI: 10.1177/15910199211057738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/25/2021] [Accepted: 10/17/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Microsurgical clipping and endovascular coiling are viable treatment options for posterior communicating artery (PComA) aneurysms, but there are still major limitations to evidence-based decisions regarding standard-of-care treatment. In this study, we aimed at assessing potential selection biases that may influence our ability to extract conclusions about the comparative effectiveness or efficacy of the aneurysm treatment. OBJECTIVE To study the patient/aneurysm characteristics as possible biases in the option for endovascular or neurosurgical treatment of PComA aneurysms. METHODS A single-center, retrospective cohort study was performed, including all patients with treated PComA aneurysms with neurosurgical clipping or endovascular coiling between January 2010 and January 2021. Clinical and morphological data were collected from electronic records, and statistical analysis was performed. RESULTS A total of 64 patients was eligible for inclusion; 24 (37.5%) patients were proposed for neurosurgical treatment, while 40 (62.5%) for endovascular treatment; 10 patients (25%) crossed over to the clipping group whereas none crossed over to the coiling side. Actual treatment analysis showed significantly higher diameters of mother vessel (t-test, p = 0.034) and aneurysm neck (Mann-Whitney, p = 0.029) in the clipping group and higher aspect and dome-to-neck ratios in the endovascular group (Mann-Whitney, p = 0.008). A significantly higher vasospasm frequency was found in the clipping group but only in the intention-to-treat analysis (Chi-square, p = 0.032). CONCLUSION Significant morphological differences between effective endovascular and surgical groups and differences in intention-to-treat analysis may limit the validity of a direct comparison between treatment options and suggest the presence of a possible selection bias.
Collapse
Affiliation(s)
- Vasco Carvalho
- Department of Neurosurgery, Centro Hospitalar Universitário São
João, Porto, Portugal
- Faculty of Medicine of the University of
Porto, Porto, Portugal
| | - Marta Moreira
- Faculty of Medicine of the University of
Porto, Porto, Portugal
| | - António Vilarinho
- Department of Neurosurgery, Centro Hospitalar Universitário São
João, Porto, Portugal
- Faculty of Medicine of the University of
Porto, Porto, Portugal
| | - António Cerejo
- Department of Neurosurgery, Centro Hospitalar Universitário São
João, Porto, Portugal
- Faculty of Medicine of the University of
Porto, Porto, Portugal
| | - Rui Vaz
- Department of Neurosurgery, Centro Hospitalar Universitário São
João, Porto, Portugal
- Faculty of Medicine of the University of
Porto, Porto, Portugal
| | - Pedro Alberto Silva
- Department of Neurosurgery, Centro Hospitalar Universitário São
João, Porto, Portugal
- Faculty of Medicine of the University of
Porto, Porto, Portugal
| |
Collapse
|
2
|
Liu HJ, Lin Y, Feng YG. Predictors of Oculomotor Nerve Palsy with Posterior Communicating Aneurysm Clipping in a Surgically Treated Series of 585 Patients: A Single-Center Study. World Neurosurg 2022; 167:e117-e121. [PMID: 35926703 DOI: 10.1016/j.wneu.2022.07.101] [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: 07/19/2022] [Accepted: 07/24/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Oculomotor nerve palsy (OMNP) is a known risk in surgical management of intracranial aneurysms. The aim of this study was to determine the risk factors for surgery-induced OMNP. METHODS This retrospective study examined 585 patients with posterior communicating artery aneurysms treated surgically between January 2000 and July 2019. The patients were categorized into 2 groups according to whether they experienced OMNP. Multiple factors, including sex, age, history of subarachnoid hemorrhage, Hunt and Hess grade, Fisher grade, preoperative time, sizes, sides, number, orientation, intraoperative rupture, and morphology, were analyzed to identify factors associated with surgery-induced OMNP. RESULTS The overall OMNP rate was 4.4%. In univariate analysis, large size (P < 0.001), posterior infratentorial projection (P = 0.003), number of subarachnoid hemorrhages (P = 0.005), and late preoperative time (P < 0.001) were associated with increased risk of OMNP. Overall, multivariate logistic regression analysis showed that size (10.1-25 mm: odds ratio [OR] 30.083, P = 0.001, 95% confidence interval [CI], 3.703-244.419; >25 mm: OR 62.179, P = 0.012, 95% CI, 2.402-1609.418), intraoperative rupture (OR 3.018, P = 0.035, 95% CI, 1.083-8.412), and preoperative time (>14 days: OR 10.985, P < 0.001, 95% CI, 3.840-31.428) were independent risk factors of surgery-induced OMNP. CONCLUSIONS This study showed that size, intraoperative rupture, and preoperative time were independent predictors of surgery-induced OMNP. Use of advanced technologies during the operation can assist in avoiding this complication.
Collapse
Affiliation(s)
- Heng-Jian Liu
- Changzhou Hospital of Traditional Chinese Medicine, Jiangsu, China; Qingdao University, Qingdao, China
| | - Yuan Lin
- Changzhou Hospital of Traditional Chinese Medicine, Jiangsu, China
| | - Yu-Gong Feng
- Department of Neurosurgery, Affiliated Hospital of Qingdao University, Qingdao, China.
| |
Collapse
|
3
|
Impact of subcallosal artery origin and A1 asymmetry on surgical outcomes of anterior communicating artery aneurysms. Acta Neurochir (Wien) 2021; 163:2955-2965. [PMID: 34453215 DOI: 10.1007/s00701-021-04979-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 08/19/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Surgical clipping of anterior communicating artery (ACoA) aneurysms remains challenging due to their complex anatomy. Anatomical risk factors for ACoA aneurysm surgery require further elucidation. The aim of this study is to investigate whether proximity of the midline perforating artery, subcallosal artery (SubCA), and associated anomaly of the ACoA complex affect functional outcomes of ACoA aneurysm surgery. METHODS A total of 92 patients with both unruptured and ruptured ACoA aneurysms, who underwent surgical clipping, were retrospectively analyzed from a multicenter, observational cohort database. Association of ACoA anatomy with SubCA origin at the aneurysmal neck under microsurgical observation was analyzed in the interhemispheric approach subgroup (n = 56). Then, we evaluated whether anatomical factors associated with SubCA neck origin affected surgical outcomes in the entire cohort (both interhemispheric and pterional approaches, n = 92). RESULTS In the interhemispheric approach cohort, combination of A1 asymmetry and aneurysmal size ≥ 5.0 mm was stratified to have the highest probability of the SubCA neck origin by a decision tree analysis. Then, among the entire cohort using either interhemispheric or pterional approach, combination of A1 asymmetry and aneurysmal size ≥ 5.0 mm was significantly associated with poor functional outcomes by multivariable logistic regression analysis (OR 6.76; 95% CI 1.19-38.5; p = 0.03) as compared with A1 symmetry group in the acute subarachnoid hemorrhage settings. CONCLUSION Combination of A1 asymmetry and larger aneurysmal size was significantly associated with SubCA aneurysmal neck origin and poor functional outcomes in ACoA aneurysm surgery. Interhemispheric approach may be proposed to provide a wider and unobstructed view of SubCA for ACoA aneurysms with this high-risk anatomical variant.
Collapse
|
4
|
λ stenting: a novel technique for posterior communicating artery aneurysms with fetal-type posterior communicating artery originating from the aneurysm dome. Neuroradiology 2021; 64:151-159. [PMID: 34351498 PMCID: PMC8724119 DOI: 10.1007/s00234-021-02775-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 07/19/2021] [Indexed: 11/04/2022]
Abstract
Purpose Endovascular treatment of posterior communicating artery aneurysms with fetal-type posterior communicating artery originating from the aneurysm dome is often challenging because, with conventional techniques, dense packing of aneurysms for posterior communicating artery preservation is difficult; moreover, flow-diversion devices are reportedly less effective. Herein, we describe a novel method called the λ stenting technique that involves deploying stents into the internal carotid artery and posterior communicating artery. Methods Between January 2018 and September 2020, the λ stenting technique was performed to treat eight consecutive cases of aneurysms. All target aneurysms had a wide neck (dome/neck ratio < 2), a fetal-type posterior communicating artery with hypoplastic P1, and a posterior communicating artery originating from the aneurysm dome. The origin of the posterior communicating artery from the aneurysm, relative to the internal carotid artery, was steep (< 90°: V shape). Results The maximum aneurysm size was 8.0 ± 1.9 mm (6–12 mm). The average packing density (excluding one regrowth case) was 32.7 ± 4.2% (26.8–39.1%). Initial occlusion was complete occlusion in 6 (75.0%) patients and neck remnants in 2 (25.0%) patients. Follow-up angiography was performed at 18.4 ± 11.6 months (3–38 months). There were no perioperative complications or reinterventions required during the study period. Conclusion The λ stenting technique enabled dense coil packing and preservation of the posterior communicating artery. This technique enabled safe and stable coil embolization. Thus, it could become an alternative treatment option for this sub-type of intracranial aneurysms. Supplementary Information The online version contains supplementary material available at 10.1007/s00234-021-02775-y.
Collapse
|
5
|
Sriamornrattanakul K, Wongsuriyanan S. Anterior Temporal Approach for Clipping Posterior-Projecting Supraclinoid Carotid Artery Aneurysms: A More Lateral Corridor to Better Visualize the Aneurysm Neck and Related Branches. World Neurosurg 2021; 149:e549-e562. [PMID: 33556599 DOI: 10.1016/j.wneu.2021.01.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 01/26/2021] [Accepted: 01/26/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Direct visualization of the aneurysm neck and its related branches during microsurgical clipping of supraclinoid internal carotid artery (SICA) aneurysms using a standard pterional approach may be difficult, especially when aneurysms are posteriorly projected. We evaluated the efficacy and safety of an anterior temporal approach for clipping posterior-projecting SICA aneurysms. METHODS Between December 2017 and March 2020, 26 patients with posterior-projecting SICA aneurysms who received microsurgical clipping via an anterior temporal approach were retrospectively reviewed. The percentage of complete aneurysm obliteration, intraoperative visualization, and preservation of related branches were evaluated. RESULTS Aneurysm locations were the posterior communicating artery (PCoA) (internal carotid artery [ICA]-PCoA) in 22 patients (84.6%), the anterior choroidal artery (AChA) (ICA-AChA) in 3 patients (11.5%), and both locations in 1 patient (3.9%). Complete aneurysm obliteration was achieved in all patients. For ICA-PCoA aneurysms in which the PCoA was preoperatively identified, the artery was intraoperatively identified in all cases and preserved 100% after surgery. For ICA-AChA aneurysms, AChAs were intraoperatively identified and preserved in all cases after surgery. Procedural-related infarction was 8.7% for ICA-PCoA aneurysms and 7.7% for all SICA aneurysms. Transient oculomotor nerve palsy was found in 2 patients (7.7%). No postoperative temporal contusion was detected. A good outcome at 3 months after surgery was achieved in 90% of patients for good clinical-grade subarachnoid hemorrhage and unruptured cases. CONCLUSIONS The anterior temporal approach is safe and effective for clipping SICA aneurysms with posterior projection, with a high preservation rate of the related branches.
Collapse
Affiliation(s)
- Kitiporn Sriamornrattanakul
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand.
| | - Somkiat Wongsuriyanan
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| |
Collapse
|
6
|
Kim M, Evins AI, Fukuda H, Kim N, Stieg PE, Bernardo A. Surgical Management of Posterior Communicating Artery Aneurysms in the Presence of a Low-Coursing Internal Carotid Artery and Narrowed Retrocarotid Window. World Neurosurg 2020; 139:558-566. [PMID: 32376373 DOI: 10.1016/j.wneu.2020.04.200] [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: 02/20/2020] [Revised: 04/24/2020] [Accepted: 04/26/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Anatomical variations of the course of the internal carotid artery (ICA) may complicate surgical clipping of posterior communicating artery (PCoA) aneurysms by narrowing the retrocarotid window. We evaluated the efficacy of the periclinoid surgical maneuvers for expanding the retrocarotid window and analyzed computed tomography angiography (CTA) data from patients with PCoA aneurysms to define parameters for low-coursing ICAs. METHODS Using cadaveric specimens, standard pterional craniotomies were fashioned and extradural or intradural periclinoid surgical maneuvers-cutting of the meningo-orbital band, anterior clinoidectomy, and cutting of the distal dural ring (DDR)-were performed, and their relative advantages for expanding the retrocarotid window were assessed. Additionally, preoperative CTA data from 24 patients with PCoA aneurysms used to calculate the angles of the ICA relative to the skull base. RESULTS Periclinoid maneuvers, especially the anterior clinoidectomy, provided additional exposure of the retrocarotid space. Cutting of the DDR allowed for partial mobilization of the ICA and widened the retrocarotid surgical window, enhancing maneuverability. The anterior clinoidectomy with cutting of the DDR allowed for enhanced exposure of the medial, middle, and posterolateral aspects of the retrocarotid space. Cutting the anterior petroclinoid fold and mobilizing cranial nerve III provided wide exposure of the lateral aspect of retrocarotid space. CONCLUSION When clipping PCoA aneurysms in the presence of normal-coursing ICAs (approximately ≥30° ICA angle), a standard pterional craniotomy with anterior clinoidectomy and cutting of the DDR allows for substantial expansion of the retrocarotid window.
Collapse
Affiliation(s)
- Michael Kim
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA; Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, NewYork, New York, USA
| | - Alexander I Evins
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, NewYork, New York, USA
| | - Hitoshi Fukuda
- Department of Neurosurgery, Kochi University Hospital, Nankoku, Kochi, Japan
| | - Namhee Kim
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, NewYork, New York, USA
| | - Philip E Stieg
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, NewYork, New York, USA
| | - Antonio Bernardo
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, NewYork, New York, USA.
| |
Collapse
|
7
|
Kim E. Clip Compression Injury of the Oculomotor Nerve: Its Prevention and Recovery. Korean J Neurotrauma 2020; 16:85-89. [PMID: 32395456 PMCID: PMC7192810 DOI: 10.13004/kjnt.2020.16.e11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/07/2020] [Accepted: 04/13/2020] [Indexed: 11/15/2022] Open
Abstract
Clip compression injury of oculomotor nerve (ON) is a preventable complication of aneurysm microsurgery. The author illustrates this condition in which ON was inadvertently occluded by the clip during repairing posterior communicating artery (PcoA) aneurysm. The report indicates that the surgeon should be meticulous in identifying and protecting ON at clipping stage when PcoA aneurysm prematurely bursts.
Collapse
Affiliation(s)
- El Kim
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| |
Collapse
|
8
|
Martínez-Pérez R, Albonette-Felicio T, Zachariah MA, Hardesty DA, Carrau RL, Prevedello DM. Quantitative Anatomic Study of the Minipterional Craniotomy in the Paraclinoid Region: Benefits of Extradural Anterior Clinoidectomy. World Neurosurg 2019; 135:e221-e229. [PMID: 31786378 DOI: 10.1016/j.wneu.2019.11.120] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 11/20/2019] [Accepted: 11/21/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Extradural anterior clinoidectomy (eAC) via the minipterional craniotomy (MPT) approach (MPT+eAC) has been recently introduced to the neurosurgical armamentarium to improve access to anterior and middle fossa skull base structures using a minimally invasive approach. However, the effect of extradural clinoidectomy on surgical exposure with the minipterional approach has not been evaluated. Moreover, the effect of eAC on surgical maneuverability has not been established for either traditional pterional or minipterional craniotomy. We sought to illustrate the microsurgical anatomy of the MPT+eAC and to evaluate the effect of eAC on surgical exposure and maneuverability. METHODS The area of exposure, area of surgical freedom, and maneuverability score for the MPT approach and MPT+eAC were compared in 5 cadaveric heads. RESULTS Compared with the MPT approach, the MPT+eAC enlarged the area of exposure approximately twofold (93 cm2 vs. 184 cm2; P < 0.001). All targets considered in the paraclinoid region, including the posterior communicating artery origin, prechiasmatic region, and ophthalmic artery origin, showed an increase in surgical freedom and maneuverability after performing eAC. Targets remote from the clinoid such as the internal carotid bifurcation were not affected. CONCLUSIONS MPT+eAC offers a larger area of exposure and greater surgical freedom and maneuverability at the paraclinoid region using this minimally invasive approach.
Collapse
Affiliation(s)
- Rafael Martínez-Pérez
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Thiago Albonette-Felicio
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Marcus A Zachariah
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Douglas A Hardesty
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA; Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ricardo L Carrau
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA; Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel M Prevedello
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA; Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.
| |
Collapse
|
9
|
Akamatsu Y, Kashimura H, Suzuki T, Aso K, Oshida S, Fujiwara S, Kubo Y, Ogasawara K. Impact of the Intracranial Course of Internal Carotid Artery on Optimal Surgical Approach for Posterior Communicating Artery Aneurysms. World Neurosurg 2019; 127:e142-e148. [PMID: 30872191 DOI: 10.1016/j.wneu.2019.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 02/28/2019] [Accepted: 03/01/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND The anterior temporal approach (ATA) has been reported as suitable for surgical clipping of posteriorly projecting internal carotid artery (ICA) aneurysms. As the ICA follows a variable course, tortuosity of the ICA may affect visualization of the aneurysm. The aim of this study was to investigate the impact of the intracranial course of the ICA and aneurysm projection on surgical approach. METHODS Consecutive patients with posterior communicating artery aneurysms treated with clipping at our hospital between May 2015 and April 2018 were retrospectively reviewed. When the transsylvian approach (TSA) could not achieve adequate exposure of the aneurysm, the ATA was subsequently performed. Distance between the ICA and the anterior and posterior clinoid line, angle between the midline and the C1 segment of the ICA, and aneurysm projection were compared between ATA and TSA groups. RESULTS Of 52 patients (40 ruptured, 12 unruptured), 12 were in the ATA group, and 40 were in the TSA group. Mean ICA-anterior and posterior clinoid distance was significantly shorter in the ATA group than in the TSA group (P = 0.002), and mean midline-C1 angle was significantly larger in the ATA group than in the TSA group (P < 0.0001). The ATA group was associated with a greater frequency of posteriorly projecting aneurysms (12 of 12; 100%) than the TSA group (9 of 40; 22.5%) (P < 0.00001). CONCLUSIONS A low-lying, laterally projecting intracranial ICA and posteriorly projecting aneurysm are predictors of the necessity for the ATA in the surgical clipping of posterior communicating artery aneurysms.
Collapse
Affiliation(s)
- Yosuke Akamatsu
- Department of Neurosurgery, Iwate Prefectural Chubu Hospital, Kitakami, Japan; Department of Neurosurgery, Iwate Medical University, Morioka, Japan
| | - Hiroshi Kashimura
- Department of Neurosurgery, Iwate Prefectural Chubu Hospital, Kitakami, Japan.
| | - Taro Suzuki
- Department of Neurosurgery, Iwate Prefectural Chubu Hospital, Kitakami, Japan
| | - Kenta Aso
- Department of Neurosurgery, Iwate Prefectural Chubu Hospital, Kitakami, Japan
| | - Sotaro Oshida
- Department of Neurosurgery, Iwate Prefectural Chubu Hospital, Kitakami, Japan
| | - Shunrou Fujiwara
- Department of Neurosurgery, Iwate Medical University, Morioka, Japan
| | - Yoshitaka Kubo
- Department of Neurosurgery, Iwate Medical University, Morioka, Japan
| | - Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University, Morioka, Japan
| |
Collapse
|
10
|
Huhtakangas J, Lehecka M, Lehto H, Rezai Jahromi B, Niemelä M, Kivisaari R. Riskier-than-expected occlusive treatment of ruptured posterior communicating artery aneurysms: treatment and outcome of 620 consecutive patients. J Neurosurg 2018; 131:1269-1277. [PMID: 30485236 DOI: 10.3171/2018.4.jns18145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 04/05/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Occlusive treatment of posterior communicating artery (PCoA) aneurysms has been seen as a fairly uncomplicated procedure. The objective here was to determine the radiological and clinical outcome of patients after PCoA aneurysm rupture and treatment and to evaluate the risk factors for impaired outcome. METHODS In a retrospective clinical follow-up study, data were collected from 620 consecutive patients who had been treated for ruptured PCoA aneurysms at a single center between 1980 and 2014. The follow-up was a minimum of 1 year after treatment or until death. RESULTS Of the 620 patients, 83% were treated with microsurgical clipping, 8% with endovascular coiling, 2% with the two procedures combined, 1% with indirect surgical methods, and 6% with conservative methods. The most common procedural complications were treatment-related brain infarctions (15%). The occurrence of artery occlusions (10% microsurgical, 8% endovascular) was higher than expected. Most patients made a good recovery at 1 year after aneurysmal subarachnoid hemorrhage (modified Rankin Scale [mRS] score 0-2: 386 patients [62%]). A fairly small proportion of patients were left severely disabled (mRS score 4-5: 27 patients [4%]). Among all patients, 20% died during the 1st year. Independent risk factors for an unfavorable outcome, according to the multivariable analysis, were poor preoperative clinical condition, intracerebral or subdural hematoma due to aneurysm rupture, age over 65 years, artery occlusion on postoperative angiography, occlusive treatment-related ischemia, delayed cerebral vasospasm, and hydrocephalus requiring a shunt. CONCLUSIONS Even though most patients made a good recovery after PCoA aneurysm rupture and treatment during the 1st year, the occlusive treatment-related complications were higher than expected and caused morbidity even among initially good-grade patients. Occlusive treatment of ruptured PCoA aneurysms seems to be a high-risk procedure, even in a high-volume neurovascular center.
Collapse
|
11
|
Goertz L, Hamisch C, Telentschak S, Kabbasch C, von Spreckelsen N, Stavrinou P, Timmer M, Goldbrunner R, Brinker G, Krischek B. Impact of Aneurysm Shape on Intraoperative Rupture During Clipping of Ruptured Intracranial Aneurysms. World Neurosurg 2018; 118:e806-e812. [DOI: 10.1016/j.wneu.2018.07.058] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 07/06/2018] [Accepted: 07/07/2018] [Indexed: 11/30/2022]
|
12
|
Monitoring Dynamic Morphological Changes With Electrocardiography-Gated Dynamic 4-Dimensional Computed Tomography Angiography to Predict Intraoperative Rupture of Intracranial Aneurysms. J Comput Assist Tomogr 2018; 42:286-292. [PMID: 28937485 DOI: 10.1097/rct.0000000000000671] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aims to evaluate dynamic morphological changes of intracranial aneurysms to predict intraoperative aneurysm rupture (IAR) during clipping. METHODS Included in this study were 153 patients, who had ruptured and microsurgical-clipped aneurysms. All patients underwent dual-source computed tomography examination of electrocardiography-gated dynamic 4-dimensional computed tomography angiography before clipping. Original scanning data were reconstructed to produce 20 data sets of cardiac cycles with 5% time intervals. The aneurysm neck, transverse and longitudinal diameters, and volume from the 20 groups of images were measured to calculate their respective change rates. In addition, other data and clinical characteristics were recorded. Data were analyzed by logistic regression to identify factors associated with IAR. RESULTS Of the 153 patients, 24 patients experienced IAR. Multivariable analysis revealed that the aneurysm neck change rate (P = 0.0001; odds ratio, 1.276) and aspect ratio (height/neck ratio, P = 0.025; odds ratio, 2.387) are predictors for IAR. When the change rate was greater than or equal to 60%, and the sensitivity and specificity were 91.7% and 76.7%, respectively. CONCLUSIONS Aneurysm neck change rate is independent predictor of IAR.
Collapse
|
13
|
Tanabe J, Ishikawa T, Moroi J, Sakata Y, Hadeishi H. Impact of Right-Sided Aneurysm, Rupture Status, and Size of Aneurysm on Perforator Infarction Following Microsurgical Clipping of Posterior Communicating Artery Aneurysms with a Distal Transsylvian Approach. World Neurosurg 2018; 111:e905-e911. [DOI: 10.1016/j.wneu.2018.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 12/28/2017] [Accepted: 01/03/2018] [Indexed: 11/16/2022]
|
14
|
Shi L, Yu J, Zhao Y, Xu K, Yu J. Clipping treatment of posterior communicating artery aneurysms associated with arteriosclerosis and calcification: A single center study of 136 cases. Exp Ther Med 2018; 15:1647-1653. [PMID: 29434749 DOI: 10.3892/etm.2017.5525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 10/13/2017] [Indexed: 01/18/2023] Open
Abstract
It is widely acknowledged that arteriosclerosis and calcification of the parent artery and aneurysm neck make it difficult to clip posterior communicating artery (PCoA) aneurysms. A total of 136 cases of PCoA aneurysms accompanied by arteriosclerosis and calcification were collected and treated with clipping in the present study. Of the 136 patients, 112 were females (82.4%) and 24 were males (17.6%), with ages ranging from 37 to 76 years (mean age, 60.2 years). Rupture of a PCoA aneurysm was identified in 132 cases (97.1%), and there were 4 cases of unruptured PCoA aneurysms (2.9%). According to the severity of arteriosclerosis and calcification, the aneurysms were divided into type I, II or III. The treatment of type I aneurysms achieved the best curative effect. It is difficult to temporarily occlude type II and III aneurysms during surgery, and temporary occlusion failed in almost 50% of cases. Types II and III were prone to intraoperative aneurysm ruptures. A significantly higher rate of intraoperative aneurysm rupture was seen in type III compared with type II cases. Type II and III cases were more likely to be treated using a fenestrated clip for aneurysm clipping compared with type I cases, and fenestrated clips were used significantly more frequently in type III cases compared with type II cases. Arteriosclerosis and calcification were likely to affect the prognosis of patients, particularly in cases with type III arteriosclerosis and calcification of the parent artery and aneurysm neck. Therefore, the stratification of the arteriosclerosis and calcification of the parent artery and aneurysm neck into types I-III can guide the intraoperative aneurysm clipping strategy, aid in choosing the correct clips, and inform predictions of the occurrence of rupture and hemorrhage, as well as the prognosis for aneurysms.
Collapse
Affiliation(s)
- Lei Shi
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Jing Yu
- Department of Operation, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Ying Zhao
- Department of Training, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Kan Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| |
Collapse
|
15
|
Secondary coiling after incomplete surgical clipping of cerebral aneurysms: a rescue strategy or a treatment option for complex cases? Institutional series and systematic review. Neurosurg Rev 2018; 42:337-350. [DOI: 10.1007/s10143-018-0950-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 01/13/2018] [Accepted: 01/24/2018] [Indexed: 12/23/2022]
|
16
|
Kamide T, Burkhardt JK, Tabani H, Safaee MM, Lawton MT. Preoperative Prediction of the Necessity for Anterior Clinoidectomy During Microsurgical Clipping of Ruptured Posterior Communicating Artery Aneurysms. World Neurosurg 2018; 109:e493-e501. [DOI: 10.1016/j.wneu.2017.10.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 09/30/2017] [Accepted: 10/03/2017] [Indexed: 12/31/2022]
|
17
|
Association of Perforator Infarction with Clinical Courses and Outcomes Following Surgical Clipping of Ruptured Anterior Communicating Artery Aneurysms. World Neurosurg 2017; 107:724-731. [DOI: 10.1016/j.wneu.2017.08.086] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 08/10/2017] [Accepted: 08/12/2017] [Indexed: 11/23/2022]
|
18
|
Zu QQ, Liu XL, Wang B, Zhou CG, Xia JG, Zhao LB, Shi HB, Liu S. Recovery of oculomotor nerve palsy after endovascular treatment of ruptured posterior communicating artery aneurysm. Neuroradiology 2017; 59:1165-1170. [DOI: 10.1007/s00234-017-1909-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 08/22/2017] [Indexed: 11/27/2022]
|
19
|
Huhtakangas J, Lehecka M, Lehto H, Jahromi BR, Niemelä M, Kivisaari R. CTA analysis and assessment of morphological factors related to rupture in 413 posterior communicating artery aneurysms. Acta Neurochir (Wien) 2017; 159:1643-1652. [PMID: 28710522 DOI: 10.1007/s00701-017-3263-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 06/27/2017] [Indexed: 10/19/2022]
Abstract
Posterior communicating artery (PcomA) aneurysms are frequently encountered, but there are few publications on their morphology. A growing number of aneurysms are incidental findings, which makes evaluation of rupture risk important. Our goal was to identify morphological features and anatomical variants associated with PComA aneurysms and to assess parameters related to rupture. We studied CT angiographies of 391 consecutive patients treated between 2000 and 2014 at a single institution. We determined clinically important morphological parameters and performed univariate and multivariate analysis. There were a total of 413 PComA aneurysms: 258 (62%) were ruptured and 155 (38%) unruptured. Ruptured PComA aneurysms had the potential to cause severe bleeding with IVH and/or temporal ICH (n = 170, 66% of ruptured). The main types of PComA origin were classified as follows: (1) separate (32%), (2) side by side (21%) and (3) a joint neck with the aneurysm (6%). After the multivariate logistic regression, the morphological parameters related to PComA aneurysm rupture were an irregular aneurysm dome, neck diameter, and aspect ratio >1.5. The most marked morphological features of the PComA aneurysms were: saccular nature (99%), infero-posterior dome orientation (42%), infrequency of large or giant aneurysms (4%), narrow neck compared to the aneurysm size, PComA originating directly from the aneurysm neck or the dome (28%), and fetal or dominant PComA on the side of the aneurysm (35%). There were location-related parameters that were more strongly associated with PComA aneurysm rupture than aneurysm size: an irregular aneurysm dome, larger diameter of the aneurysm neck and aspect ratio >1.5.
Collapse
|
20
|
Thiarawat P, Jahromi BR, Kozyrev DA, Intarakhao P, Teo MK, Choque-Velasquez J, Hernesniemi J. Microneurosurgical Management of Posterior Communicating Artery Aneurysm: A Contemporary Series from Helsinki. World Neurosurg 2017; 101:379-388. [PMID: 28213191 DOI: 10.1016/j.wneu.2017.02.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Revised: 02/06/2017] [Accepted: 02/07/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objectives of this study were to analyze microsurgical techniques and to determine correlations between microsurgical techniques and the radiographic findings in the microneurosurgical treatment of posterior communicating artery aneurysms (PCoAAs). METHODS We retrospectively analyzed radiographic findings and videos of surgeries in 64 patients with PCoAAs who underwent microsurgical clipping by the senior author from August 2010 to 2014. RESULTS From 64 aneurysms, 30 (47%) had acute subarachnoid hemorrhage (SAH) that necessitated lamina terminalis fenestration (odds ratio [OR], 67.67; P < 0.001) and Liliequist membrane fenestration (OR, 19.62; P < 0.001). The low-lying aneurysms significantly necessitated the coagulation of the dura covering the anterior clinoid process (ACP) (OR, 7.43; P = 0.003) or anterior clinoidectomy (OR, 91.0; P < 0.001). We preferred straight clips in 45 (83%) of 54 posterolateral projecting aneurysms (OR, 45.0; P < 0.001), but preferred curved clips for posteromedial projecting aneurysms (OR, 6.39; P = 0.008). The mean operative time from the brain retraction to the final clipping was 17 minutes and 43 seconds. Postoperative computed tomography angiography revealed complete occlusion of 60 (94%) aneurysms. Three (4.6%) patients with acute SAH suffered postoperative lacunar infarction. CONCLUSIONS For ruptured aneurysms, lamina terminalis and Liliequist membrane fenestration are useful for additional cerebrospinal fluid drainage. For low-lying aneurysms, coagulation of the dura covering the ACP or tailored anterior clinoidectomy might be necessary for exposing the proximal aneurysm neck. Type of clips depends on the direction of projection. The microsurgical clipping of the PCoAAs can achieve good immediate complete occlusion rate with low postoperative stroke rate.
Collapse
Affiliation(s)
- Peeraphong Thiarawat
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland; Department of Surgery, Naresuan University, Phitsanulok, Thailand.
| | | | - Danil A Kozyrev
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland; Department of Neurosurgery, North-Western State Medical University, Saint Petersburg, Russia
| | - Patcharin Intarakhao
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland; Department of Anesthesiology, Naresuan University, Phitsanulok, Thailand
| | - Mario K Teo
- Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, North Bristol University Hospital, Bristol, United Kingdom
| | | | - Juha Hernesniemi
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|