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Byoun HS, Lim JW, Han MH, Jeong EO, Koh HS, Kwon HJ. Coil embolization of the middle cerebral artery bifurcation aneurysms: Feasibility and durability. J Clin Neurosci 2024; 126:294-306. [PMID: 39002303 DOI: 10.1016/j.jocn.2024.06.016] [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: 04/04/2024] [Revised: 05/28/2024] [Accepted: 06/18/2024] [Indexed: 07/15/2024]
Abstract
OBJECTIVE To evaluate the feasibility and durability of coil embolization for MCAB aneurysms by analyzing clinical and radiological results. METHODS From January of 2008 to June of 2018, we treated a total of 1785 aneurysms using coil embolization. The aneurysms were treated by both coiling and stent-assisted coiling. Among these cases, 223 MCAB aneurysms were analyzed retrospectively. Clinical and radiological assessments were conducted at admission, after treatment, at discharge, and at last clinical follow-up. RESULTS Coil embolization was performed on 223 MCAB aneurysms in 217 patients. Peri-procedural ischemic, hemorrhagic, and other complications within 30 days after coil embolization occurred at rates of 8.0 %, 8.0 %, and 2.0 %, respectively, in the ruptured group and at 2.9 %, 1.2 %, and 0 %, respectively, in the unruptured group. The overall morbidity and mortality rates associated with complications were 2.3 % and 2.0 %. The cumulative major recurrence rates were 5.1 % at 12 months, 7.1 % at 18 months, and 11.9 % at three years after coil embolization. The mean follow-up period was 33.27 ± 25.48 months. Independent risk factors for major recurrence after coil embolization for MCAB aneurysms were a ruptured aneurysm, initial incomplete occlusion, the aneurysm size, and the neck size. CONCLUSION Coil embolization is a good alternative treatment option for MCAB aneurysms compared to surgical clipping. Considering the risk factors for major recurrence, the follow-up angiography should continue up to three years after coil embolization.
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Affiliation(s)
- Hyoung Soo Byoun
- Department of Neurosurgery, Chungnam National University Sejong Hospital, Sejong-si, South Korea
| | - Jeong-Wook Lim
- Department of Neurosurgery, Chungnam National University Sejong Hospital, Sejong-si, South Korea
| | - Myung-Hoon Han
- Department of Neurosurgery, Hanyang University Guri Hospital, Gyeonggi-do, South Korea
| | - Eun-Oh Jeong
- Department of Neurosurgery, Chungnam National University Hospital and School of Medicine, Daejeon, South Korea
| | - Hyeon-Song Koh
- Department of Neurosurgery, Chungnam National University Hospital and School of Medicine, Daejeon, South Korea
| | - Hyon-Jo Kwon
- Department of Neurosurgery, Chungnam National University Hospital and School of Medicine, Daejeon, South Korea.
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Ribeiro L, Devalckeneer A, Bretzner M, Bourgeois P, Lejeune JP, Aboukais R. Impact of preaneurysmal M 1 length in unruptured middle cerebral artery aneurysm: mid-term outcome and single-center experience. Neurochirurgie 2024; 70:101569. [PMID: 38749316 DOI: 10.1016/j.neuchi.2024.101569] [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: 03/08/2024] [Revised: 04/06/2024] [Accepted: 04/30/2024] [Indexed: 07/20/2024]
Abstract
OBJECTIVE This study was design to investigate the surgical and functional outcome based on the preaneurysmal M1 length for unruptured MCA aneurysm. METHODS Among 250 consecutive patients with unruptured aneurysms operated in our institution between 2015 and 2017, 72 were MCA aneurysms. Risk factors for IR (i.e., intraoperative rupture) were investigated including age, sex, preaneurysmal M1 length, maximal MCA aneurysm diameter, neck size, aneurysm shape, sphenoid ridge proximation sign. Outcome was measured at discharge, 1 yr and last follow-up. Outcome was compared according to the preaneurysmal M1 length. RESULTS Among 68 patients included, five patients (7.3%) suffered IR. Mean maximal diameter of MCA aneurysm (7.9 mm ± 3.4 vs. 4.5 ± 1.8; p = 0.01) was significantly associated with IR risk. Mean M1 length seemed to be shorter in the IR group although not statistically significant (16.2 mm ± 5.1 vs. 11.5 mm ± 4.8; p = 0.053). Mid-term outcome was favorable for all patients at last follow-up but was worsen in case of short preaneurysmal M1 segment (10.7 mm ± 4.8 vs. 16.4 mm ± 5.3, p = 0.02). Complete aneurysm occlusion was achieved for sixty-nine patients (95.5%) with 6.9% of early postoperative complications. CONCLUSIONS The microsurgical treatment of unruptured MCA aneurysm was associated with favorable mid-term outcome in all patients and high rates of complete occlusion. Aneurysm size was significantly associated with the intraoperative rupture risk for unruptured MCA aneurysm and patients with a short preaneurysmal M1 segment seemed to have a greater risk of intraoperative rupture although not statistically significant. Short preaneurysmal M1 patients had worsen mid-term outcome.
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Affiliation(s)
- Lucas Ribeiro
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France.
| | - Antoine Devalckeneer
- Department of Neurosurgery, Roger Salengro Hospital, Lille University Medical Center, Lille, France; Univ. Lille, INSERM, CHU Lille, U1189-ONCO-THAI-Image Assisted Laser Therapy for Oncology, F-59000, Lille, France
| | - Martin Bretzner
- Department of Neuroradiology, Roger Salengro Hospital, Lille University Medical Center, Lille, France
| | - Philippe Bourgeois
- Department of Neurosurgery, Roger Salengro Hospital, Lille University Medical Center, Lille, France
| | - Jean-Paul Lejeune
- Department of Neurosurgery, Roger Salengro Hospital, Lille University Medical Center, Lille, France; Univ. Lille, INSERM, CHU Lille, U1189-ONCO-THAI-Image Assisted Laser Therapy for Oncology, F-59000, Lille, France
| | - Rabih Aboukais
- Department of Neurosurgery, Roger Salengro Hospital, Lille University Medical Center, Lille, France; Univ. Lille, INSERM, CHU Lille, U1189-ONCO-THAI-Image Assisted Laser Therapy for Oncology, F-59000, Lille, France
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Takenaka T, Nakamura H, Yamada S, Kidani T, Tateishi A, Toyota S, Fujinaka T, Taki T, Wakayama A, Kishima H. A novel predictor of ischemic complications in the treatment of ruptured middle cerebral artery aneurysms: Neck-branching angle. World Neurosurg X 2024; 23:100370. [PMID: 38584877 PMCID: PMC10998237 DOI: 10.1016/j.wnsx.2024.100370] [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: 01/23/2024] [Revised: 03/14/2024] [Accepted: 03/20/2024] [Indexed: 04/09/2024] Open
Abstract
Objective The risk factors of procedural cerebral ischemia (CI) in ruptured middle cerebral artery (MCA) aneurysms are unclear. This study proposed the neck-branching angle (NBA), a simple quantitative indicator of the aneurysm neck and branch vessels, and analyzed its usefulness as a predictor of procedural CI in ruptured MCA aneurysms. Methods We retrospectively analyzed 128 patients with ruptured saccular MCA aneurysms who underwent surgical or endovascular treatment between January 2014 and June 2021. We defined the NBA as the angle formed by the MCA aneurysm neck and M2 superior or inferior branch vessel line. The superior and inferior NBA were measured on admission via three-dimensional computed tomography angiography on admission. We divided the patients into clipping (106 patients) and coiling (22 patients) groups according to the treatment. Risk factors associated with procedural CI were analyzed in each group. Results Both groups showed that an enlarged superior NBA was a significant risk factor for procedural CI (clipping, P < 0.0005; coiling group, P = 0.007). The receiver operating characteristic curve showed the closed thresholds of the superior NBA with procedural CI in both groups (clipping group, 128.5°, sensitivity and specificity of 0.667 and 0.848, respectively; coiling group, 130.9°, sensitivity and specificity of 1 and 0.889, respectively). Conclusion The NBA can estimate the procedural risk of ruptured MCA aneurysms. In addition, an enlarged superior NBA is a risk factor for procedural CI in both clipping and coiling techniques.
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Affiliation(s)
- Tomofumi Takenaka
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- Department of Neurosurgery, Osaka Neurological Institute, Toyonaka, Osaka, Japan
| | - Hajime Nakamura
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Shuhei Yamada
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- Department of Neurosurgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Tomoki Kidani
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital, Osaka, Osaka, Japan
| | - Akihiro Tateishi
- Department of Neurosurgery, Osaka Neurological Institute, Toyonaka, Osaka, Japan
| | - Shingo Toyota
- Department of Neurosurgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Toshiyuki Fujinaka
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital, Osaka, Osaka, Japan
| | - Takuyu Taki
- Department of Neurosurgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Akatsuki Wakayama
- Department of Neurosurgery, Osaka Neurological Institute, Toyonaka, Osaka, Japan
| | - Haruhiko Kishima
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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Arrese I, García-García S, Cepeda S, Sarabia R. Integrating endovascular techniques into established open neurosurgery practice: a temporal analysis of treatment evolution in a dual-trained neurosurgical unit. NEUROCIRUGIA (ENGLISH EDITION) 2024:S2529-8496(24)00035-2. [PMID: 38945298 DOI: 10.1016/j.neucie.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 05/15/2024] [Accepted: 06/19/2024] [Indexed: 07/02/2024]
Abstract
OBJETIVE In Europe, units with Dual-trained Neurovascular Surgeons (DTNS) skilled in both open neurosurgery (ON) and endovascular neurosurgery (EN) are scarce. For instance, in Spain, our unit is unique within the public health system, where all neurovascular procedures are carried out by DTNS. Our study aims to evaluate the evolution in treating ruptured intracranial aneurysms (rICAs) and assess the impact of this evolution on clinical outcomes. METHODS A retrospective cohort study was performed on rICAs treated in our unit from October 2012 to June 2023. We reviewed clinical and radiological data to analyze the evolution of ON and EN over time, as well as their impact on patient outcomes. Univariate, multivariate, and mixed-effects models were utilized to discern temporal changes. RESULTS The modified Fisher Scale (mFS) and the modified World Federation of Neurological Surgeons scale (mWFNS) showed strong correlation with the outcome at 6 months outcomes, both with p < 0.00001. However, the surgical intervention method, ON versus EN, did not significantly affect outcomes (p > 0.85). In adjusted multivariate logistic regression, mFS (-1.579, p: 0.011) and mWFNS (-0.872, p < 0.001) maintained their significance. rICAs location was significant when comparing ON to EN p = 0.0001. A significant temporal trend favored the selection of EN p = 0.0058). Mixed-effects time series modeling indicated that while patient characteristics and rICA specifics did not predict treatment choice, the year of treatment was significantly correlated (0.161, p = 0.002). Logistic regression with interaction terms for time and treatment type did not produce significant results. CONCLUSION Our findings suggest that despite an increased adoption of EN techniques, there has been no change in patient outcomes. Even with the rise of EN, our unit continues to perform ON for a higher proportion of rICAs than most national hospitals. We propose that a "dual approach" offers advantages in a patient individualized treatment decision protocol in the European context.
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Affiliation(s)
- Ignacio Arrese
- Unit of Vascular Neurosurgery, Hospital Universitario Río Hortega, Valladolid, Spain.
| | - Sergio García-García
- Unit of Vascular Neurosurgery, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Santiago Cepeda
- Unit of Vascular Neurosurgery, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Rosario Sarabia
- Unit of Vascular Neurosurgery, Hospital Universitario Río Hortega, Valladolid, Spain
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Gunkan A, Onal Y, Ramazanoglu L, Fouad ME, Kahraman AN, Derin Cicek E, Demirhindi H, Velioglu M. Stent plus balloon-assisted coiling with low-profile braided stents in the treatment of complex wide-necked intracranial bifurcation aneurysms. Neuroradiol J 2024:19714009241247462. [PMID: 38622821 DOI: 10.1177/19714009241247462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024] Open
Abstract
INTRODUCTION Wide-necked bifurcation aneurysms pose significant challenges for endovascular treatment. A recent innovation, the stent plus balloon-assisted coiling technique, combines a stent and a balloon to address these aneurysms effectively. PURPOSE To evaluate the safety and efficacy of the stent plus balloon-assisted coiling for the treatment of wide-necked bifurcation aneurysms. METHODS We conducted a retrospective review of our endovascular database to identify patients who were treated with this technique and had a satisfactory angiographic follow-up of at least 24 months. Technical success, initial clinical and angiographic outcomes, procedural complications, and follow-up results were analyzed. Angiographic and clinical outcomes were assessed using Modified Raymond-Roy Classification and Modified Rankin Scale, respectively. RESULTS Our study included 37 aneurysms in 36 patients (26 females) with a mean age of 56.6 years. Mean aneurysm and neck sizes were 7.3 ± 3.5 mm and 3.7 ± 1.0 mm, respectively. Technical success reached 97.2%, with an immediate occlusion rate of 65.7%. At a mean follow-up of 36.5 ± 9.7 months, final angiographic follow-up showed a 91.9% complete occlusion rate. Three aneurysms did not achieve complete occlusion; however, none required retreatment. Complications developed in 32.4% of the procedures. Mortality and morbidity rates were 5.4% and 2.7%, respectively. A good clinical outcome was observed in 91.9% of patients. CONCLUSION Our results showed that stent plus balloon-assisted coiling technique allows good angiographic outcomes for wide-necked bifurcation aneurysms. However, overall complication rate is high. Subgroup analysis indicated promising safety and efficacy for MCA bifurcation aneurysms, suggesting this technique could be a valuable option for select aneurysms.
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Affiliation(s)
- Ahmet Gunkan
- Department of Radiology, Fatih Sultan Mehmet Training and Research Hospital, Turkey
| | - Yilmaz Onal
- Department of Radiology, Fatih Sultan Mehmet Training and Research Hospital, Turkey
| | - Leyla Ramazanoglu
- Department of Neurology, Fatih Sultan Mehmet Training and Research Hospital, Turkey
| | - Mohamed Em Fouad
- Institute for Diagnostic and Interventional Radiology, Frankfurt University Hospital, Germany
| | - Ahmet Nedim Kahraman
- Department of Radiology, Fatih Sultan Mehmet Training and Research Hospital, Turkey
| | - Esin Derin Cicek
- Department of Radiology, Fatih Sultan Mehmet Training and Research Hospital, Turkey
| | - Hakan Demirhindi
- Faculty of Medicine, Department of Public Health, Cukurova University, Turkey
| | - Murat Velioglu
- Department of Radiology, Fatih Sultan Mehmet Training and Research Hospital, Turkey
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Calvanese F, Auricchio AM, Pohjola A, Hafez A, Nurminen V, Korja M, Numminen J, Lehecka M, Raj R, Niemelä M. Changes in treatment of intracranial aneurysms during the last decade in a large European neurovascular center. Acta Neurochir (Wien) 2024; 166:173. [PMID: 38594469 PMCID: PMC11004042 DOI: 10.1007/s00701-024-06064-4] [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: 02/27/2024] [Accepted: 03/26/2024] [Indexed: 04/11/2024]
Abstract
OBJECTIVE Treatment modality for ruptured and unruptured intracranial aneurysms has shifted during the last two decades from microsurgical treatment towards endovascular treatment. We present how this transition happened in a large European neurovascular center. METHODS We conducted a retrospective observational study consecutive patients treated for an unruptured or ruptured intracranial aneurysm at Helsinki University Hospital during 2012-2022. We used Poisson regression analysis to report age-adjusted treatment trends by aneurysm location and rupture status. RESULTS A total of 2491 patients with intracranial aneurysms were treated (44% ruptured, 56% unruptured): 1421 (57%) surgically and 1070 (43%) endovascularly. A general trend towards fewer treated aneurysms was noted. The proportion of patients treated surgically decreased from 90% in 2012 to 20% in 2022. The age-adjusted decrease of surgical versus endovascular treatment was 6.9%/year for all aneurysms, 6.8% for ruptured aneurysms, and 6.8% for unruptured aneurysms. The decrease of surgical treatment was most evident in unruptured vertebrobasilar aneurysms (10.8%/year), unruptured communicating artery aneurysms (10.1%/year), ruptured communicating artery aneurysms (10.0%/year), and ruptured internal carotid aneurysms (9.0%/year). There was no change in treatment modality for middle cerebral artery aneurysms, of which 85% were still surgically treated in 2022. A trend towards an increasing size for treated ruptured aneurysms was found (p = 0.033). CONCLUSION A significant shift of the treatment modality from surgical to endovascular treatment occurred for all aneurysm locations except for middle cerebral artery aneurysms. Whether this shift has affected long-term safety and patient outcomes should be assessed in the future.
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Affiliation(s)
- Francesco Calvanese
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
| | - Anna Maria Auricchio
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Anni Pohjola
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
| | - Ahmad Hafez
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
| | - Ville Nurminen
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
| | - Miikka Korja
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
| | - Jussi Numminen
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
| | - Martin Lehecka
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
| | - Rahul Raj
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland.
| | - Mika Niemelä
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
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Sternbach S, Nguyen VN, Sizdahkhani S, Abedi A, Rennert RC, Atai NA, Khahera AS, Carey JN, Russin JJ. Open Surgical Treatment of Middle Cerebral Artery Aneurysms: A Single-Center Series in the Endovascular Era. World Neurosurg 2024; 184:e577-e585. [PMID: 38336208 DOI: 10.1016/j.wneu.2024.01.172] [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: 12/09/2023] [Revised: 01/31/2024] [Accepted: 01/31/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVE We review the outcomes of open surgical treatment of middle cerebral artery aneurysms (MCAAs) at a single center, focusing on aneurysm obliteration rates and functional outcomes at the most recent follow-up. These findings can be used for future comparisons of surgical outcomes with MCAAs. METHODS We retrospectively reviewed cases from a prospectively maintained database of patients receiving open surgical treatment for ruptured or unruptured MCAAs between July 2014 and December 2022. We utilized patients' modified Rankin Scale (mRS) score and Glasgow Outcome Scale score as functional outcome measures. Means, standard deviations, medians, and interquartile ranges were calculated, and a student's t test or its nonparametric equivalent was used to compare subgroups. RESULTS One hundred fifty patients (114 women, 76%; mean age 55.0 ± 14.7 years) with a total of 156 MCAAs comprised 152 cases; 85 (56%) ruptured and 71 (46%) unruptured. Bypass was performed in 34 cases (22.4%); 18 ruptured (51.4%) and 16 unruptured (48.6%). Intraoperative rupture occurred in 5 (5%) ruptured and 1 (2%) unruptured cases. Onwe hundred forty-five patients (95.4%) had aneurysm obliteration with initial surgery, with 98.4% of patients having complete occlusion at 40.2± 65.5 weeks of follow-up. Intrahospital mortality occurred in 7 (6.9%) ruptured versus 1 (2.0%) unruptured case. Fifty-two (51.5%) of the ruptured compared to 43 (86%) unruptured patients were discharged home, with the remaining patients requiring inpatient rehabilitation or long-term hospitalization. The ruptured group had a mean hospital stay of 18.4 ± 10.5 days versus. 5.7 ± 6.0 days for unruptured. Length of stay, discharge mRS/ Glasgow Outcome Scale, and mRS at 4-6 weeks favored unruptured cases (P < 0.0001-0.0336). Mean change in mRS from presentation to last follow-up favored ruptured cases (-0.7 ± 1.2 vs. -0.04 ± 1.2, P = 0.0215). CONCLUSIONS Open surgery remains a safe and definitive treatment option for MCAAs in the endovascular era.
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Affiliation(s)
- Sarah Sternbach
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Vincent N Nguyen
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Saman Sizdahkhani
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Aidin Abedi
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA; Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Robert C Rennert
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Nadia A Atai
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA; Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Anadjeet S Khahera
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Joseph N Carey
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jonathan J Russin
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA; Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
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Bocanegra-Becerra JE, Sánchez JLA. First-generation bypass surgery for a giant fusiform aneurysm of the middle cerebral artery: an illustrative case and surgical video. J Surg Case Rep 2024; 2024:rjae083. [PMID: 38404446 PMCID: PMC10884731 DOI: 10.1093/jscr/rjae083] [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: 01/02/2024] [Accepted: 02/04/2024] [Indexed: 02/27/2024] Open
Abstract
Giant fusiform aneurysms of the middle cerebral artery (MCA) are complex and rare vascular lesions with a poor natural history and challenging treatment decision-making. We report the case of a 46-year-old male with a history of chronic hypertension and a transient ischemic attack who presented with left-sided hemiparesis. A cerebral angiotomography revealed an unruptured giant fusiform aneurysm in the M2 segment of the right MCA. After carefully evaluating the procedure's risks and benefits with the patient, he underwent a low-flow bypass surgery. An anastomosis between the superficial temporal artery and the M3 segment was performed with proximal clipping of the M2 segment. The postoperative course was uneventful, with preserved bypass patency. At follow-up, the patient was neurologically intact. This report illustrates the nuances and operative techniques for treating a giant fusiform aneurysm of the M2 segment that accounted for a preserved bypass patency and optimal patient neurological recovery.
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Affiliation(s)
| | - José Luis Acha Sánchez
- Department of Neurosurgery, Hospital Nacional Dos de Mayo, Lima, Peru
- Universidad Nacional Mayor de San Marcos , Lima, Peru
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9
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Peeters SF, Colby GP, Kim WJ, Bae WI, Sparks H, Reitz K, Tateshima S, Jahan R, Szeder V, Nour M, Duckwiler GR, Vinuela F, Martin NA, Wang AC. Arterial Bypass in the Treatment of Complex Middle Cerebral Artery Aneurysms: Lessons Learned from Forty Patients. World Neurosurg 2024; 181:e261-e272. [PMID: 37832639 DOI: 10.1016/j.wneu.2023.10.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 10/07/2023] [Indexed: 10/15/2023]
Abstract
OBJECTIVE Complex middle cerebral artery (MCA) aneurysms incorporating parent or branching vessels are often not amenable to standard microsurgical clipping or endovascular embolization treatments. We aim to discuss the treatment of such aneurysms via a combination of surgical revascularization and aneurysm exclusion based on our institutional experience. METHODS Thirty-four patients with complex MCA aneurysms were treated with bypass and aneurysm occlusion, 5 with surgical clipping or wrapping only, and 1 with aneurysm excision and primary reanastomosis. Bypasses included superficial temporal artery (STA)-MCA, double-barrel STA-MCA, occipital artery-MCA, and external carotid artery-MCA. After bypass, aneurysms were treated by surgical clipping, Hunterian ligation, trapping, or coil embolization. RESULTS The average age at diagnosis was 46 years. Of the aneurysms, 67% were large and most involved the MCA bifurcation. Most bypasses performed were STA-MCA bypasses, 12 of which were double-barrel. There were 2 wound-healing complications. All but 2 of the aneurysms treated showed complete occlusion at the last follow-up. There were 3 hemorrhagic complications, 3 graft thromboses, and 4 ischemic insults. The mean follow-up was 73 months. Of patients, 83% reported stable or improved symptoms from presentation and 73% reported a functional status (Glasgow Outcome Scale score 4 or 5) at the latest available follow-up. CONCLUSIONS Cerebral revascularization by bypass followed by aneurysm or parent artery occlusion is an effective treatment option for complex MCA aneurysms that cannot be safely treated by standard microsurgical or endovascular techniques. Double-barrel bypass consisting of 2 STA branches to 2 MCA branches yields adequate flow replacement in most cases.
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Affiliation(s)
- Sophie F Peeters
- Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Geoffrey P Colby
- Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Wi Jin Kim
- Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Whi Inh Bae
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Hiro Sparks
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Kara Reitz
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Satoshi Tateshima
- Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Reza Jahan
- Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Viktor Szeder
- Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - May Nour
- Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Gary R Duckwiler
- Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Fernando Vinuela
- Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Neil A Martin
- Department of Neurosurgery, Pacific Neuroscience Institute, Santa Monica, California, USA
| | - Anthony C Wang
- Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA.
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10
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Stroh N, Stefanits H, Maletzky A, Kaltenleithner S, Thumfart S, Giretzlehner M, Drexler R, Ricklefs FL, Dührsen L, Aspalter S, Rauch P, Gruber A, Gmeiner M. Machine learning based outcome prediction of microsurgically treated unruptured intracranial aneurysms. Sci Rep 2023; 13:22641. [PMID: 38114635 PMCID: PMC10730905 DOI: 10.1038/s41598-023-50012-8] [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: 05/22/2023] [Accepted: 12/14/2023] [Indexed: 12/21/2023] Open
Abstract
Machine learning (ML) has revolutionized data processing in recent years. This study presents the results of the first prediction models based on a long-term monocentric data registry of patients with microsurgically treated unruptured intracranial aneurysms (UIAs) using a temporal train-test split. Temporal train-test splits allow to simulate prospective validation, and therefore provide more accurate estimations of a model's predictive quality when applied to future patients. ML models for the prediction of the Glasgow outcome scale, modified Rankin Scale (mRS), and new transient or permanent neurological deficits (output variables) were created from all UIA patients that underwent microsurgery at the Kepler University Hospital Linz (Austria) between 2002 and 2020 (n = 466), based on 18 patient- and 10 aneurysm-specific preoperative parameters (input variables). Train-test splitting was performed with a temporal split for outcome prediction in microsurgical therapy of UIA. Moreover, an external validation was conducted on an independent external data set (n = 256) of the Department of Neurosurgery, University Medical Centre Hamburg-Eppendorf. In total, 722 aneurysms were included in this study. A postoperative mRS > 2 was best predicted by a quadratic discriminant analysis (QDA) estimator in the internal test set, with an area under the receiver operating characteristic curve (ROC-AUC) of 0.87 ± 0.03 and a sensitivity and specificity of 0.83 ± 0.08 and 0.71 ± 0.07, respectively. A Multilayer Perceptron predicted the post- to preoperative mRS difference > 1 with a ROC-AUC of 0.70 ± 0.02 and a sensitivity and specificity of 0.74 ± 0.07 and 0.50 ± 0.04, respectively. The QDA was the best model for predicting a permanent new neurological deficit with a ROC-AUC of 0.71 ± 0.04 and a sensitivity and specificity of 0.65 ± 0.24 and 0.60 ± 0.12, respectively. Furthermore, these models performed significantly better than the classic logistic regression models (p < 0.0001). The present results showed good performance in predicting functional and clinical outcomes after microsurgical therapy of UIAs in the internal data set, especially for the main outcome parameters, mRS and permanent neurological deficit. The external validation showed poor discrimination with ROC-AUC values of 0.61, 0.53 and 0.58 respectively for predicting a postoperative mRS > 2, a pre- and postoperative difference in mRS > 1 point and a GOS < 5. Therefore, generalizability of the models could not be demonstrated in the external validation. A SHapley Additive exPlanations (SHAP) analysis revealed that this is due to the most important features being distributed quite differently in the internal and external data sets. The implementation of newly available data and the merging of larger databases to form more broad-based predictive models is imperative in the future.
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Affiliation(s)
- Nico Stroh
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Harald Stefanits
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria.
| | | | | | | | | | - Richard Drexler
- Department of Neurosurgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Franz L Ricklefs
- Department of Neurosurgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Lasse Dührsen
- Department of Neurosurgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Aspalter
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Philip Rauch
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Andreas Gruber
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Matthias Gmeiner
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
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11
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Lauzier DC, Cler SJ, Srienc AI, Patel B, Pierce A, Gagne J, Vellimana AK, Chatterjee AR, Kansagra AP, Moran CJ, Zipfel GJ, Osbun JW. Comparative cost analysis of endovascular and open approaches for elective treatment of middle cerebral artery aneurysms. Interv Neuroradiol 2023:15910199231221298. [PMID: 38105434 DOI: 10.1177/15910199231221298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023] Open
Abstract
BACKGROUND Intracranial aneurysms of the middle cerebral artery can be treated using several open surgical and endovascular approaches. Given the growing evidence of clinical equipoise between these various treatment strategies, there is a need to assess the costs associated with each. METHODS Cost of aneurysm treatment was divided into two categories for comparison. "Initial cost" comprised the total in-hospital expenses for initial aneurysm treatment and "total cost" comprised initial aneurysm treatment and all expenses relating to readmission due to treatment-related complications, prescribed catheter angiograms for monitoring of treatment stability, and any retreatments needed for a given aneurysm. The open surgical group was subdivided into a pterional approach group and a lateral supraorbital (LSO) approach group for. RESULTS Median initial cost was $37,152 (IQR $31,318-$44,947) for aneurysms treated with the pterional approach, $29,452 (IQR $27,779-$32,826) for aneurysms treated with the LSO approach, and $19,587 (IQR $14,125-$30,521) for aneurysms treated with endovascular approaches. The median total cost was $39,737 (IQR $33,891-$62,259) for aneurysms treated with the pterional approach, $31,785 (IQR $29,513-$41,099) for aneurysms treated with the LSO approach, and $24,578 (IQR $18,977-$34,547) for aneurysms treated with endovascular approaches. Analysis of variance test demonstrated variance across groups for both initial and total cost (p = 0.004, p = 0.008, respectively). In our subsequent analysis, initial cost and total cost were higher in the pterional group than the endovascular group (p = 0.003 and p = 0.006, respectively). CONCLUSIONS Endovascular treatment of elective aneurysms has a significantly lower cost than open surgical treatment with the pterional approach, but not with the LSO approach. For aneurysms not amenable to endovascular treatment, a minimally invasive LSO approach carries a lower cost burden than a pterional approach.
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Affiliation(s)
- David C Lauzier
- Department of Neurological Surgery, Washington University in St Louis School of Medicine, St Louis, MO, USA
- Mallinckrodt Institute of Radiology, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - Samuel J Cler
- Department of Neurological Surgery, Washington University in St Louis School of Medicine, St Louis, MO, USA
- Mallinckrodt Institute of Radiology, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - Anja I Srienc
- Department of Neurological Surgery, Washington University in St Louis School of Medicine, St Louis, MO, USA
- Mallinckrodt Institute of Radiology, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - Bhuvic Patel
- Department of Neurological Surgery, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - Andrew Pierce
- Barnes Jewish Hospital Clinical Operations, St Louis, MO, USA
| | - Jason Gagne
- Barnes Jewish Hospital Clinical Operations, St Louis, MO, USA
| | - Ananth K Vellimana
- Department of Neurological Surgery, Washington University in St Louis School of Medicine, St Louis, MO, USA
- Mallinckrodt Institute of Radiology, Washington University in St Louis School of Medicine, St Louis, MO, USA
- Department of Neurology, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - Arindam R Chatterjee
- Department of Neurological Surgery, Washington University in St Louis School of Medicine, St Louis, MO, USA
- Mallinckrodt Institute of Radiology, Washington University in St Louis School of Medicine, St Louis, MO, USA
- Department of Neurology, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - Akash P Kansagra
- Department of Neurointerventional Surgery, California Center for Neurointerventional Surgery, St Louis, MO, USA
| | - Christopher J Moran
- Department of Neurological Surgery, Washington University in St Louis School of Medicine, St Louis, MO, USA
- Mallinckrodt Institute of Radiology, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - Gregory J Zipfel
- Department of Neurological Surgery, Washington University in St Louis School of Medicine, St Louis, MO, USA
- Department of Neurology, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - Joshua W Osbun
- Department of Neurological Surgery, Washington University in St Louis School of Medicine, St Louis, MO, USA
- Mallinckrodt Institute of Radiology, Washington University in St Louis School of Medicine, St Louis, MO, USA
- Department of Neurology, Washington University in St Louis School of Medicine, St Louis, MO, USA
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12
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Budohoski KP, Tajsic T, Bal J, Levrini V, Ling Cao JJ, Guilfoyle MR, Couldwell WT, Helmy AE, Kirollos RW, Kirkpatrick PJ, Trivedi RA. Results of Surgical Treatment of Aneurysmal Subarachnoid Hemorrhage in a Single Institution Over 12 Years. World Neurosurg 2023; 180:e341-e349. [PMID: 37769843 DOI: 10.1016/j.wneu.2023.09.070] [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: 08/29/2023] [Accepted: 09/18/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE For patients with aneurysmal subarachnoid hemorrhage (aSAH) in whom endovascular treatment is not the optimal treatment strategy, microsurgical clipping remains a viable option. We examined changes in morbidity and outcome over time in patients treated surgically and in relation to surgeon volume and experience. METHODS All patients who underwent microsurgery for aSAH from 2007 to 2019 at our institution were included. We compared technical complication rates and surgical outcomes between experienced (≥50 independent cases) and inexperienced (<50 independent cases) surgeons and between high-volume (≥20 cases/year) and low-volume (<20 cases/year) surgeons. RESULTS Most of the 1,003 aneurysms (970 patients, median age 56 years) were in the middle cerebral (41.4%), anterior communicating (27.6%), and posterior communicating (17.5%) arteries; 46.5% were <7 mm. The technical complication rate was 7%, resulting in postoperative infarct in 4.9% of patients. Nineteen patients (2%) died within 30 days of admission. There were no significant changes in rates of technical complication, postoperative infarct, or mortality over the study period. There were no differences in postoperative infarction and technical complication rates between experienced and inexperienced surgeons (P = 0.28 and P = 0.05, respectively), but there were differences when comparing high-volume and low-volume surgeons (P = 0.03 and P < 0.001, respectively). The independent predictors of postoperative infarctions were aneurysm size (P = 0.001), intraoperative large-vessel injury (P < 0.001), and low surgeon volume (P = 0.03). CONCLUSIONS We present real-world data on surgical morbidity and outcomes after aSAH. We demonstrated a relationship between surgeon volume and outcome for surgical treatment of aSAH, which supports the benefit of subspecialization in cerebrovascular surgery.
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Affiliation(s)
- Karol P Budohoski
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA; Department of Neurosurgery, Cambridge University Hospitals, Addenbrookes Hospital, Cambridge, UK.
| | - Tamara Tajsic
- Department of Neurosurgery, Cambridge University Hospitals, Addenbrookes Hospital, Cambridge, UK
| | - Jarnail Bal
- Department of Neurosurgery, Cambridge University Hospitals, Addenbrookes Hospital, Cambridge, UK
| | - Virginia Levrini
- Department of Neurosurgery, Cambridge University Hospitals, Addenbrookes Hospital, Cambridge, UK; Department of Neurosurgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Jenny Jia Ling Cao
- Department of Neurosurgery, Cambridge University Hospitals, Addenbrookes Hospital, Cambridge, UK
| | - Mathew R Guilfoyle
- Department of Neurosurgery, Cambridge University Hospitals, Addenbrookes Hospital, Cambridge, UK
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Adel E Helmy
- Department of Neurosurgery, Cambridge University Hospitals, Addenbrookes Hospital, Cambridge, UK
| | - Ramez W Kirollos
- Department of Neurosurgery, Cambridge University Hospitals, Addenbrookes Hospital, Cambridge, UK; Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Peter J Kirkpatrick
- Department of Neurosurgery, Cambridge University Hospitals, Addenbrookes Hospital, Cambridge, UK
| | - Rikin A Trivedi
- Department of Neurosurgery, Cambridge University Hospitals, Addenbrookes Hospital, Cambridge, UK
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13
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Yang K, Begley SL, Lynch D, Turpin J, Aminnejad M, Farrokhyar F, Dehdashti AR. Long-term outcomes of surgical clipping of saccular middle cerebral artery aneurysms: a consecutive series of 92 patients. Neurosurg Rev 2023; 46:271. [PMID: 37843680 DOI: 10.1007/s10143-023-02167-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/17/2023] [Accepted: 09/24/2023] [Indexed: 10/17/2023]
Abstract
Despite advances in endovascular treatment, microsurgical clipping of middle cerebral artery (MCA) aneurysms remains appropriate. We review the high occlusion rate and treatment durability seen with surgical clipping of MCA aneurysms. We retrospectively reviewed patients who underwent microsurgical clipping of saccular MCA aneurysms by a single surgeon. Outcomes included aneurysm occlusion rate and durability, modified Rankin scale (mRS), and postoperative neurological morbidities. Ninety-two patients with 92 saccular MCA aneurysms were included, 50% of which were ruptured aneurysms. The mean follow-up period was 59 months. Complete aneurysm occlusion was achieved in all except one patient (99%) with near-complete occlusion. MCA aneurysm clipping was durable, with only one patient (1%) requiring retreatment after 4 years due to regrowth. Of the cohort, 79.3% achieved mRS 0-2 at last follow-up, including all with unruptured aneurysms. Poor outcome at discharge was associated with age > 65 (p = .03), postoperative neurological morbidities (p = .006), and aneurysm rupture (p < .001). Older age remained the single correlate for poor long-term outcome (p = .04). For ruptured aneurysms, predictors of poor long-term outcome included hemiparesis on presentation (p = .017), clinical vasospasm requiring treatment (p = .026), and infarction related to vasospasm (p = .041). Older age (p = .046) and complex anatomy (p = .036) were predictors of new postoperative neurological morbidities in the unruptured group. MCA aneurysm clipping is safe, durable, and should be considered first-line treatment for patients with saccular MCA aneurysms, especially in centers with abundant surgical experience.
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Affiliation(s)
- Kaiyun Yang
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr Manhasset, Hempstead, NY, 11030, USA
- Community Neurosciences Institute, Community Health Partners, Fresno, CA, USA
| | - Sabrina L Begley
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr Manhasset, Hempstead, NY, 11030, USA
| | - Daniel Lynch
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr Manhasset, Hempstead, NY, 11030, USA
| | - Justin Turpin
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr Manhasset, Hempstead, NY, 11030, USA
| | - Minoo Aminnejad
- Department of Surgery, Department of Health, Evidence, Impact, McMaster University, Hamilton, ON, Canada
| | - Forough Farrokhyar
- Department of Surgery, Department of Health, Evidence, Impact, McMaster University, Hamilton, ON, Canada
| | - Amir R Dehdashti
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr Manhasset, Hempstead, NY, 11030, USA.
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14
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Diestro JDB, Li Y, Kishore K, Omar AT, Montanera W, Sarma D, Marotta TR, Spears J, Bharatha A. A shift from open to endovascular repair in the treatment of ruptured middle cerebral artery aneurysms: a single institution experience. Neuroradiology 2023; 65:1353-1361. [PMID: 37480480 DOI: 10.1007/s00234-023-03195-w] [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: 03/02/2023] [Accepted: 07/07/2023] [Indexed: 07/24/2023]
Abstract
PURPOSE Middle cerebral aneurysms were underrepresented in the two largest trials (BRAT and ISAT) for the treatment of ruptured intracranial aneurysms. Recent institutional series addressing the choice between endovascular or open repair for this subset of aneurysms are few and have not yielded a definitive conclusion. We compare clinical outcomes of patients presenting with acute subarachnoid hemorrhage from ruptured middle cerebral artery aneurysms undergoing either open or endovascular repair. METHODS We conducted a retrospective review of 138 consecutive patients with ruptured middle cerebral artery aneurysms admitted into our institution from January 2008 to March 2019 to compare endovascular and open surgical outcomes. RESULTS Of the ruptured middle cerebral artery aneurysms, 57 underwent endovascular repair while 81 were treated with open surgery. Over the study period, there was a notable shift in practice toward more frequent endovascular treatment of ruptured MCA aneurysms (31% in 2008 vs. 91% in 2018). At discharge (49.1% vs 29.6%; p = .002) and at 6 months (84.3% vs 58.6%; p = 0.003), patients who underwent endovascular repair had a higher proportion of patients with good clinical outcomes (mRS 0-2) compared to those undergoing open surgery. Long-term follow-up data (endovascular 54.9 ± 37.9 months vs clipping 18.6 ± 13.4 months) showed no difference in rebleeding (1.8% vs 3.7%, p = 0.642) and retreatment (5.3% vs 3.7%, p = 0.691) in both groups. CONCLUSION Our series suggests equipoise in the treatment of ruptured middle cerebral artery aneurysms and demonstrates endovascular repair as a potentially feasible treatment strategy. Future randomized trials could clarify the roles of these treatment modalities.
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Affiliation(s)
- Jose Danilo Bengzon Diestro
- Department of Medical Imaging, Division of Diagnostic and Therapeutic Neuroradiology, St Michael's Hospital, University of Toronto, Toronto, Canada.
| | - Yangmei Li
- Department of Medical Imaging, Division of Diagnostic and Therapeutic Neuroradiology, St Michael's Hospital, University of Toronto, Toronto, Canada
| | - Kislay Kishore
- Department of Medical Imaging, Division of Diagnostic and Therapeutic Neuroradiology, St Michael's Hospital, University of Toronto, Toronto, Canada
| | - Abdelsimar T Omar
- Department of Surgery, Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Walter Montanera
- Department of Medical Imaging, Division of Diagnostic and Therapeutic Neuroradiology, St Michael's Hospital, University of Toronto, Toronto, Canada
| | - Dipanka Sarma
- Department of Medical Imaging, Division of Diagnostic and Therapeutic Neuroradiology, St Michael's Hospital, University of Toronto, Toronto, Canada
- Department of Surgery, Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Thomas R Marotta
- Department of Medical Imaging, Division of Diagnostic and Therapeutic Neuroradiology, St Michael's Hospital, University of Toronto, Toronto, Canada
- Department of Surgery, Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Julian Spears
- Department of Medical Imaging, Division of Diagnostic and Therapeutic Neuroradiology, St Michael's Hospital, University of Toronto, Toronto, Canada
- Department of Surgery, Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Aditya Bharatha
- Department of Medical Imaging, Division of Diagnostic and Therapeutic Neuroradiology, St Michael's Hospital, University of Toronto, Toronto, Canada
- Department of Surgery, Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
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15
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Skrap B, Di Bonaventura R, Di Domenico M, Sturiale CL, Auricchio AM, Maugeri R, Giammalva GR, Iacopino DG, Olivi A, Marchese E, Albanese A. Has intraoperative neuromonitoring changed the surgery for unruptured middle cerebral artery aneurysms? A retrospective comparative study. Neurosurg Rev 2023; 46:191. [PMID: 37535200 PMCID: PMC10400477 DOI: 10.1007/s10143-023-02099-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/30/2023] [Accepted: 07/24/2023] [Indexed: 08/04/2023]
Abstract
Intraoperative neurophysiological monitoring (IONM) represents one of the available technologies able to assess ischemia and aimed to improve surgical outcome reducing the treatment related morbidity in surgery for intracranial aneurysms. Many studies analyzing the impact of IONM are poised by the heterogeneity bias affecting the cohorts. We report our experience with IONM for surgery of unruptured middle cerebral artery (MCA) aneurysm in order to highlight its influence on functional and radiological outcome and surgical strategy. We retrospectively reviewed all MCA unruptured aneurysms treated between January 2013 and June 2021 by our institutional neurovascular team. Patients were divided into 2 groups according to the use of IONM. A total of 153 patients were included in the study, 52 operated on without IONM and 101 with IONM. The groups did not differ preoperatively regarding clinical status and aneurysm characteristics. Patients operated with IONM had better functional outcomes at discharge as well as at follow-up (p= 0.048, p=0.041) due to lower symptomatic ischemia and better radiological outcome due to lower rate of unexpected aneurysmal remnants (p= 0.0173). The introduction of IONM changed the use of temporary clipping (TeC), increasing its average duration (p= 0.01) improving the safety of dissecting and clipping the aneurysm. IONM in surgery for unruptured MCA aneurysm could improve the efficacy and safety of clipping strategy in the way it showed a role in changing the use of TeC and was associated to the reduction of unexpected aneurysmal remnants' rate and improvement in both short- and long-term patient's outcome.
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Affiliation(s)
- Benjamin Skrap
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168, Rome, Italy
| | - Rina Di Bonaventura
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy.
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168, Rome, Italy.
| | - Michele Di Domenico
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168, Rome, Italy
| | - Carmelo Lucio Sturiale
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168, Rome, Italy
| | - Anna Maria Auricchio
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168, Rome, Italy
| | - Rosario Maugeri
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Department of Biomedicine Neurosciences and Advanced Diagnostics, School of medicine, University of Palermo, Palermo, Italy
| | - Giuseppe Roberto Giammalva
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Department of Biomedicine Neurosciences and Advanced Diagnostics, School of medicine, University of Palermo, Palermo, Italy
| | - Domenico Gerardo Iacopino
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Department of Biomedicine Neurosciences and Advanced Diagnostics, School of medicine, University of Palermo, Palermo, Italy
| | - Alessandro Olivi
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168, Rome, Italy
| | - Enrico Marchese
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168, Rome, Italy
| | - Alessio Albanese
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168, Rome, Italy
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16
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Le K, Heskett C, De Stefano FA, Fry L, Lei C, Dharia A, Brake A, Chatley K, Peterson J, Ebersole K. An Analysis of Landmark Articles Regarding Aneurysms of the Middle Cerebral Artery. World Neurosurg 2023; 171:72-83. [PMID: 36473598 DOI: 10.1016/j.wneu.2022.11.135] [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: 10/18/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Aneurysms located on the middle cerebral artery (MCA) range from 22% to 31.5% in prevalence of all aneurysms in the anterior cerebral circulation. This bibliometric analysis summarizes the most cited articles on MCA aneurysms and highlights the landmark publications that contributed to evidence-based practice. METHODS In the execution of this bibliometric-based review article, the Scopus database was used to perform a title-specific, keyword-based search for all publications until August 2022. The keyword "(middle cerebral artery OR MCA) AND aneurysm" was used. Our results were arranged in descending order based on the citation count of the article. The 100 most cited articles were selected for analysis. Parameters included the following: title, citation count, citations per year, authors, specialty of first author, institution, country of origin, publishing journal, Source Normalized Impact per Paper, and Hirsch index. RESULTS The keyword-based search showed that 1206 articles on MCA aneurysms were published up to August 2022. The top 100 articles were published between 1940 and 2019. The top 100 most cited articles collected a total of 6232 citations with an average of 62.3 citations per article. The rate of self-citations accounted for an average of 5.75% of the total number of citations. CONCLUSIONS The bibliometric analysis provides a quantitative overview of how medical literature and interventions are analyzed in academic medicine. In the present study, we evaluated the global trends in research regarding MCA aneurysms by finding the top 100 most cited articles.
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Affiliation(s)
- Kevin Le
- University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Cody Heskett
- University of Kansas School of Medicine, Kansas City, Kansas, USA.
| | - Frank A De Stefano
- Department of Neurological Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Lane Fry
- University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Catherine Lei
- University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Anand Dharia
- Department of Neurological Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Aaron Brake
- University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Kevin Chatley
- Department of Neurological Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jeremy Peterson
- Department of Neurological Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Koji Ebersole
- Department of Neurological Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
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17
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Piano M, Lozupone E, Milonia L, Pero G, Cervo A, Macera A, Quilici L, Visconti E, Valvassori L, Cenzato M, Boccardi E. Flow diverter devices in the treatment of complex middle cerebral artery aneurysms when surgical and endovascular treatments are challenging. J Stroke Cerebrovasc Dis 2022; 31:106760. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/17/2022] [Accepted: 09/04/2022] [Indexed: 11/21/2022] Open
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18
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Boisseau W, Darsaut TE, Fahed R, Findlay JM, Bourcier R, Charbonnier G, Smajda S, Ognard J, Roy D, Gariel F, Carlson AP, Shotar E, Ciccio G, Marnat G, Sporns PB, Gaberel T, Jecko V, Weill A, Biondi A, Boulouis G, Bras AL, Aldea S, Passeri T, Boissonneau S, Bougaci N, Gentric JC, Diestro JDB, Omar AT, Al-Jehani HM, Hage GE, Volders D, Kaderali Z, Tsogkas I, Magro E, Holay Q, Zehr J, Iancu D, Raymond J. Surgical or Endovascular Treatment of MCA Aneurysms: An Agreement Study. AJNR Am J Neuroradiol 2022; 43:1437-1444. [PMID: 36137654 PMCID: PMC9575541 DOI: 10.3174/ajnr.a7648] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/28/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE MCA aneurysms are still commonly clipped surgically despite the recent development of a number of endovascular tools and techniques. We measured clinical uncertainty by studying the reliability of decisions made for patients with middle cerebral artery (MCA) aneurysms. MATERIALS AND METHODS A portfolio of 60 MCA aneurysms was presented to surgical and endovascular specialists who were asked whether they considered surgery or endovascular treatment to be an option, whether they would consider recruitment of the patient in a randomized trial, and whether they would provide their final management recommendation. Agreement was studied using κ statistics. Intrarater reliability was assessed with the same, permuted portfolio of cases of MCA aneurysm sent to the same specialists 1 month later. RESULTS Surgical management was the preferred option for neurosurgeons (n = 844/1320; [64%] responses/22 raters), while endovascular treatment was more commonly chosen by interventional neuroradiologists (1149/1500 [76.6%] responses/25 raters). Interrater agreement was only "slight" for all cases and all judges (κ = 0.094; 95% CI, 0.068-0.130). Agreement was no better within specialties or with more experience. On delayed requestioning, 11 of 35 raters (31%) disagreed with themselves on at least 20% of cases. Surgical management and endovascular treatment were always judged to be a treatment option, for all patients. Trial participation was offered to patients 65% of the time. CONCLUSIONS Individual clinicians did not agree regarding the best management of patients with MCA aneurysms. A randomized trial comparing endovascular with surgical management of patients with MCA aneurysms is in order.
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Affiliation(s)
- W Boisseau
- From the Department of Radiology (W.B., D.R., A.W., D.I., J.R.), Division of Neuroradiology
| | - T E Darsaut
- Department of Surgery (T.E.D., J.M.F.), Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - R Fahed
- Department of Medicine (R.F.), Division of Neurology, The Ottawa Hospital, Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada
| | - J M Findlay
- Department of Surgery (T.E.D., J.M.F.), Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - R Bourcier
- Department of Neuroradiology (R.B.), University Hospital of Nantes, Nantes, France
| | - G Charbonnier
- Departments of Interventional Neuroradiology (G. Charbonnier, A.B.)
| | - S Smajda
- Departments of Interventional Neuroradiology (S.S.)
| | - J Ognard
- Department of Interventional Neuroradiology (J.O., J.C.G.), Hôpital de la Cavale Blanche, Brest, Bretagne, France
| | - D Roy
- From the Department of Radiology (W.B., D.R., A.W., D.I., J.R.), Division of Neuroradiology
| | - F Gariel
- Departments of Neuroradiology (F.G., G.M.)
| | - A P Carlson
- Department of Neurosurgery (A.P.C.), University of New Mexico Hospital, Albuquerque, New Mexico
| | - E Shotar
- Department of Neuroradiology (E.S.), Groupe Hospitalier de Pitié Salpêtrière, Paris, France
| | - G Ciccio
- Department of Interventional Neuroradiology (G. Ciccio), Centre Hospitalier de Bastia, Bastia, Corse, France
| | - G Marnat
- Departments of Neuroradiology (F.G., G.M.)
| | - P B Sporns
- Department of Neuroradiology (P.B.S., I.T.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
- Department of Diagnostic and Interventional Neuroradiology (P.B.S.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - T Gaberel
- Department of Neurosurgery (T.G.), University Hospital of Caen, Caen, France
| | - V Jecko
- Neurosurgery (V.J.), University Hospital of Bordeaux, Bordeaux, France
| | - A Weill
- From the Department of Radiology (W.B., D.R., A.W., D.I., J.R.), Division of Neuroradiology
| | - A Biondi
- Departments of Interventional Neuroradiology (G. Charbonnier, A.B.)
| | - G Boulouis
- Department of Neuroradiology (G.B.), University Hospital of Tours, Tours, Indre et Loire, France
| | - A L Bras
- Department of Radiology (A.L.B.), Groupement Hospitaliser Bretagne Atlantique-Hôpital Chubert, Vannes, Bretagne, France
| | - S Aldea
- Neurosurgery (S.A.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
| | - T Passeri
- Department of Neurosurgery (T.P.), Lariboisière Hospital, Assistance Publique Hôpitaux de Paris, University of Paris, Paris, France
| | - S Boissonneau
- Department of Neurosurgery (S.B.), La Timone Hospital
- L'Institut National de la Santé et de la Recherche Médicale (S.B.), Institut de Neurosciences des Systèmes, Aix Marseille University, Marseille, France
| | - N Bougaci
- Neurosurgery (N.B.), Besançon University Hospital, Besançon, France
| | - J C Gentric
- Department of Interventional Neuroradiology (J.O., J.C.G.), Hôpital de la Cavale Blanche, Brest, Bretagne, France
| | - J D B Diestro
- Division of Diagnostic and Therapeutic Neuroradiology (J.D.B.D.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - A T Omar
- Division of Neurosurgery (A.T.O.), Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - H M Al-Jehani
- Department of Neurosurgery, Radiology and Critical Care Medicine (H.M.A.-J.), King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University, Alkhobar, Saudi Arabia
| | - G El Hage
- Department of Neurosurgery (G.E.H.), Centre Hospitalier de l'Université de Montréal,Montreal, Québec, Canada
| | - D Volders
- Department of Radiology (D.V.), Dalhousie University, Halifax, Nova Scotia, Canada
| | - Z Kaderali
- Division of Neurosurgery (Z.K.), GB1-Health Sciences Centre, Winnipeg, Manitoba, Canada
| | - I Tsogkas
- Department of Neuroradiology (P.B.S., I.T.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - E Magro
- Department of Neurosurgery (E.M.), Centre Hospitalier Universitaire Cavale Blanche, UBO L'Institut National de la Santé et de la Recherche Médicale, LaTIM UMR 1101, Brest, France
| | - Q Holay
- Department of Radiology (Q.H.), Hôpital d'Instruction des Armées Saint-Anne, Toulon, France
| | - J Zehr
- Department of Mathematics and Statistics (J.Z.), Pavillon André-Aisenstadt,Montreal, Québec, Canada
| | - D Iancu
- From the Department of Radiology (W.B., D.R., A.W., D.I., J.R.), Division of Neuroradiology
| | - J Raymond
- From the Department of Radiology (W.B., D.R., A.W., D.I., J.R.), Division of Neuroradiology
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Arrese I, García-García S, Cepeda S, Sarabia R. Treatment of unruptured middle cerebral artery aneurysms: Systematic review in an attempt to perform a network meta-analysis. Front Surg 2022; 9:1005602. [PMID: 36248366 PMCID: PMC9554213 DOI: 10.3389/fsurg.2022.1005602] [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: 07/28/2022] [Accepted: 08/31/2022] [Indexed: 11/19/2022] Open
Abstract
Objective Open surgical clipping has been generally considered the best treatment option for unruptured middle cerebral artery aneurysms (uMCAAs). However, this type of aneurysm is being treated endovascularly with the appearance of new devices. We have carried out a systematic review of randomized and quasi-experimental studies to conduct a network meta-analysis (NMA) to assess the safety and efficacy of the different treatment methods currently used in uMCAAs. Methods The literature was searched by using PubMed and Google Scholar databases. Eligibility criteria were randomized or quasi-experimental studies including at least five cases per arm and reporting duration of follow-up and number of lost cases. The end points were: angiographic success, final neurological outcome, and the need for retreatments. Results We could only analyze four quasi-experimental studies with 398 uMCAAs. All of them compared clipping vs. coiling. Clipping showed better results than coiling in all analyzed end points. We could not conduct the proposed NMA because of the absence of randomized or quasi-experimental studies. Instead, a systematic review is further discussed. Conclusions There is an urgent need for comparative studies on the treatment of uMCAAs.
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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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21
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Multiple clips reconstruction for giant fusiform Middle Cerebral Artery aneurysm. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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22
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Srinivasan VM, Farhadi DS, Shlobin NA, Cole TS, Graffeo CS, Lawton MT. Clinical Trials of Microsurgery for Cerebral Aneurysms: Past and Future. World Neurosurg 2022; 161:354-366. [PMID: 35505555 DOI: 10.1016/j.wneu.2021.11.087] [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: 08/30/2021] [Revised: 11/19/2021] [Accepted: 11/20/2021] [Indexed: 10/18/2022]
Abstract
BACKGROUND New findings and research regarding the microsurgical treatment of intracerebral aneurysms (IAs) continue to advance even in the era of endovascular therapies. Research in the past 2 decades has continued to revolve around the question of whether open surgery or endovascular treatment is preferable. The answer remains both complex and in flux. OBJECTIVE This review focuses on microsurgery, reflects on the research decisions of previous landmark studies, and proposes future study designs that may further our understanding of IAs and how best to treat them. RESULTS The future of IA research may include a combination of pragmatic trials, artificial intelligence integrated tools, and mining of large data sets, in addition to the publication of high-quality single-center studies. CONCLUSIONS The future will likely emphasize testing innovative techniques, looking at granular patient data, and considering every patient encounter as a potential source of knowledge, creating a system in which data are updated daily because each patient interaction contributes to answering important research questions.
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Affiliation(s)
- Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Dara S Farhadi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Nathan A Shlobin
- 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
| | - Christopher S Graffeo
- 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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23
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Adeeb N, Dibas M, Diestro JDB, Phan K, Cuellar-Saenz HH, Sweid A, Lay SV, Guenego A, Aslan A, Renieri L, Sundararajan SH, Saliou G, Möhlenbruch M, Regenhardt RW, Vranic JE, Lylyk I, Foreman PM, Vachhani JA, Župančić V, Hafeez MU, Rutledge C, Waqas M, Tutino VM, Rabinov JD, Ren Y, Schirmer CM, Piano M, Kuhn AL, Michelozzi C, Elens S, Starke RM, Hassan A, Salehani A, Brehm A, MohammedAli M, Jones J, Psychogios M, Spears J, Lubicz B, Panni P, Puri AS, Pero G, Griessenauer CJ, Asadi H, Siddiqui A, Ducruet A, Albuquerque FC, Du R, Kan P, Kalousek V, Lylyk P, Stapleton CJ, Boddu S, Knopman J, Aziz-Sultan MA, Limbucci N, Jabbour P, Cognard C, Patel AB, Dmytriw AA. Comparing treatment outcomes of various intracranial bifurcation aneurysms locations using the Woven EndoBridge (WEB) device. J Neurointerv Surg 2022; 15:558-565. [PMID: 35483912 DOI: 10.1136/neurintsurg-2022-018694] [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: 01/25/2022] [Accepted: 04/12/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND The Woven EndoBridge (WEB) device has Food and Drug Administration approval for treatment of wide-necked intracranial bifurcation aneurysms. The WEB device has been shown to result in adequate occlusion in bifurcation aneurysms overall, but its usefulness in the individual bifurcation locations has been evaluated separately only in few case series, which were limited by small sample sizes. OBJECTIVE To compare angiographic and clinical outcomes after treatment of bifurcation aneurysms at various locations, including anterior communicating artery (AComA), anterior cerebral artery (ACA) bifurcation distal to AComA, basilar tip, internal carotid artery (ICA) bifurcation, and middle cerebral artery (MCA) bifurcation aneurysms using the WEB device. METHODS A retrospective cohort analysis was conducted at 22 academic institutions worldwide to compare treatment outcomes of patients with intracranial bifurcation aneurysms using the WEB device. Data include patient and aneurysm characteristics, procedural details, angiographic and functional outcomes, and complications. RESULTS A total of 572 aneurysms were included. MCA (36%), AComA (35.7%), and basilar tip (18.9%) aneurysms were most common. The rate of adequate aneurysm occlusion was significantly higher for basilar tip (91.6%) and ICA bifurcation (96.7%) aneurysms and lower for ACA bifurcation (71.4%) and AComA (80.6%) aneurysms (p=0.04). CONCLUSION To our knowledge, this is the most extensive study to date that compares the treatment of different intracranial bifurcation aneurysms using the WEB device. Basilar tip and ICA bifurcation aneurysms showed significantly higher rates of aneurysm occlusion than other locations.
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Affiliation(s)
- Nimer Adeeb
- Departments of Neurosurgery and Neurointerventional Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Mahmoud Dibas
- Neuroradiology and Neurosurgical Services, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jose Danilo Bengzon Diestro
- Department of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kevin Phan
- Neuroradiology and Neurosurgical Services, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Hugo H Cuellar-Saenz
- Departments of Neurosurgery and Neurointerventional Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Sovann V Lay
- Interventional Neuroradiology Department, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Adrien Guenego
- Interventional Neuroradiology Department, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Assala Aslan
- Departments of Neurosurgery and Neurointerventional Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Leonardo Renieri
- Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy
| | - Sri Hari Sundararajan
- Neurosurgery and Interventional Neuroradiology, New York Presbyterian Hospital, Weill Cornell School of Medicine, New York, New York, USA
| | - Guillaume Saliou
- Department of Diagnostic and Interventional Radiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Vaud, Switzerland
| | - Markus Möhlenbruch
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Robert W Regenhardt
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Justin E Vranic
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Ivan Lylyk
- Equipo de Neurocirugía Endovascular y Radiología Intervencionista, Clínica La Sagrada Familia, Buenos Aires, Argentina
| | - Paul M Foreman
- Neurosurgery Department, Orlando Health Neuroscience and Rehabilitation Institute, Orlando, FL, USA
| | - Jay A Vachhani
- Neurosurgery Department, Orlando Health Neuroscience and Rehabilitation Institute, Orlando, FL, USA
| | - Vedran Župančić
- Department of Radiology, Clinical Hospital Center 'Sisters of Mercy', Zagreb, Croatia
| | - Muhammad U Hafeez
- Department of Neurosurgery, UTMB and Baylor School of Medicine, Houston, TX
| | - Caleb Rutledge
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Muhammad Waqas
- Department of Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Vincent M Tutino
- Department of Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - James D Rabinov
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Yifan Ren
- Neurointervention Service, Department of Radiology, Austin Health, Heidelberg, Victoria, Australia
| | - Clemens M Schirmer
- Departments of Neurosurgery and Radiology, Geisinger Hospital, Danville, Virginia, USA
| | - Mariangela Piano
- Department of Neuroradiology, Ospedale Niguarda Ca' Granda, Milano, Italy
| | - Anna L Kuhn
- Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | | | - Stephanie Elens
- Department of Interventional Neuroradiology, Erasmus Hospital, Bruxelles, Bruxelles, Belgium
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ameer Hassan
- Deparment of Neuroscience, Valley Baptist Neuroscience Institute, Harlingen, TX, USA
| | | | - Alex Brehm
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - MajdEddin MohammedAli
- Departments of Neurosurgery and Neurointerventional Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Jesse Jones
- Department of Neurosurgery, UAB Hospital, Birmingham, Alabama, USA
| | - Marios Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Julian Spears
- Department of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Boris Lubicz
- Department of Interventional Neuroradiology, Erasmus Hospital, Bruxelles, Bruxelles, Belgium
| | - Pietro Panni
- Interventistica Neurovascolare, Ospedale San Raffaele, Milano, Italy
| | - Ajit S Puri
- Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Guglielmo Pero
- Department of Neuroradiology, Ospedale Niguarda Ca' Granda, Milano, Italy
| | - Christoph J Griessenauer
- Departments of Neurosurgery and Radiology, Geisinger Hospital, Danville, Virginia, USA.,Department of Neurosurgery, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Hamed Asadi
- Neurointervention Service, Department of Radiology, Austin Health, Heidelberg, Victoria, Australia
| | - Adnan Siddiqui
- Department of Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Andrew Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Rose Du
- Neuroradiology and Neurosurgical Services, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Peter Kan
- Department of Neurosurgery, UTMB and Baylor School of Medicine, Houston, TX
| | - Vladimir Kalousek
- Department of Radiology, Clinical Hospital Center 'Sisters of Mercy', Zagreb, Croatia
| | - Pedro Lylyk
- Equipo de Neurocirugía Endovascular y Radiología Intervencionista, Clínica La Sagrada Familia, Buenos Aires, Argentina
| | - Christopher J Stapleton
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Srikanth Boddu
- Neurosurgery and Interventional Neuroradiology, New York Presbyterian Hospital, Weill Cornell School of Medicine, New York, New York, USA
| | - Jared Knopman
- Neurosurgery and Interventional Neuroradiology, New York Presbyterian Hospital, Weill Cornell School of Medicine, New York, New York, USA
| | - Mohammad A Aziz-Sultan
- Neuroradiology and Neurosurgical Services, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nicola Limbucci
- Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Christophe Cognard
- Interventional Neuroradiology Department, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Aman B Patel
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Adam A Dmytriw
- Neuroradiology and Neurosurgical Services, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
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24
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Aydin K, Berdikhojayev M, Cay F, Barburoglu M, Nurzhan S, Aygun S, Sencer S, Arat A. Safety, Efficacy, and Durability of Stent-Assisted Coiling Treatment of M2 (Insular) Segment MCA Aneurysms. AJNR Am J Neuroradiol 2022; 43:560-567. [PMID: 35301223 PMCID: PMC8993191 DOI: 10.3174/ajnr.a7461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/17/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Most distal MCA aneurysms are located within the insular segment, which lies between the limen insulae and circular sulcus. However, experience is limited in the microsurgical and endovascular management of insular segment MCA aneurysms. In this multicenter retrospective case series, we aimed to investigate the safety, efficacy, and durability of stent-assisted coiling for treatment of insular segment MCA aneurysms. MATERIALS AND METHODS A retrospective review was performed to identify patients with insular MCA aneurysms that were treated with stent-assisted coiling. The technical success of the procedures and the initial and follow-up clinical and angiographic outcomes were assessed. Periprocedural and delayed complications were reviewed. RESULTS Twenty-seven aneurysms in 27 patients with a mean age of 53.3 (SD,11.3) years were included. The mean size of the aneurysms was 6.3 (SD 2.6) mm. Endovascular procedures were successfully performed in all patients. Immediate postprocedural angiography revealed complete aneurysm occlusions in 81.5%. Periprocedural complications developed in 7.4% without causing permanent morbidity. A delayed thromboembolic complication resulted in a minor permanent morbidity in 1 patient (3.7%). There was no mortality. The mean duration of angiographic follow-up was 19.5 (SD, 9.8) months. The last follow-up examinations showed complete occlusion in 92.6%. During the follow-up period, none of the treated aneurysms showed recanalization. CONCLUSIONS The results of this study demonstrate that stent-assisted coiling with a low-profile self-expandable stent is a feasible and relatively safe technique for endovascular treatment of insular segment complex MCA aneurysms. Additionally, it provides an effective and durable treatment for insular MCA aneurysms.
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Affiliation(s)
- K Aydin
- From the Department of Interventional Neuroradiology (K.A., S.A.), Koç University Hospital, Topkapi, Istanbul, Turkey
- Department of Neuroradiology (K.A., M. Barburoglu, S.S.), Istanbul Faculty of Medicine, Capa, Istanbul University, Istanbul, Turkey
| | - M Berdikhojayev
- Department of Neurosurgery (M. Berdikhojayev, S.N.), JSC Central Hospital, Almaty City, Kazakhstan
| | - F Cay
- Department of Radiology (F.C., A.A.), Hacettepe University Medical School, Hacettepe Hospitals, Sihhiye, Ankara, Turkey
| | - M Barburoglu
- Department of Neuroradiology (K.A., M. Barburoglu, S.S.), Istanbul Faculty of Medicine, Capa, Istanbul University, Istanbul, Turkey
| | - S Nurzhan
- Department of Neurosurgery (M. Berdikhojayev, S.N.), JSC Central Hospital, Almaty City, Kazakhstan
| | - S Aygun
- From the Department of Interventional Neuroradiology (K.A., S.A.), Koç University Hospital, Topkapi, Istanbul, Turkey
| | - S Sencer
- Department of Neuroradiology (K.A., M. Barburoglu, S.S.), Istanbul Faculty of Medicine, Capa, Istanbul University, Istanbul, Turkey
| | - A Arat
- Department of Radiology (F.C., A.A.), Hacettepe University Medical School, Hacettepe Hospitals, Sihhiye, Ankara, Turkey
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25
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Shah KA, Patsalides A, Dehdashti AR. Letter: Flow Diversion for Middle Cerebral Artery Aneurysms: An International Cohort Study. Neurosurgery 2022; 90:e176-e177. [PMID: 35315799 DOI: 10.1227/neu.0000000000001933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 12/14/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Kevin A Shah
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
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26
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De Leacy R, Bageac DV, Siddiqui N, Bellon RJ, Park MS, Schirmer CM, Woodward KB, Zaidat OO, Spiotta AM. Safety and Long-Term Efficacy Outcomes for Endovascular Treatment of Wide-Neck Bifurcation Aneurysms of the Middle Cerebral Artery: Insights From the SMART Registry. Front Neurol 2022; 13:830296. [PMID: 35197925 PMCID: PMC8860028 DOI: 10.3389/fneur.2022.830296] [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: 12/06/2021] [Accepted: 01/06/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Wide-necked middle cerebral artery bifurcation aneurysms pose specific challenges to endovascular management. Surgical clipping remains the standard treatment approach for these aneurysms in many centers. While recent data suggests the endovascular treatment may be comparable, a prospective datapoint has been lacking. Materials and Methods The Penumbra SMART registry, a prospective, multi-center, single-arm outcomes registry of Penumbra coil-treated aneurysms, was queried for endovascularly treated MCA bifurcation aneurysms with wide necks (dome:neck ratio <2 or neck >4 mm). Safety and efficacy outcomes were summarized for ruptured and unruptured aneurysms, including rupture, complication rate, and 1-year occlusion outcomes. Results Seventy-two aneurysms across 31 sites were enrolled. Of these, a total of 15 presented as ruptured aneurysms. Serious adverse events were reported in 21 (29.2%) of patients, with 8 (11.1%) attributed to the device/procedure. Immediately postoperatively, 75.0% of cases achieved “adequate” Raymond Roy Class I (40.3%) or II (34.7%) occlusion outcomes. Of the 72 patients treated, 60 (83.3%) underwent follow-up angiography at 1 year, and among these, 95.0% had 1-year occlusion outcomes of Raymond Roy Class I (71.7%) or II (23.3%). A total of 6 aneurysms (10.0%) were required or were planned for retreatment at the last follow-up. Conclusion This study represents the most significant prospective sample of endovascularly treated wide-neck MCA bifurcation aneurysms conducted to date. It supports the safety and efficacy of endovascular treatment of these aneurysms.
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Affiliation(s)
- Reade De Leacy
- Department of Neurosurgery, Mount Sinai Hospital, New York, NY, United States
| | - Devin V Bageac
- Department of Neurosurgery, Mount Sinai Hospital, New York, NY, United States
| | - Neha Siddiqui
- Department of Neurosurgery, Mount Sinai Hospital, New York, NY, United States
| | | | - Min S Park
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, United States
| | - Clemens M Schirmer
- Department of Neurosurgery and Neuroscience Institute, Geisinger Health System, Wilkes-Barre, PA, United States.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | | | | | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, United States
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27
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Nussbaum ES, Touchette JC, Madison MT, Goddard JK, Lassig JP, Meyers ME, Torok CM, Carroll JJ, Lowary J, Janjua T, Nussbaum LA. Procedural complications in patients undergoing microsurgical treatment of unruptured intracranial aneurysms: a single-center experience with 1923 aneurysms. Acta Neurochir (Wien) 2022; 164:525-535. [PMID: 34562151 DOI: 10.1007/s00701-021-04996-9] [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: 01/27/2021] [Accepted: 08/27/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND With the growing use of endovascular therapy (EVT) to manage unruptured intracranial aneurysms (IAs), detailed information regarding periprocedural complication rates of microsurgical clipping and EVT becomes increasingly important in determining the optimal treatment for individual cases. We report the complication rates associated with open microsurgery in a large series of unruptured IAs and highlight the importance of maintaining surgical skill in the EVT era. METHODS We reviewed all cases of unruptured IAs treated with open microsurgery by a single neurosurgeon between July 1997 and June 2019. We analyzed surgical complications, deaths, and patient-reported outcomes. RESULTS A total of 1923 unruptured IAs in 1750 patients (mean age 44 [range: 6-84], 62.0% [1085/1750] female) were treated surgically during the study period. Of the aneurysms treated, 84.9% (1632/1923) were small, 11.1% (213/1923) were large, and 4.1% (78/1923) were giant. Aneurysm locations included the middle cerebral artery (44.2% [850/1923]), internal carotid artery (29.1% [560/1923]), anterior cerebral artery (21.0% [404/1923]), and vertebrobasilar system (5.7% [109/1923]). The overall mortality rate was 0.3% (5/1750). Surgical complications occurred in 7.4% (129/1750) of patients, but only 0.4% (7/1750) experienced permanent disability. The majority of patients were able to return to their preoperative lifestyles with no modifications (95.9% [1678/1750]). CONCLUSIONS At a high-volume, multidisciplinary center, open microsurgery in carefully selected patients with unruptured IAs yields favorable clinical outcomes with low complication rates. The improvement of EVT techniques and the ability to refer cases for EVT when a high complication rate with open microsurgery was expected have contributed to an overall decrease in surgical complication rates. These results may serve as a useful point of reference for physicians involved in treatment decision-making for patients with unruptured IAs.
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28
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Pipeline embolization of MCA aneurysms in the M2-M4 segment: Dual center study and meta-analysis. Clin Neurol Neurosurg 2021; 212:107063. [PMID: 34864490 DOI: 10.1016/j.clineuro.2021.107063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/15/2021] [Accepted: 11/21/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Flow diversion of distal MCA aneurysms in the M2-M4 segments with Pipeline embolization device is promising, but further study is needed. Here, we seek to quantify the safety and efficacy of Pipeline embolization in the M2-M4 region in a dual-center cohort and comprehensive meta-analysis. METHODS Clinical and angiographic data of eligible patients was obtained from participating centers. A systematic review was performed with searches of Pubmed, Scopus, Embase, and the Cochrane Library for articles from inception to May 2021. 86 studies were identified in systematic review. Of these, 7 studies with 46 aneurysms met the inclusion criteria and were aggregated with 8 aneurysms from our dual-center cohort for analysis. RESULTS In our dual-center cohort, complete occlusion was observed in 88% (7/8) of aneurysms, and no patients experienced hemorrhagic or thromboembolic complications. Clinical outcomes were reported for 100% (54/54) of aneurysms included in meta-analysis and angiographic follow-up was available for 91% (49/54). The overall rate of complete aneurysm occlusion was 80% (95% CI, 69-91%), and the overall rate of clinical complication was 9% (95% CI, 2-16%). CONCLUSION Pipeline embolization of cerebral aneurysms of the M2-M4 segments of the MCA was reasonably effective and safe in a small group of selected patients, but further study is needed to validate these preliminary results.
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29
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Elian MMM, Issa ASI, Ibrahim MA, Khalil OAEW, Youssef FH. Endovascular management of middle cerebral artery aneurysms (single-center case series study). THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2021. [DOI: 10.1186/s43055-021-00536-8] [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
Middle cerebral artery (MCA) aneurysms were usually subjected to treatment by surgery, while endovascular treatment (EVT) was performed only in chosen patients. We assessed the efficacy, safety, and durability in addition to the clinical outcome of EVT when it is regarded as the first-line treatment modality for MCA aneurysms.
Results
We recruited 30 patients with MCA aneurysms who underwent definitive management from July 2017 to July 2018. All those patients were treated endovascularly; 22 patients (73.3%) presented with subarachnoid hemorrhage, and 8 patients (26.7%) had different presentations, including isolated headaches and seizures. EVT was performed for all patients and required the use of a balloon, stent, or double catheter techniques in 13 cases and flow diverter stents alone in two cases. Clinical outcome was assessed by the modified Rankin Scale (mRS) at 3 months. Angiographic follow-up was done by a conventional angiography at 6 months and after 1 year. EVT was efficiently conducted, leading to an outstanding accomplishment (mRS = 1–2) in 29 patients. However, one patient had a thromboembolic complication, followed by death after severe chest infection that was not related to the procedure. Immediate anatomical results included complete aneurysmal occlusion with the establishment of normal cerebral circulation. Angiographic follow-up revealed 24 unchanged occlusions and 5 cases with recanalization that required further treatment.
Conclusion
EVT of MCA aneurysms is a viable treatment option with positive outcomes in most cases. Nevertheless, the employment of long-term imaging follow-up is compulsory for validating such early results, often with respect to anatomical and functional stability.
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30
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Diestro JDB, Adeeb N, Dibas M, Boisseau W, Harker P, Brinjikji W, Xiang S, Joyce E, Shapiro M, Raz E, Parra-Farinas C, Pickett G, Alotaibi NM, Regenhardt RW, Bernstock JD, Spears J, Griessenauer CJ, Burkhardt JK, Hafeez MU, Kan P, Grandhi R, Taussky P, Nossek E, Hong T, Zhang H, Rinaldo L, Lanzino G, Stapleton CJ, Rabinov JD, Patel AB, Marotta TR, Roy D, Dmytriw AA. Flow Diversion for Middle Cerebral Artery Aneurysms: An International Cohort Study. Neurosurgery 2021; 89:1112-1121. [PMID: 34624100 DOI: 10.1093/neuros/nyab365] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 08/06/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Open surgery has traditionally been preferred for the management of bifurcation middle cerebral artery (MCA) aneurysms. Flow diverting stents present a novel endovascular strategy for aneurysm treatment. OBJECTIVE To add to the limited literature describing the outcomes and complications in the use of flow diverters for the treatment of these complex aneurysms. METHODS This is a multicenter retrospective review of MCA bifurcation aneurysms undergoing flow diversion. We assessed post-treatment radiological outcomes and both thromboembolic and hemorrhagic complications. RESULTS We reviewed the outcomes of 54 aneurysms treated with flow diversion. Four (7.4%) of the aneurysms had a history of rupture (3 remote and 1 acute). Fourteen (25.9%) of the aneurysms already underwent either open surgery or coiling prior to flow diversion. A total of 36 out of the 45 aneurysms (80%) with available follow-up data had adequate aneurysm occlusion with a median follow-up time of 12 mo. There were no hemorrhagic complications but 16.7% (9/54) had thromboembolic complications. CONCLUSION Flow diverting stents may be a viable option for the endovascular treatment of complex bifurcation MCA aneurysms. However, compared to published series on the open surgical treatment of this subset of aneurysms, flow diversion has inferior outcomes and are associated with a higher rate of complications.
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Affiliation(s)
- Jose Danilo Bengzon Diestro
- Division of Diagnostic & Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital (Unity Health), University of Toronto, Toronto, Ontario, Canada.,Département de Radiologie, Radio-oncologie et Médecine Nucléaire, Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Nimer Adeeb
- Departments of Neurosurgery & Interventional Neuroradiology, LSU Shreveport School of Medicine, Shreveport, Louisiana, USA
| | - Mahmoud Dibas
- Departments of Neurosurgery & Interventional Neuroradiology, LSU Shreveport School of Medicine, Shreveport, Louisiana, USA
| | - William Boisseau
- Département de Radiologie, Radio-oncologie et Médecine Nucléaire, Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Pablo Harker
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Waleed Brinjikji
- Departments of Radiology & Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sishi Xiang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Evan Joyce
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Maksim Shapiro
- Departments of Radiology and Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Eytan Raz
- Departments of Radiology and Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Carmen Parra-Farinas
- Division of Diagnostic & Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital (Unity Health), University of Toronto, Toronto, Ontario, Canada
| | - Gwynedd Pickett
- Department of Neurosurgery, Queen Elizabeth II Health Science Centre, Dalhousie Medical School, Halifax, Nova Scotia, Canada
| | - Naif M Alotaibi
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Robert W Regenhardt
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua D Bernstock
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Julian Spears
- Division of Diagnostic & Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital (Unity Health), University of Toronto, Toronto, Ontario, Canada
| | - Christoph J Griessenauer
- Department of Neurosurgery, Geisinger, Danville, Pennsylvania, USA.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria.,Department of Neurosurgery, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Muhammad U Hafeez
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Houston, Texas, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Philipp Taussky
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Erez Nossek
- Departments of Radiology and Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Tao Hong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Lorenzo Rinaldo
- Departments of Radiology & Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Giuseppe Lanzino
- Departments of Radiology & Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Christopher J Stapleton
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - James D Rabinov
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aman B Patel
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas R Marotta
- Division of Diagnostic & Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital (Unity Health), University of Toronto, Toronto, Ontario, Canada
| | - Daniel Roy
- Département de Radiologie, Radio-oncologie et Médecine Nucléaire, Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Adam A Dmytriw
- Division of Diagnostic & Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital (Unity Health), University of Toronto, Toronto, Ontario, Canada.,Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Giant Middle Cerebral Artery Aneurysms: A 55-Patient Series. World Neurosurg 2021; 155:e727-e737. [PMID: 34492390 DOI: 10.1016/j.wneu.2021.08.128] [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: 07/07/2021] [Revised: 08/26/2021] [Accepted: 08/27/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND The treatment of middle cerebral artery (MCA) giant aneurysms (GAs) represents a challenging task. METHODS The data for 55 patients treated for MCA GA (≥25 mm) at the N.N. Burdenko NMRCN between 2010 and 2019 were analyZed. RESULTS The GAs were located in the M1 segment in 11 (20%) patients, MCA bifurcation in 33 (60%), M2 in 7 (12.7%), and M3 in 4 (7.3%). There were 32 (58.2%) saccular and 23 (41.8%) fusiform GAs. MCA GAs were treated with neck clipping (50.9%), clipping with the artery lumen formation (3.6%), bypass surgeries (34.5%), wrapping (3.6%), and endovascular surgery (7.3%). A worsening of the neurologic state in the perioperative period was observed in 50.9% of patients. The complete closure of GA was achieved in 78.2%. Surgery-related mortality was 1.8%. The long-term outcome was favorable in 76.9% of patients. Surgery-related and disease-related plus treatment failures-related mortality was 9.6%. CONCLUSIONS Microsurgical clipping and bypass surgery are the main operative interventions for MCA GA treatment. These operations are technically complex and are followed by a relatively high percentage of complications. The main tasks that require further investigations are the introduction of new precise diagnostic methods for the collateral circulation assessment in the cortical MCA branches, the perfection of the algorithm for the bypass selection, and investigation of the long-term results of the endovascular and combined treatments. It is of major importance to thoroughly observe the patients long-term after the surgery and ensure the possibility for further angiographic studies.
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32
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Moufarrij N. Stroke due to middle cerebral artery aneurysm clipping when the intraoperative angiogram was normal. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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33
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Raper DMS, Abla AA. Letter: Safety, Efficacy, and Durability of Stent Plus Balloon-Assisted Coiling for the Treatment of Wide-Necked Intracranial Bifurcation Aneurysms. Neurosurgery 2021; 89:E272-E273. [PMID: 34332509 DOI: 10.1093/neuros/nyab285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 06/27/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Daniel M S Raper
- Department of Neurosurgery Baylor College of Medicine Houston, Texas, USA
| | - Adib A Abla
- Department of Neurological Surgery University of California, San Francisco San Francisco, California, USA
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Lu X, Huang Y, Zhou P, Zhu W, Wang Z, Chen G. Cerebral revascularization for the management of complex middle cerebral artery aneurysm: A case series. Exp Ther Med 2021; 22:883. [PMID: 34194561 PMCID: PMC8237261 DOI: 10.3892/etm.2021.10315] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 05/12/2021] [Indexed: 11/06/2022] Open
Abstract
Complex middle cerebral artery (MCA) aneurysms, including aneurysms that are sizeable (large or giant), fusiform, wide-necked or calcified, remain a significant challenge during microsurgical clipping or endovascular coiling as treatment strategies. In the present study, a retrospective analysis of cases of this type of aneurysm treated between August 2012 and December 2019 was performed. From the hospital's database, a total of 13 patients (7 males and 6 females) with a mean age of 39.0 years (range, 13-65 years) were identified. The mean size of the aneurysms was 17.5 mm (range, 3.9-35.0 mm). A total of four patients (30.8%) had ruptured aneurysms and nine (69.2%) had unruptured aneurysms. All aneurysms were treated by proximal occlusion of the parent artery, trapping or excision combined with cerebral revascularization. The bypasses performed included 10 extracranial-intracranial bypasses and 3 intracranial-intracranial bypasses (1 end-to-end re-anastomosis, 1 interpositional graft and 1 end-to-side reimplantation). Postoperative angiography confirmed that the bypass patency was 92.3% and the clinical outcomes were indicated to be favorable, with a modified Rankin Scale score ≤2 in 12 out of 13 patients (92.3%) at the last follow-up. Taken together, the results of the present analysis suggested that treatment strategies for complex MCA aneurysms should depend on the status and characteristics of the aneurysm, including aneurysm size, location and morphology. For aneurysms that lack perforating arteries in the aneurysm dome, clip trapping or aneurysm excision with or without bypass are preferred as treatment strategies. When there are perforating arteries (particularly the lenticulostriate artery) arising from the aneurysm dome, however, the aneurysms should be treated with bypass followed by proximal occlusion of the parent artery or clip reconstruction.
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Affiliation(s)
- Xiaocheng Lu
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Yabo Huang
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Peng Zhou
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Weiwei Zhu
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Zhong Wang
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Gang Chen
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
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Abouelleil M, Lyons L, Restrepo A, Singer J. Commentary: Neuroform Atlas Stent for Treatment of Middle Cerebral Artery Aneurysms: 1-Year Outcomes From Neuroform Atlas Stent Pivotal Trial. Neurosurgery 2021; 89:E160-E161. [PMID: 34089320 DOI: 10.1093/neuros/nyab190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 04/22/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Mohamed Abouelleil
- Department of Neurosurgery, Spectrum Health Medical Center/Michigan State University, Grand Rapids, Michigan, USA
| | - Leah Lyons
- Department of Neurosurgery, Spectrum Health Medical Center/Michigan State University, Grand Rapids, Michigan, USA
| | - Andres Restrepo
- Department of Neurosurgery, Spectrum Health Medical Center/Michigan State University, Grand Rapids, Michigan, USA
| | - Justin Singer
- Department of Neurosurgery, Spectrum Health Medical Center/Michigan State University, Grand Rapids, Michigan, USA
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Goertz L, Liebig T, Siebert E, Pennig L, Laukamp KR, Celik E, Timmer M, Brinker G, Schlamann M, Goldbrunner R, Dorn F, Krischek B, Kabbasch C. Woven Endobridge Embolization Versus Microsurgical Clipping for Unruptured Anterior Circulation Aneurysms: A Propensity Score Analysis. Neurosurgery 2021; 88:779-784. [PMID: 33372215 DOI: 10.1093/neuros/nyaa539] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/26/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Intrasaccular flow-disruption represents a new paradigm in endovascular treatment of wide-necked bifurcation aneurysms. OBJECTIVE To retrospectively compare Woven Endobridge (WEB) embolization with microsurgical clipping for unruptured anterior circulation aneurysms using propensity score adjustment. METHODS A total of 63 patients treated with WEB and 103 patients treated with clipping were compared based on the intention-to-treat principle. The primary outcome measures were immediate technical treatment success, major adverse events, and 6-mo complete aneurysm occlusion. RESULTS The technical success rates were 83% for WEB and 100% for clipping. Procedure-related complications occurred more often in the clipping group (13%) than the WEB group (6%, adjusted P < .01). However, the rates of major adverse events were comparable in both groups (WEB: 3%, clip: 4%, adjusted P = .53). At the 6-mo follow-up, favorable functional outcomes were achieved in 98% of the WEB embolization group and 99% of the clipping group (adjusted P = .19). Six-month complete aneurysm occlusion was obtained in 75% of the WEB group and 94% of the clipping group (adjusted P < .01). CONCLUSION Microsurgical clipping was associated with higher technical success and complete occlusion rates, whereas WEB had a lower complication rate. Favorable functional outcomes were achieved in ≥98% of both groups. The decision to use a specific treatment modality should be made on an individual basis and in accordance with the patient's preferences.
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Affiliation(s)
- Lukas Goertz
- Department of Radiology and Neuroradiology, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany.,Center for Neurosurgery, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Thomas Liebig
- Department of Neuroradiology, University Hospital Munich (LMU), Munich, Germany
| | - Eberhard Siebert
- Department of Neuroradiology, University Hospital of Berlin (Charité), Berlin, Germany
| | - Lenhard Pennig
- Department of Radiology and Neuroradiology, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Kai Roman Laukamp
- Department of Radiology and Neuroradiology, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Erkan Celik
- Department of Radiology and Neuroradiology, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Marco Timmer
- Center for Neurosurgery, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Gerrit Brinker
- Center for Neurosurgery, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Marc Schlamann
- Department of Radiology and Neuroradiology, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Roland Goldbrunner
- Center for Neurosurgery, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Franziska Dorn
- Department of Neuroradiology, University Hospital Munich (LMU), Munich, Germany
| | - Boris Krischek
- Center for Neurosurgery, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany.,Department of Neurosurgery, Hôpitaux Robert Schuman, Luxembourg, Luxembourg
| | - Christoph Kabbasch
- Department of Radiology and Neuroradiology, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
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Winkler EA, Lee A, Yue JK, Raygor KP, Rutledge WC, Rubio RR, Josephson SA, Berger MS, Raper DMS, Abla AA. Endovascular embolization versus surgical clipping in a single surgeon series of basilar artery aneurysms: a complementary approach in the endovascular era. Acta Neurochir (Wien) 2021; 163:1527-1540. [PMID: 33694012 PMCID: PMC8053658 DOI: 10.1007/s00701-021-04803-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 03/03/2021] [Indexed: 11/28/2022]
Abstract
Background Currently, most basilar artery aneurysms (BAAs) are treated endovascularly. Surgery remains an appropriate therapy for a subset of all intracranial aneurysms. Whether open microsurgery would be required or utilized, and to what extent, for BAAs treated by a surgeon who performs both endovascular and open procedures has not been reported. Methods Retrospective analysis of prospectively maintained, single-surgeon series of BAAs treated with endovascular or open surgery from the first 5 years of practice. Results Forty-two procedures were performed in 34 patients to treat BAAs—including aneurysms arising from basilar artery apex, trunk, and perforators. Unruptured BAAs accounted for 35/42 cases (83.3%), and the mean aneurysm diameter was 8.4 ± 5.4 mm. Endovascular coiling—including stent-assisted coiling—accounted for 26/42 (61.9%) treatments and led to complete obliteration in 76.9% of cases. Four patients in the endovascular cohort required re-treatment. Surgical clip reconstruction accounted for 16/42 (38.1%) treatments and led to complete obliteration in 88.5% of cases. Good neurologic outcome (mRS ≤ 2) was achieved in 88.5% and 75.0% of patients in endovascular and open surgical cohorts, respectively (p = 0.40). Univariate logistic regression analysis demonstrated that advanced age (OR 1.11[95% CI 1.01–1.23]) or peri-procedural adverse event (OR 85.0 [95% CI 6.5–118.9]), but not treatment modality (OR 0.39[95% CI 0.08–2.04]), was the predictor of poor neurologic outcome. Conclusions Complementary implementation of both endovascular and open surgery facilitates individualized treatment planning of BAAs. By leveraging strengths of both techniques, equivalent clinical outcomes and technical proficiency may be achieved with both modalities.
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Affiliation(s)
- Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Anthony Lee
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - John K Yue
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Kunal P Raygor
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - W Caleb Rutledge
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Roberto R Rubio
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - S Andrew Josephson
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Mitchel S Berger
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Daniel M S Raper
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.
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Dellaretti M, do Nascimento LM, de Oliveira Lima AD, de Almeida JC, Quadros RS. Efficacy and safety of surgical treatment for middle cerebral artery aneurysms: A retrospective case series. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.101018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Pflaeging M, Kabbasch C, Schlamann M, Pennig L, Juenger ST, Grunz JP, Timmer M, Brinker G, Goldbrunner R, Krischek B, Goertz L. Microsurgical Clipping versus Advanced Endovascular Treatment of Unruptured Middle Cerebral Artery Bifurcation Aneurysms After a "Coil-First" Policy. World Neurosurg 2021; 149:e336-e344. [PMID: 33607288 DOI: 10.1016/j.wneu.2021.02.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Although intracranial aneurysms are increasingly treated endovascularly, microsurgical clipping has been the standard approach for middle cerebral artery (MCA) aneurysms. We compared microsurgical clipping and state-of-the-art endovascular treatment of unruptured MCA bifurcation aneurysms treated at a neurovascular center following a "coil-first" policy. METHODS This single-center study included 148 patients treated for 160 unruptured MCA bifurcation aneurysms. Technical success, complications, clinical outcome, and angiographic results were retrospectively compared. RESULTS Microsurgical clipping was performed for 120 MCA aneurysms (75%) and endovascular treatment for 40 (25%; conventional coiling: 8, stent-assisted coiling: 16, balloon-assisted coiling: 3, and flow-disruption: 13). Technical treatment success was higher in the clipping group (100%) than in the endovascular group (92.5%, P = 0.015). Overall, complications occurred in 16.7% for clipping and in 20.0% for endovascular treatment (P = 0.631). Major ischemic stroke rates were 4.2% in the clipping group and 7.5% in the endovascular group (P = 0.414). At 6 months, a favorable outcome was obtained by 99.2% after clipping and 95.0% after endovascular treatment (P = 0.154). The 6-month complete aneurysm occlusion rates were by trend higher in the clipping group (89.2%) than in the endovascular group (75.9%, P = 0.078). CONCLUSIONS Microsurgical clipping was associated with a higher technical success rate and tendentially higher complete occlusion than endovascular treatment, with no additional morbidity and similar clinical outcome. On the basis of these results, clipping proves to be the standard treatment option for MCA bifurcation aneurysms. However, endovascular treatment represents a safe and efficient alternative treatment option for patients.
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Affiliation(s)
- Muriel Pflaeging
- Center for Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Christoph Kabbasch
- Department of Neuroradiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Marc Schlamann
- Department of Neuroradiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Lenhard Pennig
- Department of Neuroradiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Stephanie Theresa Juenger
- Center for Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Jan-Peter Grunz
- Institute for Diagnostic and Interventional Radiology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Marco Timmer
- Center for Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Gerrit Brinker
- Center for Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Roland Goldbrunner
- Center for Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Boris Krischek
- Center for Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Department of Neurosurgery, Hôpitaux Robert Schuman, Luxembourg, Luxembourg
| | - Lukas Goertz
- Center for Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Department of Neuroradiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.
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Clinical features of ischemic complications after unruptured middle cerebral artery aneurysm clipping: patients and radiologically related factors. Neurosurg Rev 2021; 44:2819-2829. [PMID: 33462782 DOI: 10.1007/s10143-021-01475-8] [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: 10/11/2020] [Revised: 12/17/2020] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
Postoperative ischemic complication results in neurological sequelae and longer hospitalization after unruptured middle cerebral artery (MCA) aneurysm clipping surgery. We evaluated the radiological and patient-related factors associated with ischemic complications after unruptured MCA aneurysm clipping surgery. Patient demographics, radiological findings, and intraoperative factors were compared between patients with and without postoperative ischemic complications. The clinical courses and outcomes of postoperative ischemic complications were compared according to the types of ischemic complication. Forty-two out of 2227 patients (1.9%) developed postoperative ischemic complications after MCA aneurysm clipping. Multivariate analysis revealed that diabetes mellitus (DM) was a patient-related factor. Intraarterial (IA) calcification of the distal internal carotid artery (ICA), preoperative M1 stenosis, and M1 aneurysm were radiological factors that increased the risk of postoperative ischemic complications. DM was significantly associated with divisional branch territory infarction (P = 0.04). The time to first presentation of ischemic complication was significantly longer in divisional branch territory infarction than perforator territory infarction (67.8 ± 75.9 h vs. 22 ± 20.7, P = 0.023). Twelve out of 42 patients with ischemic complications (28.6%) had unfavorable outcome (mRS > 3). Perforator territory infarction was significantly associated with an unfavorable outcome (mRS > 3, P = 0.019). IA calcification of the distal ICA, M1 stenosis and aneurysms, and DM were significantly associated with postoperative ischemic complications after unruptured MCA aneurysm clipping. Patients with DM should be closely monitored postoperatively to detect delayed occurrence of divisional branch infarction. Trial registration number: 2019-1002, Date of registration: January 1, 2005, "retrospectively registered".
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Endovascular Treatment of Ruptured Middle Cerebral Artery Bifurcation Aneurysms. A Retrospective Observational Study of Short- and Long-Term Follow-Up. Cardiovasc Intervent Radiol 2021; 44:587-595. [PMID: 33392679 DOI: 10.1007/s00270-020-02718-9] [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: 05/01/2020] [Accepted: 11/18/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE With the introduction of new devices and the development of approved devices, endovascular techniques are more and more considered as a treatment option for middle cerebral artery aneurysms (MCA). In this study, we present data on ruptured MCA aneurysms that were treated endovascularly in our hospital. MATERIAL AND METHODS In a retrospective case series of ruptured MCA bifurcation aneurysms, 118 (94%) cases were managed endovascularly between May 2008 and July 2017. Most were managed with coiling (= 62) and the remaining were managed with stent-assisted-coiling (= 35) and endovascular flow disruptor (WEB-device) (= 21). We measured the clinical outcome at the time of discharge and long-term follow-up on the modified Rankin Scale (mRS) and evaluated the rates of periprocedural complications and retreatment. RESULTS A good clinical outcome (mRS 0-2) at discharge was achieved in 58.5% of these cases. Mortality rate was 19.5%. Nine aneurysms required retreatment. Eighty-three percent demonstrated a good clinical outcome at long-term follow-up (mRS 0-2). In total, 6 (5.1%) procedure-related complications and 10 (8.5%) disease-related complications occurred. No significant difference between reintervention, complications or outcome was found between the employment of different devices (P > 0.05). Endovascular treatment of ruptured MCA aneurysms at our practice showed similar morbidity and mortality to data published about surgical clipping. CONCLUSION The endovascular device evolution permits a feasible and safe treatment of ruptured MCA bifurcation aneurysms. Endovascular treatment can therefore be considered as an alternative treatment option to microsurgery for this type of aneurysm.
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Kijima N, Miura S, Terada E, Nakagawa R, Tachi T, Murakami K, Okita Y, Kanemura Y, Nakajima S, Fujinaka T. Endovascular Treatment for Middle Cerebral Artery Aneurysms: Single-Center Experience and Review of Literatures. JOURNAL OF NEUROENDOVASCULAR THERAPY 2020; 15:213-219. [PMID: 37501692 PMCID: PMC10370921 DOI: 10.5797/jnet.oa.2019-0051] [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: 06/27/2019] [Accepted: 08/12/2020] [Indexed: 07/29/2023]
Abstract
Objective The efficacy of endovascular treatment for middle cerebral artery (MCA) aneurysms remains controversial. However, recent studies have reported the safety of endovascular treatment for MCA aneurysms. In this study, we studied the efficacy and clinical outcomes of endovascular treatment for MCA aneurysms in our hospital and the morphology and anatomy of MCA aneurysms that were suitable for endovascular treatment. Methods We retrospectively analyzed 26 cases of MCA aneurysms which had undergone endovascular treatment at our institution between January 2015 and October 2018. We studied sizes and shapes of the aneurysms, clinical and angiographical outcomes one year after the treatment, and complications in these 26 patients. We also compared the differences in these parameters of the 26 patients with those of 61 other patients who were treated with clipping during the same period. Results The median aneurysm size was 6.1 mm (1.8-29.9 mm), with the shapes of the aneurysms irregular in 8, and round in the other 18 cases. Four cases (15.4%) had ruptured aneurysms. All aneurysms were treated with assist techniques; 8 (30.8%) were treated by stent-assisted technique and 18 (69.2%) were treated by balloon-assisted technique and endovascular treatment was successfully performed in all (100%) cases. While the aneurysms were completely obliterated in 22 of them (84.6%), the remaining 4 cases (15.4%) had neck remnants. We observed periprocedural complications in 5 of the 26 (19.2%) aneurysms, all of which were transient and completely recovered during the follow-up period. The efficacy and complication rates were not different from the MCA aneurysms treated with clipping. All MCA aneurysms arising from the M1 trunk were treated with endovascular treatment, and those with a round shape with the axis not deviating from M1 were also treated with endovascular treatment. Conclusion Endovascular treatment for MCA aneurysms is safe and effective together with adjunctive techniques such as balloon-assisted technique or stent-assisted technique. Thus, M1 trunk aneurysms and MCA bifurcation aneurysms with a round shape along the same axis of MCA may be good indications for endovascular treatment. However, long-term clinical and angiographical outcomes remain unknown. Thus, further studies are needed to address the existing limitations.
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Affiliation(s)
- Noriyuki Kijima
- Department of Neurosurgery, Osaka National Hospital, National Hospital Organization, Osaka, Osaka, Japan
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Shimpei Miura
- Department of Neurosurgery, Osaka National Hospital, National Hospital Organization, Osaka, Osaka, Japan
| | - Eisaku Terada
- Department of Neurosurgery, Osaka National Hospital, National Hospital Organization, Osaka, Osaka, Japan
| | - Ryota Nakagawa
- Department of Neurosurgery, Osaka National Hospital, National Hospital Organization, Osaka, Osaka, Japan
| | - Tetsuro Tachi
- Department of Neurosurgery, Osaka National Hospital, National Hospital Organization, Osaka, Osaka, Japan
| | - Koki Murakami
- Department of Neurosurgery, Osaka National Hospital, National Hospital Organization, Osaka, Osaka, Japan
| | - Yoshiko Okita
- Department of Neurosurgery, Osaka National Hospital, National Hospital Organization, Osaka, Osaka, Japan
| | - Yonehiro Kanemura
- Department of Neurosurgery, Osaka National Hospital, National Hospital Organization, Osaka, Osaka, Japan
- Department of Biomedical Research and Innovation, Institute for Clinical Research, National Hospital Organization Osaka National Hospital, Osaka, Osaka, Japan
| | - Shin Nakajima
- Department of Neurosurgery, Osaka National Hospital, National Hospital Organization, Osaka, Osaka, Japan
| | - Toshiyuki Fujinaka
- Department of Neurosurgery, Osaka National Hospital, National Hospital Organization, Osaka, Osaka, Japan
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Koo AB, Elsamadicy AA, Lin IH, David WB, Sujijantarat N, Santarosa C, Cord BJ, Zetchi A, Hebert R, Bahrassa F, Malhotra A, Matouk CC. Predictors of Extended Length of Stay Following Treatment of Unruptured Adult Cerebral Aneurysms: A Study of The National Inpatient Sample. J Stroke Cerebrovasc Dis 2020; 29:105230. [PMID: 33066916 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105230] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/26/2020] [Accepted: 07/30/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND In an unprecedented era of soaring healthcare costs, payers and providers alike have started to place increased importance on measuring the quality of surgical procedures as a surrogate for operative success. One metric used is the length of hospital stay (LOS) during index admission. For the treatment of unruptured cerebral aneurysms, the determinants of extended length of stay are relatively unknown. The aim of this study was to identify the patient- and hospital-level factors associated with extended LOS following treatment for unruptured cerebral aneurysms. METHODS The National Inpatient Sample years 2010 - 2014 was queried. Adults (≥18 years) with unruptured aneurysms undergoing either clipping or coiling were selected using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Extended LOS was defined as greater than 75th percentile for the entire cohort (>5 days). Weighted patient demographics, comorbidities, complications, LOS, disposition and total cost were recorded. Multivariate logistic regression was used to determine the odds ratio for risk-adjusted extended LOS. The primary outcome was the degree which patient comorbidities or postoperative complications correlated with extended LOS. RESULTS A total of 46,880 patients were identified for which 9,774 (20.8%) patients had extended LOS (Normal LOS: 37,106; Extended LOS: 9,774). Patients in the extended LOS cohort presented with a greater number of comorbidities compared to the normal LOS cohort. A greater proportion of the normal LOS cohort was coiled (Normal LOS: 63.0% vs. Extended LOS: 33.5%, P<0.001), while more patients in the extended LOS cohort were clipped (Normal LOS: 37.0% vs. Extended LOS: 66.5%, P<0.001). The overall complication rate was higher in the extended LOS cohort (Normal LOS: 7.3% vs. Extended LOS: 43.8%, P<0.001). On average, the extended LOS cohort incurred a total cost nearly twice as large (Normal LOS: $26,050 ± 13,430 vs. Extended LOS: $52,195 ± 37,252, P<0.001) and had more patients encounter non-routine discharges (Normal LOS: 8.5% vs. Extended LOS: 52.5%, P<0.001) compared to the normal LOS cohort. On weighted multivariate logistic regression, multiple patient-specific factors were associated with extended LOS. These included demographics, preadmission comorbidities, choice of procedure, and inpatient complications. The odds ratio for extended LOS was 5.14 (95% CI, 4.30 - 6.14) for patients with 1 complication and 19.58 (95% CI, 15.75 - 24.34) for patients with > 1 complication. CONCLUSIONS Our study demonstrates that extended LOS after treatment of unruptured aneurysms is influenced by a number of patient-level factors including demographics, preadmission comorbidities, type of aneurysm treatment (open surgical versus endovascular), and, importantly, inpatient complications. A better understanding of these independent predictors of prolonged length of hospital stay may help to improve patient outcomes and decrease overall healthcare costs.
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Affiliation(s)
- Andrew B Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | | | - I-Hsin Lin
- Yale Center for Analytical Sciences, New Haven, CT
| | - Wyatt B David
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | | | - Corrado Santarosa
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Branden J Cord
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Akli Zetchi
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Ryan Hebert
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Farhad Bahrassa
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Ajay Malhotra
- Department of Radiology & Biomedical Imaging, Yale University School of Medicine, New Haven, CT
| | - Charles C Matouk
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT; Department of Radiology & Biomedical Imaging, Yale University School of Medicine, New Haven, CT.
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Eichberg DG, Komotar RJ, Ivan ME. Commentary: Left Modified Orbitozygomatic Approach for Clipping of Multilobulated Middle Cerebral Artery Bifurcation Aneurysm: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2020; 19:E387-E388. [PMID: 32678902 DOI: 10.1093/ons/opaa197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 04/29/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- Daniel G Eichberg
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Ricardo J Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida.,Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Michael E Ivan
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida.,Sylvester Comprehensive Cancer Center, Miami, Florida
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Toyota S, Takenaka T, Shimizu T, Murakami T, Mori K, Taki T. Sphenoid Ridge Keyhole Approach Using the Lone Star Retractor System in Clipping of Unruptured Middle Cerebral Artery Aneurysms: Technical Note. World Neurosurg 2020; 140:283-287. [DOI: 10.1016/j.wneu.2020.05.149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/15/2020] [Accepted: 05/16/2020] [Indexed: 10/24/2022]
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Liang F, Yang Y, Luo L, Liao B, Zhang G, Ou S, Xiao W, Guo N, Qi T. Endovascular treatment of complex middle cerebral artery aneurysms using TuBridge flow diverters. Interv Neuroradiol 2020; 26:539-546. [PMID: 32722987 DOI: 10.1177/1591019920946216] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The safety and efficacy of the TuBridge flow diverter in treating middle cerebral artery aneurysms remains unknown. In this study, we report our preliminary experience treating complex middle cerebral artery aneurysms using the TuBridge flow diverter. METHODS A prospectively maintained database of intracranial aneurysms treated with the TuBridge flow diverter was retrospectively reviewed, and patients with middle cerebral artery aneurysms were included in this study. Demographics, aneurysm features, complications, and clinical and angiographic outcomes were assessed. Evaluation of the angiographic results included occlusion grade of aneurysm (O'Kelly-Marotta grading scale), patency of jailed branch(es), and in-stent stenosis. RESULTS Eight patients with eight middle cerebral artery aneurysms were included in this study. The mean aneurysm size was 11.8 ± 6.8 mm. There were no procedure-related complications and there was no morbidity or mortality at a mean follow-up of 11.3 ± 3.6 months. All patients had follow-up angiograms at a mean of 7.5 ± 4.0 months after surgery. Of the eight patients, there was 1 (12.5%) O'Kelly-Marotta grading scale A, 3 (37.5%) O'Kelly-Marotta grading scale B, 1 (12.5%) O'Kelly-Marotta grading scale C, and 3 (37.5%) O'Kelly-Marotta grading scale D. Of the seven patients with jailed branch, the blood flow of jailed branch was unchanged in 4 (57.1%), decreased in 2 (28.6%), and occluded in 1 (14.3%). In-stent stenosis was mild in 2 (25%) patients and moderate in 1 (12.5%) patient. CONCLUSION Midterm results suggest that endovascular treatment of middle cerebral artery aneurysms using the TuBridge flow diverter is safe and associated with good outcomes. The TuBridge flow diverter may be an option for complex middle cerebral artery aneurysms that are difficult to treat with either clipping or coiling.
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Affiliation(s)
- Feng Liang
- Department of Neurosurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yibing Yang
- Department of Neurosurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Lijuan Luo
- Department of Neurosurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Bingye Liao
- Department of Operation Theater, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Guofeng Zhang
- Department of Neurosurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Siqi Ou
- Department of Neurosurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Weiping Xiao
- Department of Neurosurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ning Guo
- Department of Neurosurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Tiewei Qi
- Department of Neurosurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Raper DMS, Rutledge C, Abla AA. Letter: Aneurysm Treatment With Woven EndoBridge in the Cumulative Population of 3 Prospective, Multicenter Series: 2-Year Follow-up. Neurosurgery 2020; 87:E77. [PMID: 32294199 DOI: 10.1093/neuros/nyaa085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Daniel M S Raper
- Department of Neurological Surgery University of California San Francisco, California
| | - Caleb Rutledge
- Department of Neurological Surgery University of California San Francisco, California
| | - Adib A Abla
- Department of Neurological Surgery University of California San Francisco, California
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Muirhead WR, Grover PJ, Toma AK, Stoyanov D, Marcus HJ, Murphy M. Adverse intraoperative events during surgical repair of ruptured cerebral aneurysms: a systematic review. Neurosurg Rev 2020; 44:1273-1285. [PMID: 32542428 PMCID: PMC8121724 DOI: 10.1007/s10143-020-01312-4] [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: 02/04/2020] [Revised: 04/17/2020] [Accepted: 04/29/2020] [Indexed: 11/28/2022]
Abstract
Compared with endovascular techniques, clipping of ruptured cerebral aneurysms has been shown to associate with increased morbidity in several studies. Despite this, clipping remains the preferred option for many aneurysms. The objective of this study is to describe the reported adverse events of open repair of ruptured cerebral aneurysms and their impact on patient outcome. The PubMed, Embase and Cochrane databases were searched between June 1999 and June 2019 to identify original studies of at least 100 patients undergoing surgical repair of ruptured cerebral aneurysms and in which adverse event rates were reported. Thirty-six studies reporting adverse events in a total of 12,410 operations for repair of ruptured cerebral aneurysms were included. Surgical adverse events were common with 36 event types reported including intraoperative rupture (median rate of 16.6%), arterial injury (median rate of 3.8%) and brain swelling (median rate 5.6%). Only 6 surgical events were statistically shown to associate with poor outcomes by any author and for intraoperative rupture (the most frequently analysed), there was an even split between authors finding a statistical association with poor outcome and those finding no association. Even with modern surgical techniques, the technical demands of surgical aneurysm repair continue to lead to a high rate of intraoperative adverse events. Despite this, it is not known which of these intraoperative events are the most important contributors to the poor outcomes often seen in these patients. More research directed towards identifying the events that most drive operative morbidity has the potential to improve outcomes for these patients.
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Affiliation(s)
- William R Muirhead
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK.
| | - Patrick J Grover
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - Ahmed K Toma
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - Danail Stoyanov
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK.,Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Hani J Marcus
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK.,Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Mary Murphy
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
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49
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Burkhardt JK, Srinivasan V, Srivatsan A, Albuquerque F, Ducruet AF, Hendricks B, Gross BA, Jankowitz BT, Thomas AJ, Ogilvy CS, Maragkos GA, Enriquez-Marulanda A, Crowley RW, Levitt MR, Kim LJ, Griessenauer CJ, Schirmer CM, Dalal S, Piper K, Mokin M, Winkler EA, Abla AA, McDougall C, Birnbaum L, Mascitelli J, Litao M, Tanweer O, Riina H, Johnson J, Chen S, Kan P. Multicenter Postmarket Analysis of the Neuroform Atlas Stent for Stent-Assisted Coil Embolization of Intracranial Aneurysms. AJNR Am J Neuroradiol 2020; 41:1037-1042. [PMID: 32467183 DOI: 10.3174/ajnr.a6581] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 03/29/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The Neuroform Atlas is a new microstent to assist coil embolization of intracranial aneurysms that recently gained FDA approval. We present a postmarket multicenter analysis of the Neuroform Atlas stent. MATERIALS AND METHODS On the basis of retrospective chart review from 11 academic centers, we analyzed patients treated with the Neuroform Atlas after FDA exemption from January 2018 to June 2019. Clinical and radiologic parameters included patient demographics, aneurysm characteristics, stent parameters, complications, and outcomes at discharge and last follow-up. RESULTS Overall, 128 aneurysms in 128 patients (median age, 62 years) were treated with 138 stents. Risk factors included smoking (59.4%), multiple aneurysms (27.3%), and family history of aneurysms (16.4%). Most patients were treated electively (93.7%), and 8 (6.3%) underwent treatment within 2 weeks of subarachnoid hemorrhage. Previous aneurysm treatment failure was present in 21% of cases. Wide-neck aneurysms (80.5%), small aneurysm size (<7 mm, 76.6%), and bifurcation aneurysm location (basilar apex, 28.9%; anterior communicating artery, 27.3%; and middle cerebral artery bifurcation, 12.5%) were common. A single stent was used in 92.2% of cases, and a single catheter for both stent placement and coiling was used in 59.4% of cases. Technical complications during stent deployment occurred in 4.7% of cases; symptomatic thromboembolic stroke, in 2.3%; and symptomatic hemorrhage, in 0.8%. Favorable Raymond grades (Raymond-Roy occlusion classification) I and II were achieved in 82.9% at discharge and 89.5% at last follow-up. mRS ≤2 was determined in 96.9% of patients at last follow-up. The immediate Raymond-Roy occlusion classification grade correlated with aneurysm location (P < .0001) and rupture status during treatment (P = .03). CONCLUSIONS This multicenter analysis provides a real-world safety and efficacy profile for the treatment of intracranial aneurysms with the Neuroform Atlas stent.
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Affiliation(s)
- J-K Burkhardt
- From the Department of Neurosurgery (J.-K.B., V.S., A.S., O.T., J.J., S.C., P.K.), Baylor College of Medicine, Houston, Texas
| | - V Srinivasan
- From the Department of Neurosurgery (J.-K.B., V.S., A.S., O.T., J.J., S.C., P.K.), Baylor College of Medicine, Houston, Texas
| | - A Srivatsan
- From the Department of Neurosurgery (J.-K.B., V.S., A.S., O.T., J.J., S.C., P.K.), Baylor College of Medicine, Houston, Texas
| | - F Albuquerque
- Department of Neurosurgery (F.A., A.F.D., B.H.), Barrow Neurological Institute, Phoenix, Arizona
| | - A F Ducruet
- Department of Neurosurgery (F.A., A.F.D., B.H.), Barrow Neurological Institute, Phoenix, Arizona
| | - B Hendricks
- Department of Neurosurgery (F.A., A.F.D., B.H.), Barrow Neurological Institute, Phoenix, Arizona
| | - B A Gross
- Department of Neurological Surgery (B.A.G.), University of Pittsburgh Medical Center Presbyterian, Pittsburgh, Pennsylvania
| | - B T Jankowitz
- Department of Neurosurgery (B.T.J.), Cooper University, Camden, New Jersey
| | - A J Thomas
- Beth Israel Deaconess Medical Center (A.J.T., C.S.O., G.A.M.), Harvard Medical School, Boston, Massachusetts
| | - C S Ogilvy
- Beth Israel Deaconess Medical Center (A.J.T., C.S.O., G.A.M.), Harvard Medical School, Boston, Massachusetts
| | - G A Maragkos
- Beth Israel Deaconess Medical Center (A.J.T., C.S.O., G.A.M.), Harvard Medical School, Boston, Massachusetts
| | | | - R W Crowley
- Department of Neurosurgery (R.W.C.), Rush Medical College, Chicago, Illinois
| | - M R Levitt
- Department of Neurological Surgery (M.R.L., L.J.K.), University of Washington, Seattle, Washington
| | - L J Kim
- Department of Neurological Surgery (M.R.L., L.J.K.), University of Washington, Seattle, Washington
| | - C J Griessenauer
- Department of Neurosurgery (C.J.G., C.M.S., S.D.), Geisinger Health, Danville, Pennsylvania.,Research Institute of Neurointervention (C.J.G., C.M.S.), Paracelsus Medical University, Salzburg, Austria
| | - C M Schirmer
- Department of Neurosurgery (C.J.G., C.M.S., S.D.), Geisinger Health, Danville, Pennsylvania.,Research Institute of Neurointervention (C.J.G., C.M.S.), Paracelsus Medical University, Salzburg, Austria
| | - S Dalal
- Department of Neurosurgery (C.J.G., C.M.S., S.D.), Geisinger Health, Danville, Pennsylvania
| | - K Piper
- Department of Neurosurgery (K.P., M.M.), University of Southern Florida College of Public Health, Tampa, Florida
| | - M Mokin
- Department of Neurosurgery (K.P., M.M.), University of Southern Florida College of Public Health, Tampa, Florida
| | - E A Winkler
- Department of Neurological Surgery (E.A.W., A.A.A.), University of California, San Francisco, San Francisco, California
| | - A A Abla
- Department of Neurological Surgery (E.A.W., A.A.A.), University of California, San Francisco, San Francisco, California
| | - C McDougall
- Department of Neurosurgery (C.M., L.B., J.M.), University of Texas Health San Antonio, San Antonio, Texas
| | - L Birnbaum
- Department of Neurosurgery (C.M., L.B., J.M.), University of Texas Health San Antonio, San Antonio, Texas
| | - J Mascitelli
- Department of Neurosurgery (C.M., L.B., J.M.), University of Texas Health San Antonio, San Antonio, Texas
| | - M Litao
- Department of Neurosurgery (M.L., O.T., H.R.), NYU Langone Medical Center, New York, New York
| | - O Tanweer
- From the Department of Neurosurgery (J.-K.B., V.S., A.S., O.T., J.J., S.C., P.K.), Baylor College of Medicine, Houston, Texas.,Department of Neurosurgery (M.L., O.T., H.R.), NYU Langone Medical Center, New York, New York
| | - H Riina
- Department of Neurosurgery (M.L., O.T., H.R.), NYU Langone Medical Center, New York, New York
| | - J Johnson
- From the Department of Neurosurgery (J.-K.B., V.S., A.S., O.T., J.J., S.C., P.K.), Baylor College of Medicine, Houston, Texas
| | - S Chen
- From the Department of Neurosurgery (J.-K.B., V.S., A.S., O.T., J.J., S.C., P.K.), Baylor College of Medicine, Houston, Texas
| | - P Kan
- From the Department of Neurosurgery (J.-K.B., V.S., A.S., O.T., J.J., S.C., P.K.), Baylor College of Medicine, Houston, Texas
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Wang L, Lu S, Cai L, Qian H, Tanikawa R, Shi X. Internal maxillary artery bypass for the treatment of complex middle cerebral artery aneurysms. Neurosurg Focus 2020; 46:E10. [PMID: 30717068 DOI: 10.3171/2018.11.focus18457] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 11/14/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVEThe rapid innovation of the endovascular armamentarium results in a decreased number of indications for a classic surgical approach. However, a middle cerebral artery (MCA) aneurysm remains the best example of one for which results have favored microsurgery over endovascular intervention. In this study, the authors aimed to evaluate the experience and efficacy regarding surgical outcomes after applying internal maxillary artery (IMA) bypass for complex MCA aneurysms (CMCAAs).METHODSAll IMA bypasses performed between January 2010 and July 2018 in a single-center, single-surgeon practice were screened.RESULTSIn total, 12 patients (9 males, 3 females) with CMCAAs managed by high-flow IMA bypass were identified. The mean size of CMCAAs was 23.7 mm (range 10-37 mm), and the patients had a mean age of 31.7 years (range 14-56 years). The aneurysms were proximally occluded in 8 cases, completely trapped in 3 cases, and completely resected in 1 case. The radial artery was used as the graft vessel in all cases. At discharge, the graft patency rate was 83.3% (n = 10), and all aneurysms were completely eliminated (83.3%, n = 10) or greatly diminished (16.7%, n = 2) from the circulation. Postoperative ischemia was detected in 2 patients as a result of graft occlusion, and 1 patient presenting with subarachnoid hemorrhage achieved improved modified Rankin Scale scores compared to the preoperative status but retained some neurological deficits. Therefore, neurological assessment at discharge showed that 9 of the 12 patients experienced unremarkable outcomes. The mean interval time from bypass to angiographic and clinical follow-up was 28.7 months (range 2-74 months) and 53.1 months (range 19-82 months), respectively. Although 2 grafts remained occluded, all aneurysms were isolated from the circulation, and no patient had an unfavorable outcome.CONCLUSIONSThe satisfactory result in the present study demonstrated that IMA bypass is a promising method for the treatment of CMCAAs and should be maintained in the neurosurgical armamentarium. However, cases with intraoperative radical resection or inappropriate bypass recipient selection such as aneurysmal wall should be meticulously chosen with respect to the subtype of MCA aneurysm.
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Affiliation(s)
- Long Wang
- 1Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing, China.,2Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Shuaibin Lu
- 3Department of Neurosurgery, Beijing Shijingshan Hospital, Beijing, China
| | - Li Cai
- 4Department of Neurosurgery, The First Affiliated Hospital of University of South China, Hengyang, China.,5Arkansas Neuroscience Institute, St. Vincent Hospital, Little Rock, Arkansas; and
| | - Hai Qian
- 1Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing, China
| | - Rokuya Tanikawa
- 2Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Xiang'en Shi
- 1Department of Neurosurgery, SanBo Brain Hospital, Capital Medical University, Beijing, China.,6Department of Neurosurgery, Fuxing Hospital, Capital Medical University, Beijing, China
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