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Nguyen VN, Dallas J, Lin M, Demetriou AN, Khahera A, Hopkins BS, Mack WJ. Combined endovascular embolization and decompressive craniectomy for microsurgical resection of giant ruptured distal anterior cerebral artery aneurysm. Clin Neurol Neurosurg 2024; 243:108383. [PMID: 38924843 DOI: 10.1016/j.clineuro.2024.108383] [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: 02/06/2024] [Revised: 03/03/2024] [Accepted: 06/08/2024] [Indexed: 06/28/2024]
Abstract
Giant ruptured distal anterior cerebral artery aneurysms are rare, challenging pathologies that may require a combination of microsurgical and endovascular techniques for optimal treatment [1-9]. We describe the case of a female in her 40 s who presented with a Hunt-Hess 4, Fisher 4 subarachnoid hemorrhage from a multiply ruptured, giant distal anterior cerebral artery aneurysm. The patient underwent coil and n-BCA glue embolization of the aneurysm and its feeding A2 anterior cerebral artery. She subsequently underwent decompressive craniectomy, intracerebral hematoma evacuation, and microsurgical trapping and resection of the aneurysm. Postoperative imaging demonstrated no further aneurysm filling, complete hematoma evacuation, and good decompression. The technical considerations and literature for the combined treatment of large and giant ruptured aneurysms are reviewed. The case presentation, operative nuances, and postoperative course with imaging are reviewed with detailed anatomical diagrams to orient the viewer. The patient consented to the procedure and to the publication of her imaging.
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Affiliation(s)
- Vincent N Nguyen
- Department of Neurosurgery, University of Southern California, Los Angeles, CA, USA.
| | - Jonathan Dallas
- Department of Neurosurgery, University of Southern California, Los Angeles, CA, USA
| | - Michelle Lin
- Department of Neurosurgery, University of Southern California, Los Angeles, CA, USA
| | | | - Anadjeet Khahera
- Department of Neurosurgery, University of Southern California, Los Angeles, CA, USA
| | - Benjamin S Hopkins
- Department of Neurosurgery, University of Southern California, Los Angeles, CA, USA
| | - William J Mack
- Department of Neurosurgery, University of Southern California, Los Angeles, CA, USA
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2
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Chlorogiannis DD, Aloizou AM, Chlorogiannis A, Kosta N, Sänger JA, Chatziioannou A, Papanagiotou P. Exploring the latest findings on endovascular treatments for giant aneurysms: a review. Rev Neurosci 2024; 35:451-461. [PMID: 38158880 DOI: 10.1515/revneuro-2023-0082] [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: 08/02/2023] [Accepted: 12/08/2023] [Indexed: 01/03/2024]
Abstract
Giant intracranial aneurysms represent a very challenging aspect of aneurysmal pathophysiology with very high mortality and morbidity if left untreated. Their variety in clinical presentation (subarachnoid hemorrhage, cranial nerve palsy, etc.) and pathological and imaging properties (location, anatomy, presence of collateral circulation) pose serious questions regarding the best treatment option. Admirable advances have been achieved in surgical techniques, while endovascular modalities with flow diversion techniques have become widely used. However, there is still lack of data regarding whether a single endovascular technique can be the universal treatment for such cases. In this review, we aim to summarize the current funds of knowledge concerning giant intracranial aneurysms and the role of endovascular management in their treatment.
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Affiliation(s)
| | - Athina-Maria Aloizou
- Department of Neurology, St. Josef-Hospital, Ruhr Universität Bochum, 44791Bochum, Germany
| | - Anargyros Chlorogiannis
- Department of Health Economics, Policy and Management, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Nefeli Kosta
- Department of Biology, University of Patras, 265 04 Patras, Greece
| | | | - Achilles Chatziioannou
- First Department of Radiology, School of Medicine, National & Kapodistrian University of Athens, Areteion Hospital, 115 28 Athens, Greece
| | - Panagiotis Papanagiotou
- First Department of Radiology, School of Medicine, National & Kapodistrian University of Athens, Areteion Hospital, 115 28 Athens, Greece
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte/Bremen-Ost, 28205 Bremen, Germany
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Mosteiro A, Pedrosa L, Codes M, Reyes L, Werner M, Amaro S, Enseñat J, Rodríguez-Hernández A, Aalbers M, Boogaarts J, Torné R. Microsurgical and endovascular treatment of large and giant aneurysms of the anterior circulation: A systematic review. BRAIN & SPINE 2024; 4:102838. [PMID: 39071454 PMCID: PMC11279635 DOI: 10.1016/j.bas.2024.102838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/20/2024] [Accepted: 05/22/2024] [Indexed: 07/30/2024]
Abstract
Introduction Large and Giant intracranial aneurysms (LGIAs) have become the paradigm for which endovascular techniques do not provide satisfactory results. Yet, microsurgery is followed by non-negligible rates of morbimortality. This scenario may have changed since the introduction of flow-diversion devices. Research question Contemporary and standardised revision on microsurgical and endovascular results, with emphasis on anterior circulation LGIAs. Materials and methods A systematic literature search was conducted in two databases (PubMed and Embase) on treatment outcomes of LGIAs of the anterior circulation, after the introduction of flow-diverters 2008/01/01, till 2023/05/20. Small case series (<5 cases), series including >15% of posterior circulation aneurysms, and studies not reporting clinical and/or angiographic outcomes were excluded. Results 44 relevant studies (observational cohorts) were identified, including 2923 LGIAs predominantly from anterior circulation. Mean follow-up 22 (±20) months. 1494 (51%) LGIAs were treated endovascularly and 1427 (49%) microsurgically. According to the random effects model, pooled rates of favourable clinical outcomes were 85.8% (CI 95% 82.6-88.4), complete occlusion 69.4% (CI 95% 63.7-7.46), complications 19.6% (CI 95%16-23.9) and mortality 5.6% (CI 95% 4.4-7.1). Focusing on type of treatment, occlusion rates are higher with microsurgical (842/993, 85% vs 874/1,299, 67%), although good outcomes are slightly more frequent with endovascular (1045/1,135, 92% vs 1120/1,294, 87%). Discussion and conclusions According to contemporary data about occlusion rates, functional outcomes, and complications, primary or secondary treatment of LGIAs of the anterior circulation seems justified. Microsurgical occlusion rates are higher in LGIAs. An expert consensus on reporting complications and management strategies is warranted.
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Affiliation(s)
- Alejandra Mosteiro
- Department of Neurosurgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Leire Pedrosa
- Department of Neurosurgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
- IDIBAPS Biomedical Research Institute, Barcelona, Spain
| | - Marta Codes
- Department of Neurosurgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Luís Reyes
- Department of Neurosurgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Mariano Werner
- Interventional Neuroradiology Department, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Sergio Amaro
- IDIBAPS Biomedical Research Institute, Barcelona, Spain
- Comprehensive Stroke Unit, Neurology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Joaquim Enseñat
- Department of Neurosurgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
- IDIBAPS Biomedical Research Institute, Barcelona, Spain
| | | | - Marlien Aalbers
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, Gelderland, the Netherlands
| | - Jeroen Boogaarts
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, Gelderland, the Netherlands
| | - Ramon Torné
- Department of Neurosurgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
- IDIBAPS Biomedical Research Institute, Barcelona, Spain
- Interventional Neuroradiology Department, Hospital Clinic of Barcelona, Barcelona, Spain
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Grandhi R, Ravindra VM, Kallmes DF, Lopes D, Hanel RA, Lylyk P. Treatment of giant intracranial aneurysms using the Pipeline flow-diverting stent: Long-term results from the International Retrospective Study of the Pipeline Embolization Device (IntrePED) study. Interv Neuroradiol 2024; 30:218-226. [PMID: 36168255 PMCID: PMC11095340 DOI: 10.1177/15910199221123282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/03/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Traditional endovascular treatments of giant intracranial aneurysms are associated with high rates of complications and retreatment. Our objective was to examine the safety and long-term efficacy of the Pipeline Embolization Device for treatment of these aneurysms. METHODS This retrospective study using the IntrePED database included all patients with giant intracranial aneurysms treated with the Pipeline device between July 2008 and February 2013. Efficacy outcomes were stratified by using the Raymond-Roy Occlusion Classification. Predefined safety outcomes included spontaneous rupture of the target aneurysm; ipsilateral intracranial hemorrhage; ischemic stroke; parent artery stenosis; and sustained cranial neuropathy. RESULTS Sixty-six embolizations were performed to treat 63 giant intracranial aneurysms (including 2 ruptured): 49 (77.8%) in the anterior and 14 (22.2%) in the posterior circulation. The median follow-up was 22.4 (0.1-60.5) months. Class I angiographic occlusion was achieved in 72.0% (36/50). The neurological morbidity/mortality rate was 23.8% (15/63), with higher rates in the posterior circulation than in the anterior circulation (22.4% vs. 28.6%). Among seven deaths, five had neurological causes. The procedure-related neurological morbidity and mortality rates were 22.7% (15/66) and 7.6% (5/66), respectively. The spontaneous rupture rate was 4.5% (3/66). Two spontaneous ruptures (1 death), 4/4 postprocedural intracranial hemorrhages, and 6/9 ischemic events occurred within 30 days. In-stent stenosis and new-onset cranial neuropathy were not observed during the angiographic follow-up period. CONCLUSIONS Although procedure-related neurological morbidity/mortality rates were not insignificant, this study confirms the feasibility and long-term efficacy of the Pipeline Embolization Device to treat giant intracranial aneurysms.
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Affiliation(s)
- Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Vijay M. Ravindra
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
- Department of Neurosurgery, University of California San Diego, La Jolla, California, USA
| | | | - Demetrius Lopes
- Department of Neurosurgery, Advocate Health, Park Ridge, Illinois, USA
| | - Ricardo A. Hanel
- Lyerly Neurosurgery, Baptist Neurological Institute, Baptist Medical Center, Jacksonville, Florida, USA
| | - Pedro Lylyk
- Department of Interventional Neuroradiology and Neurosurgery, Instituto Medico ENERI – Clínica La Sagrada Familia, Buenos Aires, CABA, Argentina
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Park SJ, Lee YJ, Kim WB, Kim YS, Kim TS, Joo SP. Intracranial-intracranial bypass strategies for the treatment of complex intracranial aneurysms: anatomical characteristics and surgical intervention. Acta Neurochir (Wien) 2024; 166:42. [PMID: 38280083 DOI: 10.1007/s00701-024-05945-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/09/2024] [Indexed: 01/29/2024]
Abstract
OBJECTIVE The effectiveness of revascularization for complex aneurysms is well-established. This study aimed to describe the technical characteristics and clinical efficacy of intracranial-to-intracranial (IC-IC) bypass for the treatment of complex intracranial aneurysms. METHODS We retrospectively reviewed all patients with aneurysms who underwent a preplanned combination of surgical or endovascular treatment and IC-IC bypass at our institution between January 2006 and September 2023. IC-IC bypass techniques included four strategies: type A (end-to-end reanastomosis), type B (end-to-side reimplantation), type C (in situ side-to-side anastomosis), and type D (IC-IC bypass with a graft vessel). RESULTS During the study period, ten patients with aneurysms each underwent IC-IC bypass surgery. Aneurysms were located in the middle cerebral artery (60.0%), anterior temporal artery (10.0%), anterior cerebral artery (20.0%), and vertebral artery (10.0%). There were three saccular aneurysms (30.0%), two fusiform aneurysms (20.0%), one dissecting aneurysm (10.0%), and four pseudoaneurysms (40.0%). We performed the type A strategy on five patients (50.0%), type B on one (10.0%), type C on one (10.0%), and type D on three (30.0%). During a mean period of 68.3 months, good clinical outcomes (modified Rankin Scale score, 0-2) were observed in all patients. Follow-up angiography demonstrated complete aneurysmal obliteration in all patients and good bypass patency in nine of ten patients (90.0%). CONCLUSION The treatment of complex aneurysms remains a challenge with conventional surgical or endovascular treatments. IC-IC bypass surgery is a useful technique, associated with favorable clinical outcomes, for treating complex aneurysms.
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Affiliation(s)
- Sue-Jee Park
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Young-Jun Lee
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Woong-Beom Kim
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - You-Sub Kim
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Tae-Sun Kim
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Sung-Pil Joo
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea.
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Kim WB, Lee SU, Kwon MY, Pang CH, Lee Y, Kim T, Oh CW, Bang JS. Angiographic and Clinical Outcomes of Various Techniques of Intracranial-to-Intracranial Bypass for Complex Cases with a Review of Pertinent Literature and Illustrated Cases. World Neurosurg 2023:S1878-8750(23)01829-6. [PMID: 38143037 DOI: 10.1016/j.wneu.2023.12.096] [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: 12/11/2023] [Accepted: 12/16/2023] [Indexed: 12/26/2023]
Abstract
BACKGROUND We sought to determine the utility of intracranial-to-intracranial bypass (IIB) surgery and the available bypass options for complex cases. METHODS A total of 18 IIB cases were included. Each case was classified as IIB with or without an interposition graft. The clinical and angiographic status were evaluated pre- and postoperatively and at the last follow-up. Angiographic images were analyzed and reconstructed schematically. Postoperative angiography was used to measure the bypass patency and the presence of postoperative cerebral infarction. The recipient artery occlusion time for each bypass was measured. RESULTS Of the 18 patients, 14 had presented with a complex intracranial aneurysm (IA), 1 with vertebrobasilar dolichoectasia, and 3 with intracranial arterial steno-occlusive disease. Ten patients had an incidentally discovered IA. Seven patients had presented with neurological deficits due to ischemia or aneurysmal mass effects. Of the 18 cases, 10 were IIBs with an interposition graft, including 4 cases of superficial temporal artery and 6 of radial artery graft bypass, and 8 were IIBs with a noninterposition graft, including 3 cases of in situ bypass, 1 case of reanastomosis, and 4 cases of reimplantation. The pre- and postoperative modified Rankin scale score did not change or improve, and all the bypasses were patent. No patient had died during the mean follow-up period of 50.0 months. The mean occlusion time of the recipient artery was 59.5 minutes. A total of 8 patients experienced postoperative cerebral infarction but all had almost recovered at discharge. CONCLUSIONS With proper selection of the IIB type, IIB can be a suitable treatment option for some patients with complex IAs and intracranial arterial steno-occlusive disease when extracranial-to-intracranial bypass is not feasible.
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Affiliation(s)
- Woong-Beom Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Korea; Department of Neurosurgery, Chonnam National University, Chonnam National University College of Medicine, Gwangju-si, Korea
| | - Si Un Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Korea
| | - Min-Yong Kwon
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Korea
| | - Chang Hwan Pang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Korea
| | - Yongjae Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Korea
| | - Tackeun Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Korea
| | - Jae Seung Bang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Korea.
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Nishimoto K, Ozaki T, Kidani T, Nakajima S, Kanemura Y, Yamazaki H, Fujinaka T. Flow Diverter Stenting for Symptomatic Intracranial Internal Carotid Artery Aneurysms: Clinical Outcomes and Factors for Symptom Improvement. Neurol Med Chir (Tokyo) 2023; 63:343-349. [PMID: 37286482 PMCID: PMC10482490 DOI: 10.2176/jns-nmc.2022-0389] [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: 12/12/2022] [Accepted: 03/22/2023] [Indexed: 06/09/2023] Open
Abstract
Flow diverter (FD) stenting is expected to improve cranial nerve symptoms caused by aneurysms via the theoretical reduction of the mass effect by promoting spontaneous thrombosis through the flow diversion effect. However, the factors involved in symptom improvement after treatment remain unclear. This study was performed to identify factors for symptom improvement after FD stenting and the symptom improvement rate of each impaired cranial nerve. We retrospectively evaluated 33 patients who underwent FD stenting for symptomatic internal carotid artery aneurysms at our institution from January 2016 to June 2021. Twenty-three (69.7%) patients had resolved or improved symptoms after 1 year of treatment. The optic nerve was affected in 12 patients; the oculomotor nerve, in 16; the trigeminal nerve, in 2; and the abducens nerve, in 13. There was no statistically significant difference in the symptom improvement rate of each impaired cranial nerve. The patients were classified into the improved and nonimproved groups based on their symptoms after 1 year of treatment, and the factors related to the symptoms were analyzed. The time from onset to treatment was significantly shorter in the improved group than in the nonimproved group (197.1 and 800 days, respectively; p = 0.023). There were no significant differences in age, aneurysm diameter, adjunctive coil embolization, partial thrombosis, change in mass diameter on magnetic resonance imaging, or aneurysm occlusion rate on angiography between the two groups. These results suggest that early treatment after the onset of aneurysm-induced cranial neuropathies increases the likelihood of symptom improvement.
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Affiliation(s)
- Keisuke Nishimoto
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital
- Department of Neurosurgery, Osaka University Graduate School of Medicine
| | - Tomohiko Ozaki
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital
| | - Tomoki Kidani
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital
| | - Shin Nakajima
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital
| | - Yonehiro Kanemura
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital
- Department of Biomedical Research and Innovation, Institute for Clinical Research, National Hospital Organization Osaka National Hospital
| | - Hiroki Yamazaki
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital
| | - Toshiyuki Fujinaka
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital
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Ion G, Chiriac A, Cucu AI, Costea CF, Scripcariu DV, Poeată I. A cases series of endovascular and microsurgical combined treatment of intracranial aneurysms. ROMANIAN JOURNAL OF MORPHOLOGY AND EMBRYOLOGY = REVUE ROUMAINE DE MORPHOLOGIE ET EMBRYOLOGIE 2023; 64:379-387. [PMID: 37867355 PMCID: PMC10720936 DOI: 10.47162/rjme.64.3.09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 09/05/2023] [Indexed: 10/24/2023]
Abstract
OBJECTIVE Our scientific paper is aimed at describing multimodal treatment of intracranial aneurysms represented by microsurgery and endovascular therapy. PATIENTS, MATERIALS AND METHODS We report four cases of intracranial aneurysms treated in our Department of Neurosurgery by microsurgery (clipping) and endovascular treatment (coiling), through the joint efforts of a team of highly skilled neurosurgeons. RESULTS Mixed treatment has been imposed by the complications we were presented with, resulting from either of the two surgical methods employed. CONCLUSIONS Although endovascular surgery is considered a newer treatment method, favored by many practitioners, and preferred by patients, there are situations where open surgery is still required. There are certain situations were using one of the surgical methods fails and a complementary procedure is required for a secure and successful treatment. The cases reported here will demonstrate the utility of combining the two procedures.
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Affiliation(s)
- Georgiana Ion
- Department of Neurosurgery, Prof. Dr. Nicolae Oblu Emergency Clinical Hospital, Iaşi, Romania
- Department of Neurosurgery, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iaşi, Romania
| | - Alexandru Chiriac
- Department of Neurosurgery, Prof. Dr. Nicolae Oblu Emergency Clinical Hospital, Iaşi, Romania
- Department of Neurosurgery, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iaşi, Romania
| | - Andrei Ionuţ Cucu
- Department of Neurosurgery, Prof. Dr. Nicolae Oblu Emergency Clinical Hospital, Iaşi, Romania
- Department of Biomedical Sciences, Faculty of Medicine and Biological Sciences, Ştefan cel Mare University of Suceava, Romania
| | - Claudia Florida Costea
- Department of Ophthalmology, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iaşi, Romania
- Department of Ophthalmology, Prof. Dr. Nicolae Oblu Emergency Clinical Hospital, Iaşi, Romania
| | - Dragoş Viorel Scripcariu
- Department of General Surgery, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iaşi, Romania
| | - Ion Poeată
- Department of Neurosurgery, Prof. Dr. Nicolae Oblu Emergency Clinical Hospital, Iaşi, Romania
- Department of Neurosurgery, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iaşi, Romania
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Shenoy VS, Sekhar LN. Microsurgical Clipping of a Ruptured Wide-Neck Basilar Tip Aneurysm by an Extended Transsylvian Transcavernous Approach: 2-Dimensional Operative Video. World Neurosurg 2023; 173:1-2. [PMID: 36775234 DOI: 10.1016/j.wneu.2023.02.024] [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: 01/13/2023] [Revised: 02/03/2023] [Accepted: 02/04/2023] [Indexed: 02/12/2023]
Abstract
Basilar tip aneurysms are difficult to treat due to their deep location, proximity to cranial nerves and brainstem, and risk of perforator stroke.1-3 A 49-year-old woman presenting to the emergency department with subarachnoid hemorrhage was found to have a wide-neck basilar tip aneurysm measuring 8.6 mm × 5.6 mm × 7.6 mm. The aneurysm had a 4.9-mm wide neck located at the level of the dorsum sellae.4,5 Microsurgical clipping was recommended to the patient due to the complexity of the aneurysm neck, the patient's young age, the expertise of the surgical-anesthetic team, treatment durability, and the low risk of recurrence.2,6-9 We used an extended transsylvian transcavernous approach to expose the aneurysm (Video 1). We preferred this anterolateral approach over the more lateral subtemporal transzygomatic approach because of its versatility in providing better visualization of the bilateral posterior cerebral arteries and superior cerebellar arteries.10 The surgical exposure to the proximal basilar artery was gained by drilling the posterior clinoid process and dorsum sellae. Two titanium clips were applied across the aneurysm neck, and indocyanine green angiography confirmed complete aneurysm obliteration. Protection of critical brainstem perforators was ensured using the rubber-dam technique. The patient tolerated the procedure well with no deficits at the 12-month follow-up. We review the microsurgical nuances of treating complex wide-neck basilar tip aneurysms that are not good candidates for endovascular treatment. Although endovascular tools are favored as the first-line treatment choice for most cerebral aneurysms, microsurgical clipping techniques remain an important tool in the contemporary cerebrovascular neurosurgeon's toolkit.2,6,11-15.
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Affiliation(s)
- Varadaraya Satyanarayan Shenoy
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA; Co-Motion, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Laligam N Sekhar
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA; Radiology, Harborview Medical Center, University of Washington, Seattle, Washington, USA.
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10
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Misra BK, Khandhar AV, Pradhan R. Bilateral blindness following flow diverter placement in a giant thrombosed cavernous carotid aneurysm: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 4:CASE22352. [PMID: 36681971 PMCID: PMC9745586 DOI: 10.3171/case22352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 11/04/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The best treatment option for giant intracranial aneurysms (GIAs) is still debated. The authors report a case of a giant thrombosed cavernous carotid artery (CCA) aneurysm for which two sessions of flow diverter (FD) placement failed, leading to bilateral blindness. OBSERVATIONS A 66-year-old man presented to an outside center with a history of rapid-onset right-sided retro-orbital pain, visual deterioration, and restricted eye movements associated with headache, vomiting, and diminished sensations on the right side of the face. He was diagnosed with an unruptured thrombosed giant CCA aneurysm and was treated twice with unsuccessful FDs. At follow-up, he developed blindness in both eyes. After 1.5 years, he presented to the authors' institution with headache, vomiting, and epistaxis, for which he underwent high-flow external carotid artery-M2 segment of the middle cerebral artery bypass grafting using the radial artery as a conduit and ligation of the internal carotid artery in the neck without any added neurological deficits. LESSONS This dreadful complication of bilateral blindness after being treated with repeated unsuccessful FDs has not been reported in the literature. It could have been avoided if microsurgery had been the primary modality of treatment.
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Affiliation(s)
- Basant K. Misra
- Department of Neurosurgery and Gamma Knife Radiosurgery, P.D. Hinduja National Hospital and Medical Research Center, Mumbai, Maharashtra, India
| | - Alay V. Khandhar
- Department of Neurosurgery and Gamma Knife Radiosurgery, P.D. Hinduja National Hospital and Medical Research Center, Mumbai, Maharashtra, India
| | - Reema Pradhan
- Department of Neurosurgery and Gamma Knife Radiosurgery, P.D. Hinduja National Hospital and Medical Research Center, Mumbai, Maharashtra, India
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Pedrosa L, Hoyos J, Reyes L, Llull L, Santana D, de Riva N, Mellado R, Sala X, Rodríguez-Hernández A, Enseñat J, Amaro S, Torné R. MicroRNA cerebrospinal fluid profile during the early brain injury period as a biomarker in subarachnoid hemorrhage patients. Front Cell Neurosci 2022; 16:1016814. [PMID: 36505512 PMCID: PMC9732100 DOI: 10.3389/fncel.2022.1016814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 11/14/2022] [Indexed: 11/27/2022] Open
Abstract
Introduction Delayed cerebral ischemia (DCI) is a dreadful complication present in up to 30% of patients with spontaneous subarachnoid hemorrhage (SAH). Indeed, DCI is one of the main causes of long-term disability in SAH, yet its prediction and prevention are troublesome in poor-grade SAH cases. In this prospective study, we explored the potential role of micro ribonucleic acid (microRNA, abbreviated miRNAs)-small non-coding RNAs involved in clue gene regulation at the post-transcriptional level-as biomarkers of neurological outcomes in SAH patients. Methods We analyzed the expression of several miRNAs present in the cerebrospinal fluid (CSF) of SAH patients during the early stage of the disease (third-day post-hemorrhage). NanoString Technologies were used for the characterization of the CSF samples. Results We found an overexpression of miRNAs in the acute stage of 57 SAH in comparison with 10 non-SAH controls. Moreover, a differential expression of specific miRNAs was detected according to the severity of clinical onset, but also regarding the development of DCI and the midterm functional outcomes. Conclusion These observations reinforce the potential utility of miRNAs as prognostic and diagnostic biomarkers in SAH patients. In addition, the identification of specific miRNAs related to SAH evolution might provide insights into their regulatory functions of pathophysiological pathways, such as the TGF-β inflammatory pathway and blood-brain barrier disruption.
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Affiliation(s)
- Leire Pedrosa
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Jhon Hoyos
- Department of Neurosurgery, Institute of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Luis Reyes
- Department of Neurosurgery, Institute of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Laura Llull
- Comprehensive Stroke Center, Institute of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Daniel Santana
- Comprehensive Stroke Center, Institute of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Nicolás de Riva
- Neuroanesthesia Division, Department of Anesthesiology, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Ricard Mellado
- Department of Anesthesiology and Critical Care, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Xavier Sala
- Neuroanesthesia Division, Department of Anesthesiology, Hospital Clinic of Barcelona, Barcelona, Spain
| | | | - Joaquim Enseñat
- Department of Neurosurgery, Institute of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Sergio Amaro
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain,Comprehensive Stroke Center, Institute of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain,Department of Medicine, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain,*Correspondence: Sergio Amaro,
| | - Ramon Torné
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain,Department of Neurosurgery, Institute of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain,Department of Medicine, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain,Ramon Torné,
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12
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Bozzetto M, Soliveri L, Volpi J, Remuzzi A, Barbieri A, Lanterna LAA, Lanzarone E. Computational fluid dynamic modeling of flow-altering surgical procedures: feasibility assessment on saccular aneurysm case study. COMPUTER METHODS IN BIOMECHANICS AND BIOMEDICAL ENGINEERING: IMAGING & VISUALIZATION 2022. [DOI: 10.1080/21681163.2022.2140310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Michela Bozzetto
- Laboratory of Medical Imaging, Istituto di Ricerche Famacologiche “Mario Negri” IRCCS, Ranica, Italy
| | - Luca Soliveri
- Laboratory of Medical Imaging, Istituto di Ricerche Famacologiche “Mario Negri” IRCCS, Ranica, Italy
| | - Jessica Volpi
- Department of Management, Information and Production and Engineering, University of Bergamo, Dalmine, Italy
| | - Andrea Remuzzi
- Department of Management, Information and Production and Engineering, University of Bergamo, Dalmine, Italy
| | - Antonio Barbieri
- Department of Neurosurgery, San Carlo Borromeo Hospital, Milan, Italy
| | | | - Ettore Lanzarone
- Department of Management, Information and Production and Engineering, University of Bergamo, Dalmine, Italy
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13
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Wang H, Lu J, Chen X, Hao Q. Risk factors and outcomes of postoperative stroke in surgical treatment for giant intracranial aneurysms. Chin Neurosurg J 2022; 8:31. [PMID: 36184606 PMCID: PMC9528132 DOI: 10.1186/s41016-022-00297-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 08/30/2022] [Indexed: 11/07/2022] Open
Abstract
Background Giant intracranial aneurysms (GIAs) are challenges for surgical treatment. Risk factors of postoperative stroke remain unclear. This study aims to investigate the predictors of postoperative stroke in GIAs and the impact of stroke on outcomes. Methods We performed a retrospective medical record review of patients with GIAs who received microsurgery at our institution between 2011 and 2018. Multivariate logistic regression analyses were carried out to identify risk factors for postoperative stroke. The clinical and angiographic outcomes were compared between patients with and without stroke. Results A total of 97 patients were included in this study. Surgical modalities included direct aneurysm neck clipping in 85 patients (87.7%), trapping with the bypass in 8 (8.2%), proximal artery ligation in 1 (1%), and bypass alone in 3 (3.1%). Postoperative stroke was found in 26 patients (26.8%). Independent factors that affect postoperative stroke were recurrent aneurysm (OR, 10.982; 95% CI, 1.976–61.045; P = 0.006) and size ≥ 3.5 cm (OR, 3.420; 95% CI, 1.133–10.327; P = 0.029). Combined perioperative mortality and morbidity was 26.8%. Follow-up was achieved from 89 patients (91.8%), with a mean follow-up period of 39 months (range 19 to 94 months). Good outcomes were observed in 75 patients (84.3%) and poor outcomes were observed in 14 patients (15.7%). Conclusions Postoperative stroke was significantly associated with clinical outcome. Favorable outcomes can be achieved in most patients with GIAs after appropriate microsurgical modality. Recurrent aneurysm and size ≥ 3.5 cm are risk factors of postoperative stroke. Supplementary Information The online version contains supplementary material available at 10.1186/s41016-022-00297-x.
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Affiliation(s)
- Hao Wang
- grid.411617.40000 0004 0642 1244Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring Rd West, Beijing, 100070 China
| | - Junlin Lu
- grid.412901.f0000 0004 1770 1022Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan China
| | - Xin Chen
- grid.411617.40000 0004 0642 1244Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring Rd West, Beijing, 100070 China
| | - Qiang Hao
- grid.411617.40000 0004 0642 1244Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring Rd West, Beijing, 100070 China
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Srinivasan VM, Rahmani R, Labib MA, Lang MJ, Catapano JS, Graffeo CS, Lawton MT. Evolution in Cerebrovascular Bypass. Neurosurg Clin N Am 2022; 33:383-402. [DOI: 10.1016/j.nec.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
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15
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Muacevic A, Adler JR. Giant Vertebrobasilar Aneurysm: The Rule of Decompressive Craniectomy Previous to Endovascular Treatment. Cureus 2022; 14:e30187. [PMID: 36397908 PMCID: PMC9648616 DOI: 10.7759/cureus.30187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2022] [Indexed: 01/25/2023] Open
Abstract
Giant vertebral-basilar aneurysms are rare and represent 1% of intracranial aneurysms. Natural history and treatment are associated with severe clinical manifestations, such as ischemia, mass effect, hydrocephalus, and subarachnoid hemorrhage, leading to high mortality and morbidity. In this case, a 51-year-old male with no relevant medical history presented to the emergency department with severe pulsatile right temporo-occipital headache, radiating to the territory of the maxillary branch of the trigeminal nerve. Investigation revealed a giant unruptured vertebrobasilar aneurysm partially thrombosed. As treatment strategy, a suboccipital craniectomy was initially performed, and a week later, as a second stage, the patient underwent a stent placement from the V3 segment of the vertebral artery to the distal segment of the basilar trunk. Very few cases of this entity have been reported, and the endovascular treatment of this type of aneurysm is complex, with a high risk of mortality or morbidity, caused by thrombosis or by the inflammatory response secondary to the treatment, with compression of the brainstem. Decompressive craniectomy prior to endovascular treatment may play an important role in preventing life-threatening complications.
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Metayer T, Leclerc A, Borha A, Derrey S, Langlois O, Barbier C, Aldea S, le Guerinel C, Piotin M, Vivien D, Briant AR, Emery E, Gaberel T. Microsurgical clipping of middle cerebral artery aneurysms: complications and risk factors for complications. World Neurosurg 2022; 168:e87-e96. [PMID: 36115562 DOI: 10.1016/j.wneu.2022.09.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/08/2022] [Accepted: 09/09/2022] [Indexed: 10/14/2022]
Abstract
OBJECTIVE Middle cerebral artery aneurysms (MCAas) are considered good candidates for microsurgery. The objective was to evaluate the risk of complications and the risk factors for microsurgical treatment of MCAas to better define the indications for microsurgery. METHODS We conducted a retrospective cohort study from three tertiary neurosurgical units from January 2013 to May 2020. We evaluated the frequency of complications and searched for the risk factors for complications after microsurgery. Complications were defined as a composite criterion with the presence of one of the following: procedural-related death, symptomatic cerebral ischemia, impossible exclusion, incomplete exclusion, or (re)bleeding of the treated aneurysm and symptomatic surgical site hematoma. RESULTS 292 MCAas were treated. A total of 29 (9.9%) had a complication: symptomatic cerebral ischemia: 4.8%, aneurysm rebleeding: 0.3%, surgical site hematoma: 1.0%, impossible exclusion: 0.3%, and incomplete exclusion: 4.1%. Severe complications, defined as mRs score >4 at 3 months, were infrequent and occurred in 7/292 patients (2.4%). In multivariate analysis, risk factors were: ruptured aneurysm, larger maximum aneurysm size, larger neck size and arterial branches passing less than <1 mm from the aneurysm's neck or dome. CONCLUSIONS Microsurgical management of MCA aneurysms can be performed with very low morbidity rates. In some cases, at least for factors that do not present a significant difficulty for endovascular therapy, such as the presence of an "en passage" artery or ruptured aneurysm, endovascular therapy EVT may be considered at the same level as the clip.
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Affiliation(s)
- Thomas Metayer
- Department of Neurosurgery, University Hospital of Caen, Caen, F-14000, France; Normandie Univ, UNICAEN, INSERM, U1237, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Cyceron, 14000 Caen, France.
| | - Arthur Leclerc
- Department of Neurosurgery, University Hospital of Caen, Caen, F-14000, France
| | - Alin Borha
- Department of Neurosurgery, University Hospital of Caen, Caen, F-14000, France; Normandie Univ, UNICAEN, INSERM, U1237, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Cyceron, 14000 Caen, France
| | - Stephane Derrey
- Department of Neuroradiology, University Hospital of Rouen, Rouen, F-76000, France
| | - Olivier Langlois
- Department of Neuroradiology, University Hospital of Rouen, Rouen, F-76000, France
| | - Charlotte Barbier
- Department of Neuroradiology, University Hospital of Caen, Caen, F-14000, France
| | - Sorin Aldea
- Department of Neurosurgery, Rothschild Foundation Hospital, Paris, F-75017, France
| | - Caroline le Guerinel
- Department of Neurosurgery, Rothschild Foundation Hospital, Paris, F-75017, France
| | - Michel Piotin
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, F-75017, France
| | - Denis Vivien
- Normandie Univ, UNICAEN, INSERM, U1237, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Cyceron, 14000 Caen, France; Medical School, University of Caen Normandy, Caen, F-14000, France
| | - Anaïs R Briant
- Department of Biostatistics, University Hospital of Caen, Caen, France
| | - Evelyne Emery
- Department of Neurosurgery, University Hospital of Caen, Caen, F-14000, France; Medical School, University of Caen Normandy, Caen, F-14000, France
| | - Thomas Gaberel
- Department of Neurosurgery, University Hospital of Caen, Caen, F-14000, France; Normandie Univ, UNICAEN, INSERM, U1237, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Cyceron, 14000 Caen, France
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Surgical Treatment of Large and Giant Anterior Cerebral Artery Aneurysms in the Endovascular Era: Analysis of Large Clinical Series. World Neurosurg 2022; 165:e298-e310. [PMID: 35714949 DOI: 10.1016/j.wneu.2022.06.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 06/07/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Analysis of results of surgical treatment of 112 patients with large and giant anterior cerebral artery (ACA) aneurysms. METHODS This is the largest clinical series of large and giant ACA aneurysms ever reported. Retrospective analysis of medical charts, radiographic studies, and intraoperative videos was performed. Univariate and multivariate analysis of relations among 3 types of outcomes (complete aneurysm occlusion, ischemic complications, and clinical outcomes) and predicting factors was performed. RESULTS Most aneurysms were communicant (84.8%). Aneurysms of the A1 segment and distal segments (A2-A5) were encountered rarely. Complete aneurysm occlusion (class I) was shown in 95 cases (90.5%). In 4 patients, only exploration and wrapping were performed because of severe atherosclerosis and chronic intraluminal thrombi. Partial occlusion (class III) was shown in 2 patients, and neck residual (class II) in 4 patients. Cerebral ischemia developed in 29 patients postoperatively. Occlusion or injury of the A1 segment and anterior communicating artery perforators and recurrent branch of Heubner were the most common reason for ischemic complications. At follow-up, 97 patients (86.6%) had favorable outcomes. Ten patients (8.9%) had unfavorable outcomes because of postoperative complications. CONCLUSIONS Microsurgery provides effective and relatively safe occlusion of complex ACA aneurysms. Direct clipping can be applied in most cases independent of their precise location. In certain cases, alternative methods can be safely used. According to multivariate analysis, giant aneurysm size, aneurysm-related mass effect, involvement of large arterial branches in the aneurysm wall, and intraoperative complications were significant predicting factors for ischemic complications.
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Sirakova K, Penkov M, Matanov S, Minkin K, Ninov K, Hadzhiyanev A, Karakostov V, Ivanova I, Sirakov S. Progressive volume reduction and long-term aneurysmal collapse following flow diversion treatment of giant and symptomatic cerebral aneurysms. Front Neurol 2022; 13:972599. [PMID: 36034286 PMCID: PMC9403733 DOI: 10.3389/fneur.2022.972599] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 07/18/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe primary goal of conventional endovascular and microvascular approaches is the clinical and radiological resolution of the symptomatic aneurysm-induced mass effect. This study assessed the volume changes and mass effect reduction due to sac shrinkage after treatment with flow diverter stents (FD) for unruptured cerebral aneurysms.MethodsWe analyzed retrospectively 36 symptomatic aneurysms that were larger or equal to 25 mm in diameter in patients treated at our center from January 2016 to April 2022. Radiological and clinical outcomes were analyzed, including aneurysmal volume changes and resolution of aneurysm-related symptoms.ResultsAt 6 months, 25 aneurysms decreased in size, 2 remained unchanged, and 9 aneurysms demonstrated a post-treatment dimensional increase. At 12 months, 30 aneurysms showed a progressive radiological volume reduction. Either no change or negligible shrinkage was observed in the remaining six aneurysms. At 24 months, 32 aneurysms showed aneurysmal shrinkage by a mean 47% volume loss with respect to baseline. At the last follow-up, all 13 patients who had presented with third cranial nerve palsy showed improvements. Complete reversal of the pretreatment edematous changes was confirmed in all cases. The overall post-treatment complication rate was 8.3%, as 3 patients experienced non-fatal delayed rupture of their aneurysm. There was no mortality in this study.ConclusionFlow diversion could effectively induce progressive aneurysmal shrinkage and resolution of the mass effect associated with giant symptomatic cerebral aneurysms.
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Affiliation(s)
| | - Marin Penkov
- Radiology Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Svetozar Matanov
- Radiology Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Krasimir Minkin
- Neurosurgery Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Kristian Ninov
- Neurosurgery Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Asen Hadzhiyanev
- Neurosurgery Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Vasil Karakostov
- Neurosurgery Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Irena Ivanova
- Clinical Laboratory Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Stanimir Sirakov
- Radiology Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
- *Correspondence: Stanimir Sirakov
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Wu Q, Li T, Jiang W, Hernesniemi JA, Li L, He Y. Conservative Therapy vs. Endovascular Approach for Intracranial Vertebrobasilar Artery Trunk Large Aneurysms: A Prospective Multicenter Cohort Study. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:9682507. [PMID: 35770042 PMCID: PMC9236797 DOI: 10.1155/2022/9682507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 05/30/2022] [Indexed: 11/30/2022]
Abstract
Background Intracranial vertebrobasilar trunk large (≥10 mm) aneurysms (IVBTLAs) are rare and challenging to manage. In this study, we describe the natural prognosis and evaluate the safety and efficacy of endovascular treatment of IVBTLAs compared with conservative therapy. Methods This prospective multicenter cohort study included patients with IVBTLAs, who chose either endovascular treatment (endovascular group) or conservative therapy (conservative group) after discussion with their doctors. The primary endpoint was the incidence of serious adverse events (SAEs) related to the target vessel, while secondary endpoints included target vessel-related mortality, major stroke, other serious adverse events, and aneurysm occlusion rate. Results In total, 258 patients were referred to our two centers for the management of vertebrobasilar aneurysms, and 69 patients had IVBTLAs. Among them, 51 patients underwent endovascular treatment, and 18 patients received conservative therapy. The incidence of target vessel-related SAEs was 15.7% (8/51) in the endovascular group and 44.4% (8/18) in the conservative group (P = 0.031). The target vessel-related mortality was 2.0% (1/51) in the endovascular group and 38.9% (7/18) in the conservative group (P < 0.001). The cumulative survival rates in the endovascular group and conservative group within 1-year, 3-year, and 5-year were 98.0% vs. 83.3%, P = 0.020; 98.0% vs. 66.7%, P = 0.001; and 98.0% vs. 35.6%, P < 0.001, respectively. Multivariate analysis revealed conservative therapy, giant aneurysm, and ischemic onset as risks factor for SAEs. Conclusions Compared with conservative treatment, endovascular treatment of the IVBTLAs may be associated with a lower incidence of SAEs, with higher 1-year, 3-year, and 5-year survival rates. Conservative therapy, giant aneurysm, and ischemic onset were associated with a high risk of SAEs.
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Affiliation(s)
- Qiaowei Wu
- Cerebrovascular Department of Interventional Center, Zhengzhou University People's Hospital, Henan University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, Henan, China
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Tianxiao Li
- Cerebrovascular Department of Interventional Center, Zhengzhou University People's Hospital, Henan University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Weijian Jiang
- Department of Vascular Neurosurgery, Chinese People's Liberation Army Rocket Force Characteristic Medical Center, Beijing, China
| | - Juha Antero Hernesniemi
- Cerebrovascular Department of Interventional Center, Zhengzhou University People's Hospital, Henan University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Li Li
- Cerebrovascular Department of Interventional Center, Zhengzhou University People's Hospital, Henan University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Yingkun He
- Cerebrovascular Department of Interventional Center, Zhengzhou University People's Hospital, Henan University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, Henan, China
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Liu P, Yang L, Shi A, Qian Y, Liu X, Dong D, Zhang X, Lv Y, Xiang J. Regional anticoagulation magnetic artificial blood vessels constructed by heparin-PLCL core-shell nanofibers for rapid deployment of veno-venous bypass. Biomater Sci 2022; 10:3559-3568. [PMID: 35621240 DOI: 10.1039/d2bm00205a] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Veno-venous bypass (VVB) is necessary for maintaining hemodynamic and internal environment stabilities in complex liver surgeries. However, the current VVB strategies require systematic anticoagulation and are time-consuming, leading to unexpected complications. This study aims to overcome these limitations by using a novel magnetic artificial blood vessel constructed with heparin-PLCL core-shell nanofibers. Coaxial electrospinning was used to fabricate core-shell nanofibers with heparin encapsulated into the core layer. The microstructure, physical and chemical properties, hemocompatibility, and heparin release behavior were characterized. The regional anticoagulation magnetic artificial vessel was constructed with these nanofibers and used to perform VVB in a rat liver transplantation model for in vivo evaluation. The core-shell nanofibers appeared smooth and uniform without apparent defects. Fluorescence and TEM images indicated that heparin was successfully encapsulated into the core layer. In addition, the in vitro heparin release test presented a two-phase release profile, burst release at day 1 and sustained release from days 2 to 14, which resulted in better hemocompatibility. The VVB could be rapidly deployed in 3.65 ± 0.83 min by the magnetic artificial vessel without systemic anticoagulation. Moreover, the novel device could reduce portal pressure and abdominal organ congestion, protect intestinal function, and increase the survival rate of liver transplantation with a long anhepatic phase from 0 to 65%. In summary, VVB can be rapidly deployed using regional anticoagulation magnetic artificial blood vessels without systemic anticoagulation, which is promising for improving patient outcomes after complex liver surgery.
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Affiliation(s)
- Peng Liu
- Center for Regenerative and Reconstructive Medicine, Med-X Institute, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China.,National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Lifei Yang
- National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Aihua Shi
- National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Yerong Qian
- National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China.,Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Xin Liu
- Department of Radiotherapy, Shaanxi Provincial Cancer Hospital, Xi'an, Shaanxi 710061, China
| | - Dinghui Dong
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Xufeng Zhang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Yi Lv
- Center for Regenerative and Reconstructive Medicine, Med-X Institute, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China.,National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China.,Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Junxi Xiang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
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Srinivasan VM, Karahalios K, Rumalla K, Shlobin NA, Rahmani R, Scherschinski L, Benner D, Catapano JS, Labib MA, Graffeo CS, Lawton MT. Giant cerebral cavernous malformations: redefinition based on surgical outcomes and systematic review of the literature. J Neurosurg 2022; 137:1733-1741. [PMID: 35535830 DOI: 10.3171/2022.2.jns22166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 02/07/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Giant cerebral cavernous malformations (GCCMs) are rare vascular malformations. Unlike for tumors and aneurysms, there is no clear definition of a "giant" cavernous malformation (CM). As a result of variable definitions, working descriptions and outcome data of patients with GCCM are unclear. A new definition of GCCM related to surgical outcomes is needed. METHODS An institutional database was searched for all patients who underwent resection of CMs > 1 cm in diameter. Patient information, surgical technique, and clinical and radiographic outcomes were assessed. A systematic review was performed to augment an earlier published review. RESULTS In the authors' institutional cohort of 183 patients with a large CM, 179 with preoperative and postoperative modified Rankin Scale (mRS) scores were analyzed. A maximum CM diameter of ≥ 3 cm was associated with greater risk of severe postoperative decline (≥ 2-point increase in mRS score). After adjustment for age and deep versus superficial location, size ≥ 3 cm was strongly predictive of severe postoperative decline (OR 4.5, 95% CI 1.2-16.9). A model with CM size and deep versus superficial location was developed to predict severe postoperative decline (area under the receiver operating characteristic curve 0.79). Thirteen more patients with GCCMs have been reported in the literature since the most recent systematic review, including some patients who were treated earlier and not discussed in the previous review. CONCLUSIONS The authors propose that cerebral CMs with a diameter ≥ 3 cm be defined as GCCMs on the basis of the inflection point for functional and neurological outcomes. This definition is in line with the definitions for other giant lesions. It is less exclusive than earlier definitions but captures the rarity of these lesions (approximately 1% incidence) and variation in outcomes. GCCMs remain operable with potentially favorable outcomes. The term "giant" is not meant to deter or contraindicate surgery.
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22
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Wu Q, Xu S, Wang C, Ji Z, Li Y, Sun B, Meng Y, Shi H, Wu P. Endovascular Management of Vertebrobasilar Trunk Artery Large Aneurysms: Complications and Long-Term Results. Front Neurol 2022; 13:839219. [PMID: 35250840 PMCID: PMC8894876 DOI: 10.3389/fneur.2022.839219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 01/19/2022] [Indexed: 12/11/2022] Open
Abstract
Objective To analyze the complications and long-term results of endovascular management of vertebrobasilar trunk large (≥10 mm) aneurysms (VBTLAs) and identify predictors of outcomes. Methods Between 2014 and 2020, 6,987 patients with intracranial aneurysms were referred to our center for aneurysm management and 2,224 patients have undergone the endovascular procedures. We retrospectively reviewed the database and identify all the patients with VBTLAs. Results A total of 62 VBTLAs were identified. The median aneurysm size was 13.4 mm [interquartile range (IQR) 11.5–18.7]. Among them, 24 aneurysms were treated with overlapping stent techniques, 18 aneurysms were treated with flow diversion, 14 aneurysms were treated with single stent-assisted coiling, and 6 aneurysms were treated with coiling alone. Ten patients were treated with parent artery occlusion or unilateral vertebral artery occlusion. Periprocedural complications were occurred in 7 (11.3%) patients. Clinical follow-up was obtained at the median of 27.5 months (IQR 15.3–58.5). The overall complication rate was 16.1% (10/62), including nine ischemic events and one hemorrhagic event. The combined disability and neurological mortality rate was 12.9% (8/62), with 4 (6.5%) deaths. The favorable outcome rate at follow-up was 87.1% (54/62). The complication-free cumulative survival rates at 1 and 5 years were 86.8 and 82.0%, respectively. The overall cumulative survival rates at 1 and 5 year were 96.5 and 89.8%, respectively. In the multivariate Cox regression analysis, longer procedure time (>115 min) (P = 0.037) and ischemic onset (P = 0.005) predict complications. Angiography follow-up was available for 36 patients at the median of 6.0 months (IQR 6–12), with a complete occlusion rate of 77.8% (28/36). Two (5.6%) aneurysms were recanalized and subsequently received the retreatment. Subgroup analysis did not find any differences in the complete occlusion rate between endovascular strategies. Conclusion Endovascular management of VBTLAs has a reasonable safety profile with favorable 5-year cumulative survival rates and imaging outcomes at follow-up. Prolonged procedure and ischemic onset are associated with a high risk of overall complications.
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Spiriev T, Laleva L, Alioski N, Dobrikov R, Gelev V, Milev M, Nakov V. Contrast-induced neurotoxicity presented as transient cortical blindness after stent-assisted coiling of a medium-sized unruptured basilar artery aneurysm: A case report and review of the literature. Surg Neurol Int 2022; 13:48. [PMID: 35242414 PMCID: PMC8888313 DOI: 10.25259/sni_1143_2021] [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: 11/16/2021] [Accepted: 01/20/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Contrast-induced neurotoxicity is a rare event after endovascular diagnostic procedures or interventions and presents as transient neurological deficit. Herewith, we present a case of reversible complete cortical blindness after uneventful stent-assisted coiling of a medium-sized unruptured basilar artery aneurysm.
Case Description:
A 70-year-old woman with a medium-sized 10 mm/6 mm wide neck basilar tip aneurysm was planned for endovascular obliteration of the lesion. The procedure was done under general anesthesia. The contrast agent was iso-osmolar, nonionic. The aneurysm was coiled, and a stent was placed in the left posterior cerebral artery achieving sufficient aneurysm packing. No signs of vessel obliteration were observed during the procedure. On awakening of anesthesia, the patient reported complete visual loss. Ophthalmological examination was normal. The patient was brought back to the angio-suite but there were no signs of parent vessel compromise from the endovascular implants or distal vessel occlusion. An MRI of the brain was done showing no signs of brain ischemia, just mild brain edema in both occipital lobes. Given the results of the radiological studies and clinical presentation, the diagnosis of contrast-induced neurotoxicity was accepted. In 72 h, the patient had complete resolution of the visual loss and was discharged home with no additional neurological worsening.
Conclusion:
Contrast-induced neurotoxicity is a rare event that can occur after uneventful endovascular interventions of the brain vessels. Knowledge of this rare complication, after exclusion of all other possible reversible causes, is important for the treatment and prognosis of the patient.
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Affiliation(s)
- Toma Spiriev
- Department of Neurosurgery, Acibadem CityClinic University Hospital Tokuda, Sofia, Bulgaria
| | - Lili Laleva
- Department of Neurosurgery, Acibadem CityClinic University Hospital Tokuda, Sofia, Bulgaria
| | - Nurfet Alioski
- Department of Neurosurgery, Acibadem CityClinic University Hospital Tokuda, Sofia, Bulgaria
| | - Raicho Dobrikov
- Department of Imaging Diagnostics Acibadem CityClinic University Hospital Tokuda, Sofia, Bulgaria
| | - Valeri Gelev
- Department of Cardiology, Acibadem CityClinic University Hospital Tokuda, Sofia, Bulgaria
| | - Milko Milev
- Department of Neurosurgery, Acibadem CityClinic University Hospital Tokuda, Sofia, Bulgaria
| | - Vladimir Nakov
- Department of Neurosurgery, Acibadem CityClinic University Hospital Tokuda, Sofia, Bulgaria
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Bypass Surgery Management of Complex Proximal and Distal Posterior Inferior Cerebellar Artery Aneurysms. J Craniofac Surg 2022; 33:2049-2054. [PMID: 35119411 DOI: 10.1097/scs.0000000000008507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/13/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND For the complex posterior inferior cerebellar artery (PICA) aneurysms, standard microsurgical or endovascular technical options were not feasible. To determine the efficacy and outcomes of bypass surgery for complex PICA aneurysms, the authors herein review our recent surgical experience for complex PICA aneurysms. METHODS The authors retrospectively reviewed our experience of extracranial-intracranial bypass and intracranial-intracranial bypass surgery in treatment of proximal and distal complex PICA aneurysms at our institution from 2016 to 2020. RESULTS Twelve patients harboring 12 complex PICA aneurysms received bypass surgery at our institution. Seven (58.3%) patients with proximal PICA aneurysms underwent extracranial-intracranial bypass. Five (41.7%) patients with distal PICA aneurysms accepted intracranial-intracranial bypass. The postoperative symptom improvement: Of the 6 patients with preoperative hypoperfusion or ischemic of the cerebellar hemisphere, the symptom resolved in 5 patients, improved in 1 patient, of 5 patients with preoperative mass effect, the symptom resolved in 5 patients. During the follow-up period, ten patients had a modified Rankin scale (mRS) score of 0 to 1, and 1 patient had an mRS score of 2. One patient had an mRS score of 3. The long-term graft patency rate was 91.7%. All patients had no recurrence of intracranial aneurysm. CONCLUSIONS Base on the complexity of anatomy structure and the vascular architecture, an individualized strategy was proposed for each patient. The use of different types of bypass procedures (occipital artery-PICA end-to-end bypass, PICA-PICA end-to-end anastomosis, and/or occipital artery graft) can safely and effectively manage these complex PICA aneurysms.
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25
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Noh Y, Lee SH, Yoon SM, Song IH, Oh JS. Staged hybrid treatment for giant thrombosed fusiform aneurysm. J Cerebrovasc Endovasc Neurosurg 2021; 23:359-364. [PMID: 34963258 PMCID: PMC8743827 DOI: 10.7461/jcen.2021.e2021.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 07/13/2021] [Indexed: 11/23/2022] Open
Abstract
Partially thrombosed intracranial aneurysm was difficult to treat because of higher recurrence rate compared to non-thrombosed saccular aneurysm. The author reports a case of partially thrombosed intracranial aneurysm causing transient ischemic symptom. A 40-year-old man presented with transient right hemiparesis. Brain magnetic resonance imaging (MRI) depicted low-signal intensity target-like mass lesion on left sylvian fissure, and magnetic resonance angiography (MRA) showed aneurysm on left middle cerebral artery bifurcation (MCBF), suggested thrombosed aneurysm. On operative finding, aneurysm wall had thick and atherosclerotic change, and it was fusiform aneurysm not saccular type. We initially planned direct clip for the aneurysm, but it was failed due to collapse of parent artery after clipping on aneurysm neck. To prevent ischemia, extracranial-intracranial bypass was performed and then thrombectomy with clip reconstruction. To remodeling the fusiform aneurysm, stent-assisted coiling was performed for remnant portion of aneurysm. With staged hybrid technique, giant thrombosed fusiform aneurysm was completely obliterated and the patient did not suffer any neurologic symptoms no longer.
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Affiliation(s)
- Yunho Noh
- Department of Neurosurgery, Cheonan Hospital, Soonchunhyang University School of Medicine, Cheonan, Korea
| | - Sung Ho Lee
- Department of Neurosurgery, Cheonan Hospital, Soonchunhyang University School of Medicine, Cheonan, Korea
| | - Seok Mann Yoon
- Department of Neurosurgery, Cheonan Hospital, Soonchunhyang University School of Medicine, Cheonan, Korea
| | - In Hag Song
- Department of Cardiothoracic surgery, Cheonan Hospital, Soonchunhyang University School of Medicine, Cheonan, Korea
| | - Jae Sang Oh
- Department of Neurosurgery, Cheonan Hospital, Soonchunhyang University School of Medicine, Cheonan, Korea
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Ishak FH, Yusof Khan AHK, Mohd Yaakob MN, Al Khafiz Kamis MF, Abdul Rashid AM, Loh WC, Baharin J, Ibrahim A, Inche Mat LN, Wan Sulaiman WA, Hoo FK, Basri H. Giant intracavernous aneurysm presenting with isolated trigeminal neuralgia: a case report. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021. [DOI: 10.1186/s41983-021-00365-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Trigeminal neuralgia (TN) commonly affects individuals aged more than 50 years and is mostly primary owing to trigeminal nerve neurovascular compression. We report a case of secondary TN attributed to a giant intracavernous aneurysm compressing the trigeminal nerve.
Case presentation
A 74-year-old female presented with classic TN symptoms, which were initially refractory to medical treatment. Imaging including MRI brain, MR angiography, and cerebral angiogram revealed a giant intracavernous aneurysm measuring 1.7 cm × 2.8 cm, inducing mass effect on the left Meckel's cave. Aneurysm embolization was challenging due to the difficult cannulation of the distal portion of the aneurysm. The patient opted for conservative management with mild improvement of symptoms.
Conclusions
Intracavernous aneurysm rarely present with isolated trigeminal neuralgia. This case report emphasizes that the assessment of the intracranial vasculature should be considered as part of the diagnostic imaging work-up for patients presenting with TN
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Lauzier DC, Root BK, Kayan Y, Almandoz JED, Osbun JW, Chatterjee AR, Whaley KL, Tipps ME, Moran CJ, Kansagra AP. Pipeline embolization of distal posterior inferior cerebellar artery aneurysms. Interv Neuroradiol 2021; 27:821-827. [PMID: 33892602 PMCID: PMC8673893 DOI: 10.1177/15910199211013195] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/04/2021] [Accepted: 03/29/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND PURPOSE Flow diversion is commonly used to treat intracranial aneurysms in various regions of the cerebral vasculature, but is only approved for use in the internal carotid arteries. Treatment of distal PICA aneurysms with PED is sometimes performed but has not been well studied. Here, we report our experience with flow diversion of distal PICA aneurysms with PED. MATERIALS AND METHODS Clinical and angiographic data of eligible patients was retrospectively obtained and assessed for key demographic characteristics and clinical and angiographic outcomes. Principal outcomes included rates of aneurysm occlusion, ischemic or hemorrhagic complication, technical complication, and in-stent stenosis. RESULTS Three female and 2 male patients underwent placement of PED in the PICA for treatment of 5 distal PICA aneurysms. Clinical and angiographic follow-up was obtained for all patients. Complete aneurysm occlusion was observed in 100% (5/5) of treated aneurysms at 6 month and longest angiographic follow-up. While there were no ischemic or device-related complications, delayed hemorrhagic complications occurred in 20% (1/5) of patients. CONCLUSION Pipeline embolization of distal PICA aneurysms can be performed in select patients. Further study is necessary in larger cohorts to better define clinical scenarios in which flow diversion in the distal PICA should be considered.
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Affiliation(s)
- David C Lauzier
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Brandon K Root
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Yasha Kayan
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Josser E Delgado Almandoz
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Joshua W Osbun
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Arindam R Chatterjee
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Kayla L Whaley
- Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Megan E Tipps
- Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Christopher J Moran
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
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Fujii T, Teranishi K, Yatomi K, Suzuki K, Mitome-Mishima Y, Kondo A, Oishi H. Long-term Follow-up Results after Flow Diverter Therapy Using the Pipeline Embolization Device for Large or Giant Unruptured Internal Carotid Artery Aneurysms: Single-center Retrospective Analysis in the Japanese Population. Neurol Med Chir (Tokyo) 2021; 62:19-27. [PMID: 34707069 PMCID: PMC8754679 DOI: 10.2176/nmc.oa.2021-0203] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Flow diverter (FD) therapy using Pipeline embolization device (PED) has become an important alternative to treat internal carotid artery (ICA) aneurysms. Herein, we report the long-term outcome for 3 years after FD therapy using PED for ICA aneurysms in Japan. The patients who underwent angiographical and/or clinical follow-up for 3 years after the FD therapy using PED of large or giant unruptured ICA aneurysms from December 2012 at our university hospital are the subjects of this study. We retrospectively reviewed the in- and outpatients’ medical charts, and written operative and radiological records. There were 84 patients with 90 aneurysms who could be clinically and/or angiographically followed up for 3 years. Of these, 7 aneurysms were only available for clinical follow-up. Of the remaining 83 aneurysms, 6 aneurysms had vessel occlusion due to stent thrombosis or parent artery occlusion, and 60 of the remaining 77 (77.9%) had complete occlusion. In multivariate analysis, older age (>70 years), wide neck, and non-adjunctive coiling contributed statistically significantly to incomplete occlusion. Of the 84 patients, 2 patients (2.4%) had delayed complications between 6 months and 3 years after the initial FD placement. Three patients (3.6%) had poor outcome due to postoperative major stroke complications, 2 of which were acute complications. The long-term results after FD therapy are good both angiographically and clinically. Endothelialization of the aneurysmal neck and intra-aneurysmal thrombosis contribute to complete occlusion. The primary reason for the somewhat low complete occlusion in Japan may be the patients are generally older.
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Affiliation(s)
- Takashi Fujii
- Department of Neuroendovascular Therapy, Juntendo University, Graduate School of Medicine
| | - Kohsuke Teranishi
- Department of Neurosurgery, Juntendo University, Graduate School of Medicine
| | - Kenji Yatomi
- Department of Neurosurgery, Juntendo University, Graduate School of Medicine
| | - Kazumoto Suzuki
- Department of Neurosurgery, Juntendo University, Graduate School of Medicine
| | | | - Akihide Kondo
- Department of Neurosurgery, Juntendo University, Graduate School of Medicine
| | - Hidenori Oishi
- Department of Neuroendovascular Therapy, Juntendo University, Graduate School of Medicine.,Department of Neurosurgery, Juntendo University, Graduate School of Medicine
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Scullen T, Mathkour M, Werner C, Zeoli T, Amenta PS. Vertebral artery dissection and associated ruptured intracranial pseudoaneurysm successfully treated with coil assisted flow diversion: A case report and review of the literature. Brain Circ 2021; 7:159-166. [PMID: 34667899 PMCID: PMC8459696 DOI: 10.4103/bc.bc_67_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 02/01/2021] [Accepted: 04/30/2021] [Indexed: 11/14/2022] Open
Abstract
Dissecting intracranial pseudoaneurysms (IPs) are associated with a high incidence of rupture and poor neurologic outcomes. Lesions in the posterior circulation are particularly malignant and pose even greater management challenges. Traditional management consists of microsurgical vessel sacrifice with or without bypass. Flow diversion (FD) in the setting of subarachnoid hemorrhage (SAH) represents a reconstructive treatment option and can be paired with coil embolization to promote more rapid thrombosis of the lesion. We report a case of a ruptured dissecting vertebral artery (VA) IP successfully acutely treated with coil-assisted FD. A 53-year-old male presented with a right V4 dissection spanning the origin of the posterior inferior cerebellar artery and associated ruptured V4 IP. The patient was treated with coil-assisted FD. Oral dual-antiplatelet therapy (DAPT) was initiated during the procedure, and intravenous tirofiban was used as a bridging agent. Immediate obliteration of the IP was achieved, with near-complete resolution of the dissection within 48 h. The patient made a complete recovery, and angiography at 6 weeks confirmed total IP obliteration, reconstruction of the VA, and a patent stent. The use of FD and DAPT in the setting of acute SAH remains controversial. We believe that coil-assisted FD in carefully selected patients offers significant advantages over traditional microsurgical and endovascular options. The risks posed by DAPT and potential for delayed thrombosis with FD can be effectively mitigated with planning and the development of protocols. We discuss the current literature in the context of our case and review the challenges associated with treating these often devastating lesions.
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Affiliation(s)
- Tyler Scullen
- Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Mansour Mathkour
- Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, LA, USA.,Department of Surgery, Neurosurgery Division, Jazan University, Jazan, Kingdom of Saudi Arabia
| | - Cassidy Werner
- Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Tyler Zeoli
- Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Peter S Amenta
- Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, LA, USA
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30
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Izumo T, Fujimoto T, Morofuji Y, Tateishi Y, Matsuo T. Partial Clipping Occlusion Including Rupture Point Is an Effective Strategy for Ruptured Giant Fusiform Basilar Artery Aneurysm: A Technical Case Report. Front Neurol 2021; 12:743654. [PMID: 34659100 PMCID: PMC8516352 DOI: 10.3389/fneur.2021.743654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/06/2021] [Indexed: 11/13/2022] Open
Abstract
Treatment of fusiform basilar artery aneurysms is still challenging today. The authors present a case of a patient with a ruptured giant fusiform basilar artery aneurysm successfully treated by clipping occlusion of the rupture point. A 62-year-old man suddenly fell into a coma due to subarachnoid hemorrhage (SAH) with a ruptured giant fusiform basilar artery aneurysm with a bleb on the right shoulder. We considered treating the lesion with stent-assisted coil embolization because of the aneurysm's shape, but we had to give up because stents were off-label in the acute phase SAH in our country. Instead, we successfully performed clipping surgery to partially occlude the aneurysm, including the rupture point via the anterior transpetrosal approach. His postoperative course was uneventful, without rerupture of the aneurysm, and his conscious level tended to improve. The postoperative imaging studies showed no complications and disappearance of the rupture point of the aneurysm. Although direct surgery for the giant fusiform basilar artery aneurysms is one of the challenging operations, it is an essential and highly effective treatment as a last resort for complex aneurysms if other treatments are not available.
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Affiliation(s)
- Tsuyoshi Izumo
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Takashi Fujimoto
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yoichi Morofuji
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yohei Tateishi
- Department of Clinical Neuroscience and Neurology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Takayuki Matsuo
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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Lu J, Xue C, Hu X, Zhao Y, Zhang D, Chen X, Zhao JZ. Quantitative angiographic haemodynamic evaluation of bypasses for complex aneurysms: a preliminary study. Stroke Vasc Neurol 2021; 7:54-61. [PMID: 34642254 PMCID: PMC8899645 DOI: 10.1136/svn-2021-000858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 09/20/2021] [Indexed: 11/15/2022] Open
Abstract
Objective Open microsurgery, often with bypass techniques, is indispensable for complex aneurysms. To date, it remains unknown whether arterial anatomy or quantitative blood flow measurements can predict insufficient flow-related stroke (IRS). The present study aimed to evaluate the risk factors for IRS in patients treated with open microsurgery with bypass procedures for complex internal carotid artery aneurysms. Methods Patients with complex aneurysms undergoing bypass surgery were retrospectively reviewed. The recipient/donor flow index (RDFI) was preoperatively evaluated using colour-coding angiography. RDFI was defined as the ratio of the cerebral blood volume of the recipient and donor arteries. The sizes of the recipient and donor arteries were measured. The recipient/donor diameter index (RDDI) was then calculated. IRS was defined as the presence of new postoperative neurological deficits and infarction on postoperative CT scans. We assessed the association between RDFI and other variables and the IRS. Results Twenty patients (38±12 years) were analysed. IRS was observed in 12 patients (60%). Patients with postoperative IRS had a higher RDFI than those without postoperative IRS (p<0.001). RDDI was not significantly different between patients with and without IRS (p=0.905). Patients with RDFI >2.3 were more likely to develop IRS (p<0.001). Conclusion Quantitative digital subtraction angiography enables preoperative evaluation of cerebral blood volume. RDFI >2.3, rather than RDDI, was significantly associated with postoperative IRS. This preoperative evaluation allows appropriate decisions regarding the treatment strategy for preventing postoperative IRS.
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Affiliation(s)
- Junlin Lu
- Neurosurgery, Beijing Tiantan Hospital, Beijing, People's Republic of China
| | - Chao Xue
- Department of Industrial Engineering, Tsinghua University, Beijing, People's Republic of China
| | - Xulin Hu
- Chengdu Institute of Organic Chemistry, Chinese Academy of Sciences, Chengdu, People's Republic of China.,University of the Chinese Academy of Sciences, Beijing, People's Republic of China
| | - Yuanli Zhao
- Neurosurgery, Beijing Tiantan Hospital, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.,Stroke Center, Beijing Institute for Brain Disorders, Beijing, People's Republic of China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, People's Republic of China.,Beijing Translational Engineering Enter for 3D Printer in Clinical Neuroscience, Beijing, People's Republic of China
| | - Dong Zhang
- Neurosurgery, Beijing Tiantan Hospital, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.,Stroke Center, Beijing Institute for Brain Disorders, Beijing, People's Republic of China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, People's Republic of China
| | - Xiaolin Chen
- Neurosurgery, Beijing Tiantan Hospital, Beijing, People's Republic of China
| | - Ji Zong Zhao
- Neurosurgery, Beijing Tiantan Hospital, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.,Stroke Center, Beijing Institute for Brain Disorders, Beijing, People's Republic of China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, People's Republic of China.,Beijing Translational Engineering Enter for 3D Printer in Clinical Neuroscience, Beijing, People's Republic of China
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Abstract
BACKGROUND With the development of bypass technique, more and more complex aneurysms can be treated with bypass surgery. The goal of this study is to evaluate the efficacy and safety of bypass in patients with giant cavernous carotid aneurysms (GCCAs). To further discuss the treatment of asymptomatic GCCAs. METHODS The authors retrospectively reviewed our experience of the internal carotid artery (ICA) ligation/constriction combined with high/low-flow bypass surgery in the treatment of GCCAs. RESULTS Among the entire cohort, 4 patients underwent ICA ligation combined with high-flow bypass, 7 patients underwent ICA ligation/constriction combined with low-flow bypass. The postoperative symptom improvement: of 9 patients with preoperative ophthalmoplegia, the symptom resolved in 2 patients, improved in 7 patients, of 7 patients with preoperative pain, the symptom resolved in 2 patients, improved in 4 patients and was unchanged in 1 patient. The results of following-up were measured using the modified Rankin scale (mRS). During the follow-up, there were 9 patients with mRS score 0 to 1, 1 patient with mRS score 2, and 1 patient with mRS score 3. The long-term graft patency rate was 100%. All patients had no recurrence of intracranial aneurysm. CONCLUSIONS Bypass surgery is a safe and effective method to treat GCCAs. Because of the risk of GCCAs and the improvement of bypass surgery technology, active surgical strategies should be adopted for asymptomatic or mild symptomatic GCCAs.
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Misra BK, Warade AG, Rohan R, Sarit S. Microsurgery of Giant Intracranial Aneurysm: A Single Institution Outcome Study. Neurol India 2021; 69:984-990. [PMID: 34507426 DOI: 10.4103/0028-3886.325355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Giant intracranial aneurysms (GIAs) are treacherous lesions and in spite of the many advances, endovascular therapy (EVT) of GIAs is challenging. Objective A retrospective analysis of our results with microsurgery of GIAs is presented to examine the role of microsurgery in the current trend of EVT. Materials and Methods Between 1996 and 2019, 134 patients with 147 GIAs had microsurgery by the senior author in a single institute. The medical and imaging records for all the patients were reviewed. The patient outcome was determined by modified Rankin scale (mRS); ≤3 was considered as a good outcome. Statistical analysis was done using the SPSS program and odds ratios and their 95% confidence intervals were computed; a probability value of < 0.05 was considered significant. Results There were 123 aneurysms (83.7%) in the anterior circulation and 24 aneurysms (16.3%) in the posterior circulation. Overall 103 out of 134 (76.8%) patients had a good outcome postoperatively. Good preoperative mRS score (≤3) had an overall good prognosis in the postoperative period and was statistically significant (P = 0.000, odds ratio: 0.036, 95% CI: 0.008-0.171). Presence of subarachnoid hemorrhage (SAH) was also statistically significant for good outcome (P = 0.04, odds ratio: 2.898, 95% CI: 1.051-7.991), but age was not a significant prognostic factor. Mortality within 30 days of treatment was 4.47%. Conclusion GIAs need treatment because of their dismal natural history. Results of microsurgical treatment by a single surgeon of the large current series compare well with the results of EVT and justifies pursuing microsurgery for GIAs.
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Affiliation(s)
- Basant K Misra
- Department of Neurosurgery and Gamma Knife Surgery, P. D. Hinduja Hospital and MRC, Mumbai, Maharashtra, India
| | - Abhijit G Warade
- Department of Neurosurgery and Gamma Knife Surgery, P. D. Hinduja Hospital and MRC, Mumbai, Maharashtra, India
| | - Roy Rohan
- Department of Neurosurgery and Gamma Knife Surgery, P. D. Hinduja Hospital and MRC, Mumbai, Maharashtra, India
| | - Shah Sarit
- Department of Neurosurgery and Gamma Knife Surgery, P. D. Hinduja Hospital and MRC, Mumbai, Maharashtra, India
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Dodier P, Wang WT, Hosmann A, Hirschmann D, Marik W, Frischer JM, Gruber A, Rössler K, Bavinzski G. Combined standard bypass and parent artery occlusion for management of giant and complex internal carotid artery aneurysms. J Neurointerv Surg 2021; 14:593-598. [PMID: 34353887 DOI: 10.1136/neurintsurg-2021-017673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/25/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Complex aneurysms do not have a standard protocol for treatment. In this study, we investigate the safety and efficacy of microsurgical revascularization combined with parent artery occlusion (PAO) in giant and complex internal carotid artery (ICA) aneurysms. METHODS Between 1998 and 2017, 41 patients with 47 giant and complex ICA aneurysms were treated by an a priori planned combined treatment strategy. Clinical and radiological outcomes were stratified according to mRS and Raymond classification. Bypass patency was assessed. Median follow-up time was 3.9 years. RESULTS After successful STA-MCA bypass, staged endovascular (n=37) or surgical (n=1) PAO was executed in 38 patients following a negative balloon occlusion test. Intolerance to PAO led to stent/coil treatments in two patients. Perioperative bypass patency was confirmed in 100% of completed STA-MCA bypass procedures. Long-term overall bypass patency rate was 99%. Raymond 1 occlusion and good outcome were achieved in 95% and 97% (mRS 0-2) of cases, respectively. No procedure-related mortality was encountered. Eighty-four percent of patients with preoperative cranial nerve compression syndromes improved during follow-up. CONCLUSIONS The combined approach of STA-MCA bypass surgery followed by parent artery occlusion achieves high aneurysm occlusion and low morbidity rates in the management of giant and complex ICA aneurysms. This combined indirect approach represents a viable alternative to flow diversion in patients with cranial nerve compression syndromes or matricidal aneurysms, and may serve as a backup strategy in cases of peri-interventional complications or lack of suitable endovascular access.
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Affiliation(s)
- Philippe Dodier
- Department of Neurosurgery, Medical University of Vienna, Wien, Austria
| | - Wei-Te Wang
- Department of Neurosurgery, Medical University of Vienna, Wien, Austria
| | - Arthur Hosmann
- Department of Neurosurgery, Medical University of Vienna, Wien, Austria
| | - Dorian Hirschmann
- Department of Neurosurgery, Medical University of Vienna, Wien, Austria
| | - Wolfgang Marik
- Department of Radiology, Medical University of Vienna, Wien, Austria
| | - Josa M Frischer
- Department of Neurosurgery, Medical University of Vienna, Wien, Austria
| | - Andreas Gruber
- Department of Neurosurgery, Kepler Universitätsklinikum GmbH, Linz, Oberösterreich, Austria
| | - Karl Rössler
- Department of Neurosurgery, Medical University of Vienna, Wien, Austria
| | - Gerhard Bavinzski
- Department of Neurosurgery, Medical University of Vienna, Wien, Austria
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Frisoli FA, Catapano JS, Farber SH, Baranoski JF, Singh R, Benet A, Cole TS, Mooney MA, Lawton MT. Thrombectomy and Clip Occlusion of a Giant, Stent-Coiled Basilar Bifurcation Aneurysm: 3-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 21:E117-E118. [PMID: 33929027 DOI: 10.1093/ons/opab108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 02/08/2021] [Indexed: 11/12/2022] Open
Abstract
Giant basilar apex aneurysms are associated with significant therapeutic challenges.1-6 Multiple techniques exist to treat giant basilar apex aneurysms, including direct clipping, stent-assisted coil embolization, and proximal occlusion with bypass revascularization.7-9 Hypothermic circulatory arrest was a useful adjunct for surgical repair of these aneurysms but has been abandoned because of associated risks.10,11 Rapid ventricular pacing can achieve similar aneurysm softening with minimal risks and assist in clip occlusion. This case illustrates clip occlusion of a giant, partially thrombosed, previously stent-coiled basilar apex aneurysm in a 15-yr-old boy with progressive cranial neuropathies and sensorimotor impairment. Although a wire was placed preoperatively for ventricular pacing, it was not needed during the procedure. Patient consent was obtained. A right-sided orbitozygomatic craniotomy transcavernous approach with anterior and posterior clinoidectomies was performed. The basilar quadrification was dissected, and proximal control was obtained. After aneurysm trapping, the aneurysm was incised and thrombectomized using an ultrasonic aspirator. Back-bleeding from the aneurysm was anticipated, and ventricular pacing was ready, but back-bleeding was minimal. With the coil mass left in place, stacked, fenestrated clips were applied in a tandem fashion to occlude the aneurysm neck. Indocyanine green videoangiography confirmed occlusion of the aneurysm and patency of parent and branch arteries. The patient was at a neurological baseline after the operation, with improvement in motor skills and cognition at 3-mo follow-up. This case demonstrates the use of trans-sylvian-transcavernous exposure, rapid ventricular pacing, and thrombectomy amid previous coils and stents to clip a giant, thrombotic basilar apex aneurysm. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.
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Affiliation(s)
- Fabio A Frisoli
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - S Harrison Farber
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Rohin Singh
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Arnau Benet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael A Mooney
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Garrido E, Metayer T, Borha A, Langlois O, Curey S, Papagiannaki C, Di Palma C, Emery E, Derrey S, Gaberel T, Gilard V. Intracranial aneurysms in pediatric population: a two-center audit. Childs Nerv Syst 2021; 37:2567-2575. [PMID: 33876302 DOI: 10.1007/s00381-021-05151-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/29/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Intracranial aneurysms (IA) in children are rare, accounting for less than 5% of all IA. Due to their scarcity, the epidemiology is poorly understood and differs from adults in term of clinical presentation, size, location, and origin. Consequently, the treatment strategies are specific and cannot be only based on data from adult series. The aim of our study was to report the characteristics, management, and outcomes of children treated for IA in two university hospitals located in Normandy (France) over the last 17 years and to perform a literature review of this rare pathology. METHODS This retrospective study included 18 consecutive children (< 18 years old) admitted with cerebral aneurysm treated in two neurosurgery departments in Normandy, from 2001 to 2018. Computerized tomography and cerebral angiography established the diagnosis. Both endovascular and surgical procedures were discussed in all cases. Data focused on clinical condition at admission, characteristics of the IA, choice of the treatment modalities, and complications. The outcome at follow-up is based on Glasgow outcomes scale (GOS) at 1 year. RESULTS During the study period, 18 children (mean age: 12.6 years; sex ratio male/female: 2.3) were admitted with 21 IA. Aneurysms had a mean size of 13.6 mm with 4 giant aneurysms and were mostly located in the anterior circulation (16/21). Clinical presentations at onset were sudden symptoms related to a subarachnoid hemorrhage in 13 patients, headaches in 4 patients with giant aneurysm, and asymptomatic in one patient. Among the 13 patients with ruptured IA, 6 presented in poor preoperative condition (Hunt and Hess Grade ≥ 4). Treatment modalities consisted in embolization in 9 patients and surgery in 9 patients including 2 by-pass surgeries in fusiform aneurysms. Complications were similar in the two groups, but two cases of recanalization were observed in the endovascular group. At 1 year of follow-up, 14 children were in good condition (GOS Score > 4) and one died. Three children presented associated IA treated by the same technique as initial aneurysm. CONCLUSIONS Pediatric aneurysm is a different pathology compared with adults, occurring more frequently in male population with a higher proportion of giant aneurysms and aneurysms located in the internal carotid bifurcation. The use of endovascular techniques has progressed in the last years, but surgery was proposed for half of our population.
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Affiliation(s)
- Elisabeth Garrido
- Department of Neurosurgery, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France.
| | - Thomas Metayer
- Department of Neurosurgery, Caen University Hospital, Caen, France.,PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Normandie Univ, UNICAEN, I INSERM, U1237, Cyceron, 14000, Caen, France
| | - Alin Borha
- Department of Neurosurgery, Caen University Hospital, Caen, France.,PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Normandie Univ, UNICAEN, I INSERM, U1237, Cyceron, 14000, Caen, France
| | - Olivier Langlois
- Department of Neurosurgery, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France
| | - Sophie Curey
- Department of Neurosurgery, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France
| | | | - Camille Di Palma
- Department of Neurosurgery, Caen University Hospital, Caen, France
| | - Evelyne Emery
- Department of Neurosurgery, Caen University Hospital, Caen, France.,PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Normandie Univ, UNICAEN, I INSERM, U1237, Cyceron, 14000, Caen, France
| | - Stéphane Derrey
- Department of Neurosurgery, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France
| | - Thomas Gaberel
- Department of Neurosurgery, Caen University Hospital, Caen, France.,PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Normandie Univ, UNICAEN, I INSERM, U1237, Cyceron, 14000, Caen, France
| | - Vianney Gilard
- Department of Neurosurgery, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France.,Laboratory of Microvascular Endothelium and Neonate Brain Lesions, Normandie Univ, UNIROUEN, INSERM U1245, Rouen, France
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Hannan CJ, Javadpour M. How I do it: coil extraction and clip reconstruction of a previously coiled giant middle cerebral artery aneurysm. Acta Neurochir (Wien) 2021; 163:2363-2366. [PMID: 33506290 DOI: 10.1007/s00701-021-04727-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 01/18/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Microsurgical clipping of previously coiled intracranial aneurysms can be technically challenging. We present the case of a 48-year-old female with a partially coiled, previously ruptured giant middle cerebral artery aneurysm and the associated technical nuances. METHODS We performed a successful coil extraction and clip reconstruction of this aneurysm using an ultrasonic aspirator and stacked fenestrated aneurysm clips. CONCLUSION Coil extraction and clip occlusion of previously coiled intracranial aneurysms is a complex and technically challenging procedure but can be performed safely and effectively when employed judiciously.
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Affiliation(s)
| | - Mohsen Javadpour
- National Neurosurgical Centre, Beaumont Hospital, Beaumont Road, Dublin, Ireland.
- Royal College of Surgeons in Ireland, Dublin, Ireland.
- School of Medicine, Trinity College Dublin, Dublin, Ireland.
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Current Strategies in the Treatment of Intracranial Large and Giant Aneurysms. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021. [PMID: 33973024 DOI: 10.1007/978-3-030-63453-7_3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
INTRODUCTION Very large and giant aneurysms are among the most challenging cerebrovascular pathologies in neurosurgery. METHODS The aim of this paper is to review the current literature on the management of very large and giant aneurysms and to describe representative cases illustrating possible treatment strategies. RESULTS In view of the poor natural history, active management using multiprofessional individualized approaches is required to achieve aneurysm occlusion, relief of mass effect, and obliteration of the embolic source. Both reconstructive (clipping, coiling, stent-assisted coiling, flow diversion [FD]) and deconstructive techniques (parent artery occlusion [PAO], PAO in conjunction with bypass surgery, and strategies of flow modification) are available to achieve definitive treatment with acceptable morbidity. CONCLUSIONS Patients harboring such lesions should be managed at high-volume cerebrovascular centers by multidisciplinary teams trained in all techniques of open and endovascular neurosurgery.
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39
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Lee KS, Zhang JJY, Nguyen V, Han J, Johnson JN, Kirollos R, Teo M. The evolution of intracranial aneurysm treatment techniques and future directions. Neurosurg Rev 2021; 45:1-25. [PMID: 33891216 PMCID: PMC8827391 DOI: 10.1007/s10143-021-01543-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/21/2021] [Accepted: 04/07/2021] [Indexed: 01/06/2023]
Abstract
Treatment techniques and management guidelines for intracranial aneurysms (IAs) have been continually developing and this rapid development has altered treatment decision-making for clinicians. IAs are treated in one of two ways: surgical treatments such as microsurgical clipping with or without bypass techniques, and endovascular methods such as coiling, balloon- or stent-assisted coiling, or intravascular flow diversion and intrasaccular flow disruption. In certain cases, a single approach may be inadequate in completely resolving the IA and successful treatment requires a combination of microsurgical and endovascular techniques, such as in complex aneurysms. The treatment option should be considered based on factors such as age; past medical history; comorbidities; patient preference; aneurysm characteristics such as location, morphology, and size; and finally the operator’s experience. The purpose of this review is to provide practicing neurosurgeons with a summary of the techniques available, and to aid decision-making by highlighting ideal or less ideal cases for a given technique. Next, we illustrate the evolution of techniques to overcome the shortfalls of preceding techniques. At the outset, we emphasize that this decision-making process is dynamic and will be directed by current best scientific evidence, and future technological advances.
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Affiliation(s)
- Keng Siang Lee
- Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, UK. .,Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Southmead Hospital, Bristol, UK.
| | - John J Y Zhang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Vincent Nguyen
- Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Southmead Hospital, Bristol, UK.,Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Julian Han
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Jeremiah N Johnson
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Ramez Kirollos
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore.,Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK
| | - Mario Teo
- Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Southmead Hospital, Bristol, UK
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40
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Wang HW, Wu C, Xue Z, Shu XJ, Sun ZH. A Supplemental Technique for Preoperative Evaluation of Giant Intracranial Aneurysm. J Neurol Surg A Cent Eur Neurosurg 2021; 82:424-429. [PMID: 33583010 DOI: 10.1055/s-0040-1721006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Preoperative planning mainly relies on digital subtraction angiography (DSA) and computed tomography angiography. However, neither technique can reveal thrombi in giant intracranial aneurysms (GIAs). In this study, we aimed to reconstruct the circulating and noncirculating parts of GIAs with the time-of-flight (TOF) and motion-sensitized driven-equilibrium (MSDE) sequences with 3D Slicer to reveal an integrated presentation of GIAs, compare its accuracy, and validate the usefulness for preoperative planning. MATERIAL AND METHODS Patients with GIAs who were treated with microsurgery in our department were included in this study. Both the TOF and MSDE sequence data for each patient were loaded into 3D Slicer for reconstruction and segmentation. The parameters measured by 3D Slicer were compared with those measured by DSA. RESULTS The mean diameter for all GIAs was 28.7 ± 1.5 mm (range, 25.9-31.9 mm). The mean diameter for all GIAs measured by DSA and 3D Slicer was 24.46 ± 5.25 and 28.66 ± 1.48 mm, respectively (t = 4.948, p < 0.01). When only the nonthrombotic GIAs were included, the mean diameter measured by DSA and 3D Slicer was 28.69 ± 2.03 and 28.97 ± 1.79 mm, respectively (t = 1.023, p = 0.323). The mean aneurysmal volume was 8,292.6 ± 1,175.1 mm3 and the mean thrombotic volume was 3,590.0 ± 1,003.7 mm3. CONCLUSION The MSDE sequence brings diagnostic benefits as a comparison to other MRI sequences. Reconstruction of GIAs with 3D Slicer is a low-cost, dependable, and useful supplemental technique for surgical planning.
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Affiliation(s)
- Hua-Wei Wang
- Chinese PLA General Hospital, Neurosurgery, Beijing, China
| | - Chen Wu
- Chinese PLA General Hospital, Neurosurgery, Beijing, China
| | - Zhe Xue
- Chinese PLA General Hospital, Neurosurgery, Beijing, China
| | - Xu-Jun Shu
- Chinese PLA General Hospital, Neurosurgery, Beijing, China
| | - Zheng-Hui Sun
- Chinese PLA General Hospital, Neurosurgery, Beijing, China
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41
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Mura J, Alvarez VH, Oberman DZ, Cardenas AR, Rabelo NN, Figueiredo EG. Management of Giant Thrombosed MCA Aneurysm: Double STA-MCA Revascularization. World Neurosurg 2021; 149:1. [PMID: 33548526 DOI: 10.1016/j.wneu.2021.01.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/24/2021] [Accepted: 01/25/2021] [Indexed: 10/22/2022]
Abstract
Giant middle cerebral artery (MCA) aneurysms are rare complex cerebrovascular lesions to treat.1 The management of those aneurysms may be very challenging, despite the introduction of refined microsurgical techniques and the rapid progress in endovascular methods, which often require bypass surgery as part of the strategy.2-4 This approach is particularly relevant to giant, dolichoectatic, and thrombotic aneurysms.5,6 This video shows the surgical strategy and stepwise depiction of the surgical treatment of a complex giant thrombosed aneurysm using a double-barrel superficial temporal artery (STA) to MCA bypass (Video 1). Informed written consent was obtained from the patient and his family. The patient was a 50-year-old man, previously healthy, who presented with headache, memory difficulty, and left-sided involuntary movements for 2 months. Computed tomography scan showed a giant round calcified and heterogeneous lesion compatible with a thrombosed MCA aneurysm. Brain magnetic resonance imaging showed the same lesion with a flow void signal inside in a serpentine fashion and a complete hemosiderin halo. Conventional angiography showed the false lumen and the filling of the distal MCA branches with a certain degree of arterial delay. The lesion was located between M1 and M3 segments of MCA. Extracranial-intracranial STA-MCA bypass was performed. Then we opened the aneurysm sac for decompression and observed the lenticulostriate artery branches arising away from the aneurysm sac. The complete clipping and patency of the anastomosis was validated during surgery by indocyanine green angiography. Postoperative cerebral computed tomography angiography revealed good patency from the STA to the MCA. The patient was neurologically intact without complains.
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Affiliation(s)
- Jorge Mura
- Department of Cerebrovascular and Skull Base Surgery, Instituto de Neurocirurgia Dr. Alfonso Asenjo, Providencia, Chile
| | - Victor Hernandez Alvarez
- Department of Neurosurgery, Barros Luco Trudeau Hospital, Universidad de Santiago de Chile, Santiago, Chile
| | | | - Aladino Rojas Cardenas
- Department of Neurosurgery, Barros Luco Trudeau Hospital, Universidad de Santiago de Chile, Santiago, Chile
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Settecase F, Rayz VL. Advanced vascular imaging techniques. HANDBOOK OF CLINICAL NEUROLOGY 2021; 176:81-105. [DOI: 10.1016/b978-0-444-64034-5.00016-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Lu J, Li M, Burkhardt JK, Zhao Y, Li Y, Chen X, Zhao Y, Zhao J. Unruptured Giant Intracranial Aneurysms: Risk Factors for Mortality and Long-Term Outcome. Transl Stroke Res 2020; 12:593-601. [PMID: 33169315 DOI: 10.1007/s12975-020-00861-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/24/2020] [Accepted: 10/01/2020] [Indexed: 11/30/2022]
Abstract
This study aims to investigate the long-term outcomes of unruptured giant intracranial aneurysms (GIAs) with different treatment modalities and to analyze the factors affecting prognosis. We performed a retrospective medical record review of patients with unruptured GIAs treated at our institution from 2011 to 2018. Prognosis was compared to the best medical treatment without intervention (conservative treatment, CT) and surgical (ST) or endovascular (ET) treatment. Risk factors for mortality were investigated. A total of 276 patients were included in this study. Patients received CT in 16.3%, ST in 30.1%, and ET in 53.6% of cases. After an average 7-year follow-up, the rupture rate after CT was 22.2%, accounting for an annual rupture rate of 7.3%. The postoperative complication rate was 30.1% and 8.1% after ST and ET, respectively. The recurrence rate after ET was 10.1%, compared with ST which was 1.2%. The follow-up mortality in unruptured GIAs was 26.7% after CT, 7.2% after ST, and 5.4% after ET. Older age (50~59, HR 5.877; 60~69, HR 8.565), size ≥ 40 mm (HR 3.916), and posterior circulation location (HR 6.411) were associated with increased mortality. ET significantly decreased mortality (HR 0.191). Unruptured GIAs warrant treatment if feasible due to the high rupture rate and mortality of the natural history. Older age, posterior circulation location, and larger size are risk factors for poor prognosis. Both ST and ET showed a lower mortality rate than CT. ST showed less likely recurrence compared to ET, while ET had a lower complication rate than ST.
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Affiliation(s)
- Junlin Lu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Mingtao Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Baylor College of Medicine Medical Center, Houston, TX, USA
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Stroke Center, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Beijing Translational Engineering Enter for 3D Printer in Clinical Neuroscience, Beijing, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Yang Zhao
- Department of Neurosurgery, Peking University International Hospital, Peking University, Beijing, China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China. .,China National Clinical Research Center for Neurological Diseases, Beijing, China. .,Stroke Center, Beijing Institute for Brain Disorders, Beijing, China. .,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China. .,Beijing Translational Engineering Enter for 3D Printer in Clinical Neuroscience, Beijing, China.
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44
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Choi JH, Lee KS, Kim BS, Shin YS. Treatment outcomes of large and giant intracranial aneurysms according to various treatment modalities. Acta Neurochir (Wien) 2020; 162:2745-2752. [PMID: 32827268 DOI: 10.1007/s00701-020-04540-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/16/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE This study aimed to compare the treatment outcomes of large (15-25 mm) and giant (> 25 mm) intracranial aneurysms (IAs), according to different treatment modalities. METHODS In total, 112 patients with large and giant IAs treated with various treatment modalities between January 2009 and December 2018 were retrospectively reviewed. Clinical and radiological parameters were analyzed and correlated with the treatment modality. RESULTS A total of 141 procedures were performed on 112 patients. We initially treated 47 cases with coil embolization, 39 with flow diverter (FD), 13 with direct clipping, and 13 with parent artery occlusion (PAO). Recurrence (46.8%) and retreatment (31.9%) rates were significantly higher in the coiling group (p < 0.001). Complete occlusion rate (36.3%) was significantly lower in the coiling group (p = 0.027). PAO could achieve a high complete occlusion rate (90.9%) with low complication rate (12.5%). The total complication rate was 17%. In the multivariate logistic regression analysis, FD (OR 3.406, p = 0.036) and direct clipping (OR 5.732, p = 0.017) showed a significantly higher complication rate than coiling. The overall mortality rate was 8% (8/139 procedures). At the last follow-up (mean 30.6 ± 26.4 months), 70 of 96 patients (72.9%) showed complete or near-complete occlusion. Good functional outcome (mRS ≤ 2) was observed in 90 of 112 (80.3%) patients at the last follow-up (mean 33.2 ± 30.5 months). CONCLUSIONS Good clinical and radiologic outcomes with acceptable complication and mortality rates can be achieved by various treatment modalities. The selection of appropriate modality should be individualized based on the angiographic findings and clinical symptoms.
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Affiliation(s)
- Jai Ho Choi
- Department of Neurosurgery, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpodaero, Seochogu,, Seoul, Korea
| | - Kwan Sung Lee
- Department of Neurosurgery, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpodaero, Seochogu,, Seoul, Korea
| | - Bum-Soo Kim
- Department of Radiology, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpodaero, Seochogu, Seoul, Korea
| | - Yong Sam Shin
- Department of Neurosurgery, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpodaero, Seochogu,, Seoul, Korea.
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Li SJ, Wang F, Chen W, Su Y. Application of three dimensional (3D) curved multi-planar reconstruction images in 3D printing mold assisted eyebrow arch keyhole microsurgery. Brain Behav 2020; 10:e01785. [PMID: 32794658 PMCID: PMC7559599 DOI: 10.1002/brb3.1785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 06/08/2020] [Accepted: 07/19/2020] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE The application of multi-planar reconstruction of three dimensional (3D) curved surface in microsurgery of 3D printing mold assisted eyebrow arch keyhole approach was studied. METHODS Eighty patients with intracranial aneurysms who underwent treatment at our hospital were enrolled. The patients were divided into two groups: the traditional eyebrow keyhole approach microsurgery group (38 cases in the conventional treatment group) and the three-dimensional curved surface multi-plane reconstruction image combined with 3D printing technology assisted eyebrow keyhole approach microsurgery group (42 cases in the 3D printing assisted treatment group). The Hunt-Hess classification was used to make a preliminary estimation of the patient's condition. The 3D curved multi-planar reconstruction method was used to assist the surgical plan; CT scan was used to establish a 3D printing mold, and the patient's condition and surgical plan were accurately analyzed before surgery. The operative time and the size of the incision area were recorded; postoperative GOS score and postoperative complications were statistically investigated. RESULTS The 3D printing assisted treatment group (70.13 ± 15.56), (411.26 ± 10.38) mm2 , the operative time and incision area were significantly shorter than the conventional treatment group (120.35 ± 20.46), (663.55 ± 13.54) mm2 , p < .05); the GOS score showed that the 3D printing-assisted treatment group was significantly higher than the conventional treatment group (p < .05). The postoperative complication rate was significantly lower in the 3D print-assisted treatment group (9.52%) than in the conventional treatment group (47.36%, p < .05); the cure of intracranial aneurysms in the 3D printing assisted treatment group was more thorough than that in the conventional treatment group, and the difference was significant (p < .05). CONCLUSION Compared with the conventional eyebrow arch-hole approach microsurgery, the 3D surface multi-planar reconstruction image combined 3D printing assisted technology was safer and more effective, and the postoperative recovery was better and the incidence of complications was lower.
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Affiliation(s)
- Sheng-Jun Li
- Department of Neurosurgery, Linyi Central Hospital, Linyi, China
| | - Fang Wang
- Department of Emergency, Linyi Central Hospital, Linyi, China
| | - Wei Chen
- Department of Neurosurgery, Linyi Central Hospital, Linyi, China
| | - Ying Su
- Department of Neurosurgery, Linyi Central Hospital, Linyi, China
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Luzzi S, Gragnaniello C, Giotta Lucifero A, Del Maestro M, Galzio R. Surgical Management of Giant Intracranial Aneurysms: Overall Results of a Large Series. World Neurosurg 2020; 144:e119-e137. [PMID: 32949801 DOI: 10.1016/j.wneu.2020.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/30/2020] [Accepted: 08/01/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To review and discuss surgical treatment options for giant intracranial aneurysms (GIAs), focusing on indications, technical aspects, and results, along with some illustrative cases. METHODS We reviewed the data of 82 consecutive patients surgically managed between January 2000 and December 2019 for treatment of a GIA. RESULTS Male sex and hemorrhage at presentation were prevalent. The average follow-up was 81.2 ± 45 months. The anterior circulation was involved in 76.8% of GIAs. If the GIA showed a clear neck, minimal atherosclerosis, or intrasaccular thrombosis, and ≤2 branches arising from the neck, it was reconstructed. This procedure was possible in 78% of cases. The technique also involved temporary clipping, remodeling, and thrombectomy, as well as fragmentation techniques. Angioarchitectural features other than these techniques underwent bypass and aneurysm trapping. Most bypasses were extracranial to intracranial and high flow. Flow capacity, collateral circulation, and availability of the donor vessel mainly affected the choice of the type of bypass. Overall, successful exclusion of the GIA was 91.4%. The need for retreatment and complication rate were 3.6% and 19.5%, respectively. A good overall outcome (modified Rankin Scale score 0-3) was achieved in 84.2% of patients, and mortality was 10%. CONCLUSIONS Microneurosurgical techniques still maintain a significant role for most GIAs, with a high durability and acceptable rate of morbidity and mortality. Clip reconstruction is the first-line surgical treatment option, whereas bypass is indicated in cases of planned or unplanned sacrifice of the parent artery to prevent long-term ischemic complications.
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Affiliation(s)
- Sabino Luzzi
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy; Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Cristian Gragnaniello
- Department of Neurological Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Alice Giotta Lucifero
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Mattia Del Maestro
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; PhD School in Experimental Medicine, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Renato Galzio
- Neurosurgery Unit, Maria Cecilia Hospital, Cotignola, Italy
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Peng A, Dai H, Zhou L, Liu Y. Infantile Giant Intracranial Aneurysm Resection and In Situ Anastomosis. World Neurosurg 2020; 142:112-116. [PMID: 32615291 DOI: 10.1016/j.wneu.2020.06.201] [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: 05/09/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Infantile intracranial aneurysms (IAs) are extremely rare. IA clipping and embolization have been the most common treatment options. Infantile giant IAs treated by surgical resection and in situ anastomosis have rarely been reported. CASE DESCRIPTION A 43-day-old female infant was admitted to our hospital because of abnormal crying and vomiting. Multimodal images showed a right temporal hematoma and a giant dissecting IA. With comprehensive preoperative management, IA resection and in situ anastomosis were successfully performed. Furthermore, intraoperative and postoperative multimodal images demonstrated that the parent vessel was patent. Pathological examination showed chronic inflammation of this IA wall. The infant had a favorable outcome during the 3-month follow-up period. CONCLUSIONS Infantile giant IAs are extremely rare. Chronic inflammation might be involved in the pathogenesis of infantile dissecting IAs. IA resection and in situ anastomosis could be a reasonable choice in the management of infantile giant IAs that cannot be completely clipped or embolized.
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Affiliation(s)
- AiJun Peng
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - HuiYan Dai
- Department of Orthopaedics, Affiliated Hospital of Yangzhou University, Yangzhou, China
| | - LiangXue Zhou
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Liu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China.
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Linfante I, Andreone V, Ravelo N, Starosciak AK, Arif B, Shallwani H, Tze Man Kan P, McDermott MW, Dabus G. Endovascular Treatment of Giant Intracranial Aneurysms. Cureus 2020; 12:e8290. [PMID: 32601564 PMCID: PMC7317134 DOI: 10.7759/cureus.8290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective Giant intracranial aneurysms (GIAs) are associated with a high risk of rupture and have a high mortality rate when they rupture (65-100%). The traditional microsurgical approach to secure these lesions is challenging, and as such endovascular embolization has been increasingly selected as a treatment option. Methods We performed a retrospective analysis of consecutive patients with ruptured and unruptured GIAs at three medical centers from October 2008 to April 2016. Clinical follow-up and digital subtraction angiography were conducted at six months post-treatment. Chi-square analysis was used to determine differences in outcomes between anterior and posterior circulation aneurysms and if a pipeline embolization device (PED) provided favorable outcomes in unruptured GIAs. Results A total of 45 consecutive patients (mean/median age = 57/59; range: 16-82 years) were included. The mean/median aneurysm size was 29.9/28.3 mm (range: 25-50 mm). Eight (18%) patients presented with aneurysmal subarachnoid hemorrhage and 37 (82%) with unruptured GIAs. Twenty-eight (62%) were treated with a PED: 11 (24.4%) with one PED, 1 (2.2%) with PED + coils, 11 (24.4%) with more than one PED, and 5 (13.5%) with multiple PED + coils. The overall mortality rate was 3/45 (6.7%). No deaths were procedure-related. Five (11.1%) patients experienced ischemic stroke but only 2 had a 90-day modified Rankin Scale (mRS) score of ≥3. Of 33 patients available for six-month angiography, Raymond scale (RS) scores were 1, 2, and 3 for 23/45 (70%), 7/45 (20.9%), and 3/45 (9.1%), respectively. Chi-square test demonstrated that overall, anterior circulation GIAs had better clinical (mRS score) and radiographic (RS score) outcomes than posterior GIAs. PED alone provided similar clinical mRS outcomes but had a higher rate of complete occlusion at six months compared with PED + coils and coils alone in unruptured GIAs (p < 0.05). Conclusions Endovascular embolization using PED or PED + coils appears to be a moderately safe and effective treatment option for patients with GIAs.
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Affiliation(s)
- Italo Linfante
- Neurology, Miami Cardiac & Vascular Institute/Miami Neuroscience Institute, Baptist Health South Florida, Miami, USA
| | | | - Natalia Ravelo
- Neuroscience, Herbert Wertheim College of Medicine, Florida International University, Miami, USA
| | - Amy K Starosciak
- Neurology, Miami Neuroscience Institute, Baptist Health South Florida, Miami, USA
| | - Bilal Arif
- Neuroscience, Herbert Wertheim College of Medicine, Florida International University, Miami, USA
| | - Hussain Shallwani
- Neurosurgery, University at Buffalo - The State University of New York, Buffalo, USA
| | | | | | - Guilherme Dabus
- Radiology, Miami Cardiac & Vascular Institute/Miami Neuroscience Institute, Miami, USA
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Campos JK, Ball BZ, Cheaney II B, Sweidan AJ, Hasjim BJ, Hsu FPK, Wang AS, Lin LM. Multimodal management of giant cerebral aneurysms: review of literature and case presentation. Stroke Vasc Neurol 2020; 5:22-28. [PMID: 32411404 PMCID: PMC7213518 DOI: 10.1136/svn-2019-000304] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 02/18/2020] [Accepted: 02/27/2020] [Indexed: 12/27/2022] Open
Abstract
The pathophysiology of giant cerebral aneurysms renders them difficult to treat. Advances in technology have attempted to address any shortcomings associated with open surgery or endovascular therapies. Since the introduction of the flow diversion technique, the endovascular approach with flow diversion has become the first-line modality chosen to treat giant aneurysms. A subset of these giant aneurysms may persistent despite any treatment modality. Perhaps the best option for these recurrent and/or persistent giant aneurysms is to employ a multimodal approach-both surgical and endovascular-rather than any single technique to provide a curative result with favourable patient outcomes. This paper provides a review of the histopathology and treatment options for giant cerebral aneurysms. Additionally, an illustrative case is presented to highlight the unique challenges of a curative solution for giant cerebral aneurysms that persist despite initial treatment.
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Affiliation(s)
- Jessica K Campos
- Department of Neurosurgery, University of California Irvine Medical Center, Orange, California, USA
| | - Benjamin Z Ball
- Department of Neurosurgery, University of California Irvine Medical Center, Orange, California, USA
| | - Barry Cheaney II
- Oregon Health & Science University, School of Medicine, Portland, Oregon, USA
| | - Alexander J Sweidan
- Department of Neurology, University of California Irvine Medical Center, Orange, California, USA
| | - Bima J Hasjim
- Department of Neurosurgery, University of California Irvine Medical Center, Orange, California, USA
| | - Frank P K Hsu
- Department of Neurosurgery, University of California Irvine Medical Center, Orange, California, USA
| | - Alice S Wang
- Western University of Health Sciences, College of Osteopathic Medicine of the Pacific, Pomona, California, USA
| | - Li-Mei Lin
- Carondelet Neurological Institute, St Joseph’s Hospital, Carondelet Health Network, Tucson, Arizona, USA
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Badea R, Olaru O, Ribigan A, Ciobotaru A, Dorobat B. Decompressive Craniectomy: the Right Call at the Right Moment. MAEDICA 2020; 15:129-133. [PMID: 32419874 PMCID: PMC7221286 DOI: 10.26574/maedica.2020.15.1.129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Introduction:Massive intracerebral hemorrhages and large internal carotid artery infarcts may cause early death due to severe cerebral edema with elevated intracranial pressure, despite maximal medical therapy. Decompressive craniectomy may be of benefit to these patients in terms of survival and even functional outcome. The aim of our paper is to present two cases that illustrate the use of decompressive craniectomy both in ischemic and hemorrhagic stroke, followed by a discussion on the indication and right timing of the intervention, but also on the outcome of these patients. Materials and methods: We present the cases of a 38-year-old man with a right lenticular and capsular hemorrhage who underwent decompressive craniectomy in the first 24 hours from onset of symptoms and a 64-year-old patient with an ischemic stroke in the territory of the left carotid artery with a decompressive craniectomy performed at more than 72 hours from the beginning. For each of the two cases, we analyzed the following parameters: neurologic status, Glasgow Coma Scale, aspect of the cerebral computed tomography before and after surgery, in-hospital complications and modified Rankin Scale at discharge. Outcomes: While the intervention was life-saving in both cases, the procedure had different functional outcomes. Conclusion: Decompressive craniectomy may be a life-saving procedure for patients with both hemorrhagic or ischemic strokes complicated with massive edema and increased intracranial pressure. When performed in the first 48 hours, especially in patients with ischemic stroke aged less than 60, it may also improve the functional outcome compared to conservative treatment.
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Affiliation(s)
- R Badea
- University and Emergency Hospital of Bucharest, Neurology Department, Bucharest, Romania
| | - O Olaru
- University and Emergency Hospital of Bucharest, Neurology Department, Bucharest, Romania
| | - A Ribigan
- University and Emergency Hospital of Bucharest, Neurology Department, Bucharest, Romania
| | - A Ciobotaru
- University and Emergency Hospital of Bucharest, Interventional Radiology Department,Bucharest, Romania
| | - B Dorobat
- University and Emergency Hospital of Bucharest, Interventional Radiology Department,Bucharest, Romania
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