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Grüter BE, Catalano K, Anon J, Gruber P, Thanabalasingam A, Andereggen L, Schubert GA, Remonda L, Marbacher S. Intra-aneurysmal contrast agent stasis during intraoperative digital subtraction angiography may predict long-term occlusion after clipping. Acta Neurochir (Wien) 2024; 166:309. [PMID: 39078422 DOI: 10.1007/s00701-024-06162-3] [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: 04/04/2024] [Accepted: 06/05/2024] [Indexed: 07/31/2024]
Abstract
PURPOSE The routine use of intraoperative digital subtraction angiography (iDSA) increases detection of intracranial aneurysm (IA) remnants after microsurgical clipping. Spontaneous thrombosis of IA remnants after clipping is considered a rare phenomenon. We analyse iDSA characteristics to find predictors for IA remnant thrombosis. METHODS IA with intraoperative detection of a remnant after clipping were identified and divided into remnants experiencing spontaneous thrombosis, and remnants with long-term patency and/or remnant growth. Angiographic features of iDSA were analysed and compared between the two groups. RESULTS Of 37 IAs with intraoperative remnant on 3D-iDSA, five sustained a spontaneous remnant thrombosis and remained occluded in long-term follow-up. In all five cases, iDSA revealed delayed inflow and consequent stasis of the contrast agent until the late venous phase. On the other hand, in all cases with persistent long-term IA remnants (n = 32) iDSA demonstrated timely arterial contrast inflow and wash-out without stasis of intra-aneurysmal contrast agent. CONCLUSIONS Contrast stasis in IA remnants during iDSA appears to predict long-term IA occlusion, indicating that clip correction manoeuvres or even attempted endovascular treatment of the remnant IA may be avoided in these patients.
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Affiliation(s)
- Basil E Grüter
- Division of Neuroradiology, Aarau Cantonal Hospital, Aarau, Switzerland.
- Department of Neurosurgery, Aarau Cantonal Hospital, Aarau, Switzerland.
| | - Kristina Catalano
- Department of Neurosurgery, Aarau Cantonal Hospital, Aarau, Switzerland
| | - Javier Anon
- Division of Neuroradiology, Aarau Cantonal Hospital, Aarau, Switzerland
| | - Philipp Gruber
- Division of Neuroradiology, Aarau Cantonal Hospital, Aarau, Switzerland
| | | | - Lukas Andereggen
- Department of Neurosurgery, Aarau Cantonal Hospital, University of Bern, Bern, Switzerland
| | - Gerrit A Schubert
- Department of Neurosurgery, Aarau Cantonal Hospital, Aarau, Switzerland
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Luca Remonda
- Division of Neuroradiology, Aarau Cantonal Hospital, University of Bern, Bern, Switzerland
| | - Serge Marbacher
- Department of Neurosurgery, Aarau Cantonal Hospital, University of Bern, Bern, Switzerland
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2
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Diana F, Romoli M, Raz E, Agid R, Albuquerque FC, Arthur AS, Beck J, Berge J, Boogaarts HD, Burkhardt JK, Cenzato M, Chapot R, Charbel FT, Desal H, Esposito G, Fifi JT, Florian S, Gruber A, Hassan AE, Jabbour P, Jadhav AP, Korja M, Krings T, Lanzino G, Meling TR, Morcos J, Mosimann PJ, Nossek E, Pereira VM, Raabe A, Regli L, Rohde V, Siddiqui AH, Tanikawa R, Tjoumakaris SI, Tomasello A, Vajkoczy P, Valvassori L, Velinov N, Walsh D, Woo H, Xu B, Yoshimura S, van Zwam WH, Peschillo S. Complex intracranial aneurysms: a DELPHI study to define associated characteristics. Acta Neurochir (Wien) 2024; 166:294. [PMID: 38990336 DOI: 10.1007/s00701-024-06182-z] [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: 04/15/2024] [Accepted: 07/02/2024] [Indexed: 07/12/2024]
Abstract
PURPOSE Intracranial aneurysms present significant health risks, as their rupture leads to subarachnoid haemorrhage, which in turn has high morbidity and mortality rates. There are several elements affecting the complexity of an intracranial aneurysm. However, criteria for defining a complex intracranial aneurysm (CIA) in open surgery and endovascular treatment could differ, and actually there is no consensus on the definition of a "complex" aneurysm. This DELPHI study aims to assess consensus on variables defining a CIA. METHODS An international panel of 50 members, representing various specialties, was recruited to define CIAs through a three-round Delphi process. The panelists participated in surveys with Likert scale responses and open-ended questions. Consensus criteria were established to determine CIA variables, and statistical analysis evaluated consensus and stability. RESULTS In open surgery, CIAs were defined by fusiform or blister-like shape, dissecting aetiology, giant size (≥ 25 mm), broad neck encasing parent arteries, extensive neck surface, wall calcification, intraluminal thrombus, collateral branch from the sac, location (AICA, SCA, basilar), vasospasm context, and planned bypass (EC-IC or IC-IC). For endovascular treatment, CIAs included giant size, very wide neck (dome/neck ratio ≤ 1:1), and collateral branch from the sac. CONCLUSIONS The definition of aneurysm complexity varies by treatment modality. Since elements related to complexity differ between open surgery and endovascular treatment, these consensus criteria of CIAs could even guide in selecting the best treatment approach.
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Affiliation(s)
- Francesco Diana
- Interventional Neuroradiology, University Hospital Vall d'Hebron, Barcelona, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
- Department of Scienze della Vita, Della Salute e delle Professioni Sanitarie Link Campus University, Rome, Italy
| | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy
| | - Eytan Raz
- Department of Radiology, New York University Langone Health, New York, NY, USA
| | - Ronit Agid
- Division of Neuroradiology, JDMI, University Health Network, Toronto, Canada
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Adam S Arthur
- University of Tennessee, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Jerome Berge
- Interventional Neuroradiology Department, CHRU, Bordeaux, France
| | | | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, USA
| | - Marco Cenzato
- Department of Neurosurgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - René Chapot
- Department of Interventional Neuroradiology, Alfried Krupp Hospital Ruttenscheid, Essen, Germany
| | - Fady T Charbel
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Hubert Desal
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nantes, Nantes, France
| | - Giuseppe Esposito
- Department of Neurosurgery, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Johanna T Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Stefan Florian
- Department of Neurosurgery, Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj County Clinical Emergency Hospital, Cluj-Napoca, Romania
| | - Andreas Gruber
- Department of Neurosurgery, Johannes Kepler University, Neuromed Campus, Kepler Universitätsklinikum, Linz, Austria
| | - Ameer E Hassan
- Department of Neurology, Valley Baptist - University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson Hospital, Philadelphia, PA, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Miikka Korja
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Timo Krings
- Interventional and Diagnostic Neuroradiology, University of Toronto & Toronto Western Hospital, Toronto, ON, Canada
| | - Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Jaques Morcos
- Vivian L. Smith Department of Neurosurgery, UTHealth Houston Neurosciences, Houston, TX, USA
| | - Pascal J Mosimann
- Interventional and Diagnostic Neuroradiology, University of Toronto & Toronto Western Hospital, Toronto, ON, Canada
| | - Erez Nossek
- Department of Neurosurgery, New York University School of Medicine, New York, NY, USA
| | - Vitor Mendes Pereira
- Division of Neurosurgery, Departments of Surgery & Medical Imaging, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Andreas Raabe
- Department of Neurosurgery Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Veit Rohde
- Department of Neurosurgery, University Medical Center Göttingen, Georg-August-University, Göttingen, Germany
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Rokuya Tanikawa
- Department of Neurosurgery, Stroke Center, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | | | - Alejandro Tomasello
- Interventional Neuroradiology, University Hospital Vall d'Hebron, Barcelona, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Nikolay Velinov
- Clinics of Neurosurgery, Vascular and Endovascular Neurosurgery, University Hospital Pirogov, Sofia, Bulgaria
| | - Daniel Walsh
- King's College Hospital NHS Foundation Trust, London, UK
| | - Henry Woo
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Bin Xu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, School for Cardiovascular Diseases (CARIM), Maastricht UMC+, Maastricht, The Netherlands
| | - Simone Peschillo
- Endovascular Neurosurgery, Guido Guglielmi Endowed Chair in Endovascular Neurosurgery, Unicamillus International University of Health Sciences, Rome, Italy.
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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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4
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Marbacher S, Grüter BE, Wanderer S, Andereggen L, Cattaneo M, Trost P, Gruber P, Diepers M, Remonda L, Steiger HJ. Risk of intracranial aneurysm recurrence after microsurgical clipping based on 3D digital subtraction angiography. J Neurosurg 2023; 138:717-723. [PMID: 35907194 DOI: 10.3171/2022.5.jns22424] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 05/16/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Current knowledge of recurrence rates after intracranial aneurysm (IA) surgery relies on 2D digital subtraction angiography (DSA), which fails to detect more than 75% of small aneurysm remnants. Accordingly, the discrimination between recurrence and growth of a remnant remains challenging, and actual assessment of recurrence risk of clipped IAs could be inaccurate. The authors report, for the first time, 3D-DSA-based long-term durability and risk factor data of IA recurrence and remnant growth after microsurgical clipping. METHODS Prospectively collected data for 305 patients, with a total of 329 clipped IAs that underwent baseline 3D-DSA, were evaluated. The incidence of recurrent IA was described by Kaplan-Meier curves. Risk factors for IA recurrence were analyzed by multivariable Cox proportional hazards and logistic regression models. RESULTS The overall observed proportion of IA recurrence after clipping was 2.7% (9 of 329 IAs) at a mean follow-up of 46 months (0.7% per year). While completely obliterated IAs did not recur during follow-up, incompletely clipped aneurysms (76 of 329) demonstrated remnant growth in 11.8% (3.4% per year). Young age and large initial IA size significantly increased the risk of IA recurrence. CONCLUSIONS The findings support those in previous studies that hypothesized that completely clipped IAs have an extremely low risk of recurrence. Conversely, the results highlight the significant risk posed by incompletely clipped IAs. Young patients with initial large IAs and incomplete obliteration have an especially high risk for IA recurrence and therefore should be monitored more closely.
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Affiliation(s)
- Serge Marbacher
- 1Department of Neurosurgery, Kantonsspital Aarau, University of Bern
| | - Basil Erwin Grüter
- 1Department of Neurosurgery, Kantonsspital Aarau, University of Bern.,2Division of Neurosurgery, Kantonsspital Aarau, University of Bern, and
| | - Stefan Wanderer
- 1Department of Neurosurgery, Kantonsspital Aarau, University of Bern
| | - Lukas Andereggen
- 1Department of Neurosurgery, Kantonsspital Aarau, University of Bern
| | - Marco Cattaneo
- 3Clinical Trial Unit, Department of Clinical Research, University of Basel, University Hospital Basel, Switzerland
| | - Patricia Trost
- 1Department of Neurosurgery, Kantonsspital Aarau, University of Bern
| | - Philipp Gruber
- 2Division of Neurosurgery, Kantonsspital Aarau, University of Bern, and
| | - Michael Diepers
- 2Division of Neurosurgery, Kantonsspital Aarau, University of Bern, and
| | - Luca Remonda
- 2Division of Neurosurgery, Kantonsspital Aarau, University of Bern, and
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5
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Spetzger U. Enhance Safety in Aneurysm Surgery: Strategies for Prevention of Intraoperative Vascular Complications. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 130:53-64. [PMID: 37548724 DOI: 10.1007/978-3-030-12887-6_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Complications during surgery for intracranial aneurysms can be devastating. Notorious pitfalls include premature rupture, parent vessel occlusion, local cerebral injury and brain contusion, and incomplete neck obliteration. These unfavorable intraoperative events can result in major neurological deficits with permanent morbidity and even mortality. Herein, the author highlights the relevant surgical strategies used in his daily practice of aneurysm surgery (e.g., aneurysm clipping with adenosine-induced temporary cardiac arrest), application of which may help prevent vascular complications and enhance surgical safety through reduction of the associated risks, thus allowing improvement of postoperative outcomes. Overall, all described methods and techniques should be considered as small pieces in the complex puzzle of prevention of vascular complications during aneurysm surgery.
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Affiliation(s)
- Uwe Spetzger
- Department of Neurosurgery, Klinikum Karlsruhe, Karlsruhe, Germany.
- Faculty of Computer Science, Institute for Anthropomatics, Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany.
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6
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Han HJ, Lee W, Kim J, Park KY, Park SK, Chung J, Kim YB. Incidence rate and predictors of recurrent aneurysms after clipping: long-term follow-up study of survivors of subarachnoid hemorrhage. Neurosurg Rev 2022; 45:3209-3217. [PMID: 35739336 DOI: 10.1007/s10143-022-01828-x] [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: 03/11/2022] [Revised: 06/08/2022] [Accepted: 06/16/2022] [Indexed: 10/17/2022]
Abstract
Recurrent aneurysms are a major cause of re-aneurysmal subarachnoid hemorrhage (aSAH), but information on long-term clip durability and predictors is insufficient. This study aimed to present the incidence rate of > 10 years and investigate predictors of a recurrent aneurysm in aSAH survivors. We included 1601 patients admitted with aSAH and treated by microsurgical clipping between January 1993 and May 2010. Of these patients, 435 aSAH survivors were included in this study (27.2%). The total follow-up time was 5680.9 patient-years, and the overall incidence rate was 0.77% per patient-year. The cumulative probability of recurrence without residua and regrowth of the neck remnant was 0.7% and 13.9% at 10 years, respectively. Neck remnant (hazard ratio [HR], 10.311; 95% confidence interval [CI], 5.233-20.313) and alcohol consumption over the moderate amount (HR, 3.166; 95% CI, 1.313-7.637) were independent risk factors of recurrent aneurysm. Current smoking and multiplicity at initial aSAH presentation were significant factors in a univariate analysis. Furthermore, de novo intracranial aneurysms (DNIAs) were more common in the recurrent group than in the non-recurrent group (40.9% vs. 11.5%, P < 0.001). In the present study, we noted the long-term clip durability and predictor of recurrence after microsurgical clipping. These findings can assist clinicians in identifying patients at a high risk of recurrent aneurysm and recommending selective long-term surveillance after microsurgical clipping.
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Affiliation(s)
- Hyun Jin Han
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Woosung Lee
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Junhyung Kim
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Keun Young Park
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Sang Kyu Park
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joonho Chung
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong Bae Kim
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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7
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Schartz D, Mattingly TK, Rahmani R, Ellens N, Akkipeddi SMK, Bhalla T, Bender MT. Noncurative microsurgery for cerebral aneurysms: a systematic review and meta-analysis of wrapping, residual, and recurrence rates. J Neurosurg 2022; 137:129-139. [PMID: 34798602 DOI: 10.3171/2021.9.jns211698] [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: 07/10/2021] [Accepted: 09/03/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Microsurgery for cerebral aneurysms is called definitive, yet some patients undergo a craniotomy that results in noncurative treatment. Furthermore, the overall rate of noncurative microsurgery for cerebral aneurysms is unclear. The objective of this study was to complete a systematic review and meta-analysis to quantify three scenarios of noncurative treatment: aneurysm wrapping, postclipping remnants, and late regrowth of completely obliterated aneurysms. METHODS A PRISMA-guided systematic literature review of the MEDLINE and Cochrane Library databases and meta-analysis was completed. Studies were included that detailed rates of aneurysm wrapping, residua confirmed with imaging, and regrowth after confirmed total occlusion. Pooled rates were subsequently calculated using a random-effects model. An assessment of statistical heterogeneity and publication bias among the included studies was also completed for each analysis, with resultant I2 values and p values determined with Egger's test. RESULTS Sixty-four studies met the inclusion criteria for final analysis. In 41 studies, 573/15,715 aneurysms were wrapped, for a rate of 3.5% (95% CI 2.7%-4.2%, I2 = 88%). In 43 studies, 906/13,902 aneurysms had residual neck or dome filling, for a rate of 6.4% (95% CI 5.2%-7.6%, I2 = 93%). In 15 studies, 71/2568 originally fully occluded aneurysms showed regrowth, for a rate of 2.1% (95% CI 1.2%-3.1%, I2 = 58%). Together, there was a total rate of noncurative surgery of 12.0% (95% CI 11.5%-12.5%). Egger's test suggested no significant publication bias among the studies. Meta-regression analysis revealed that the reported rate of aneurysm wrapping has significantly declined over time, whereas the rates of aneurysm residua and recurrence have not significantly changed. CONCLUSIONS Open microsurgery for cerebral aneurysm results in noncurative treatment approximately 12% of the time. This metric may be used to counsel patients and as a benchmark for other treatment modalities. This investigation is limited by the high degree of heterogeneity among the included studies.
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Affiliation(s)
- Derrek Schartz
- 1Department of Imaging Sciences, University of Rochester Medical Center, Rochester, New York; and
- 2Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York
| | - Thomas K Mattingly
- 2Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York
| | - Redi Rahmani
- 2Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York
| | - Nathaniel Ellens
- 2Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York
| | | | - Tarun Bhalla
- 2Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York
| | - Matthew T Bender
- 2Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York
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8
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Schwandt E, Kockro R, Kramer A, Glaser M, Ringel F. Presurgical selection of the ideal aneurysm clip by the use of a three-dimensional planning system. Neurosurg Rev 2022; 45:2887-2894. [PMID: 35546216 PMCID: PMC9349090 DOI: 10.1007/s10143-022-01794-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 03/19/2022] [Accepted: 04/19/2022] [Indexed: 11/25/2022]
Abstract
Aneurysm occlusion rate after clipping is higher than after endovascular treatment. However, a certain percentage of incompletely clipped aneurysms remains. Presurgical selection of the proper aneurysm clips could potentially reduce the rate of incomplete clippings caused by inadequate clip geometry. The aim of the present study was to assess whether preoperative 3D image-based simulation allows for preoperative selection of a proper aneurysm clip for complete occlusion in individual cases. Patients harboring ruptured or unruptured cerebral aneurysms prior to surgical clipping were analyzed. CT angiography images were transferred to a 3D surgical-planning station (Dextroscope®) with imported models of 58 aneurysm clips. Intracranial vessels and aneurysms were segmented and the virtual aneurysm clips were placed at the aneurysm neck. Operating surgeons had information about the selected aneurysm clip, and patients underwent clipping. Intraoperative clip selection was documented and aneurysm occlusion rate was assessed by postoperative digital subtraction angiography. Nineteen patients were available for final analysis. In all patients, the most proximal clip at the aneurysm neck was the preselected clip. All aneurysms except one were fully occluded, as assessed by catheter angiography. One aneurysm had a small neck remnant that did not require secondary surgery and was occluded 15 months after surgery. 3D image-based preselection of a proper aneurysm clip can be translated to the operating room and avoids intraoperative clip selection. The associated occlusion rate of aneurysms is high.
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Affiliation(s)
- Eike Schwandt
- Department of Neurosurgery, University Medical Center Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Ralf Kockro
- Department of Neurosurgery, Klinik Hirslanden, Zurich, Switzerland
| | - Andreas Kramer
- Department of Neurosurgery, University Medical Center Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Martin Glaser
- Department of Neurosurgery, University Medical Center Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center Mainz, Langenbeckstr. 1, 55131, Mainz, Germany.
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9
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Halter M, Wanderer S, Grüter B, Anon J, Diepers M, Gruber P, Andereggen L, Remonda L, Marbacher S. Interrater and intrarater agreement superior for three-dimensional digital subtraction angiography (3D-DSA) over 2D-DSA classification for detecting remnants after intracranial aneurysm clipping, a GRRAS Reliability and Agreement Study. Acta Neurochir (Wien) 2022; 164:2173-2179. [PMID: 35239014 DOI: 10.1007/s00701-022-05156-3] [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: 10/28/2021] [Accepted: 02/07/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Growing evidence suggests that three-dimensional digital subtraction angiography (3D-DSA) is superior to 2D-DSA in detection of intracranial aneurysm (IA) remnants after clipping. With a simple, practical quantitative scale proposed to measure maximal remnant dimension on 3D-DSA, this study provides a rigorous interrater and intrarater reliability and agreement study comparing this newly established scale with a commonly used (Sindou) 2D-DSA scale. METHOD Records of 43 patients with clipped IAs harboring various sized remnants who underwent 2D- and 3D-DSA between 2012 and 2018 were evaluated. Using the 2D and 3D scales, six raters scored these remnants and repeated the scoring task 8 weeks later. Interrater and intrarater agreement for both grading schemes were calculated using kappa (κ) statistics. RESULTS Interrater agreement was highly significant, yielding κ-values at 95% CI (p = 0.000) of 0.225 for the first [0.185; 0.265] and 0.368 s [0.328; 0.408] time points for 2D-DSA and values of 0.700 for the first [0.654; 0.745] and 0.776 s [0.729; 0.822] time points for 3D-DSA. Intrarater agreement demonstrated κ-values between 0.139 and 0.512 for 2D-DSA and between 0.487 and 0.813 for 3D-DSA scores. CONCLUSION Interrater and intrarater agreement was minimal or weak for 2D-DSA scores, but strong for 3D-DSA scores. We propose that baseline 3D-DSA characterization may prove more reliable when categorizing clipped IA remnants for purposes of risk stratification and lifelong follow-up.
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10
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Repeated Aneurysm Intervention. Adv Tech Stand Neurosurg 2022; 44:277-296. [PMID: 35107686 DOI: 10.1007/978-3-030-87649-4_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Over the past 25 years the endovascular treatment of cerebral aneurysms has gained preference in some countries over the traditional surgical procedures. The review part of the article clearly demonstrates that the clinical results of both modalities are similar and the difference is seen only in technical effectivity. Surgical techniques fail far less frequently than the endovascular ones. Incompletely occluded or growing aneurysms after the endovascular approach expose the patient to the risk of rebleeding with all possible consequences. Markedly repeated procedures are much more common for endovascularly treated aneurysms, again with all the risks.In the authors institution over the past 20 years, a total of 2032 aneurysms were treated. In 1263 endovascularly managed aneurysms the regrowth or inclomplete initial occlusion necessitated 159 repeated propcedures (12.6%). In surgical group the total of 27 aneurysms needed retreatment (3.5%). The difference is statistically significant. In nine patients in endovascular group the rebleeding was the reason for repeated procedures. No rebleeding was seen in the surgical group.This fact, also shown in the review part of the article, is important in patients counseling. Given the similar clinical results of both modalities the patient should be advised on the necessity of repeated follow-ups and of possible technical failure and eventual repeated procedure which is more likely if endovascular procedure is chosen.
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Detection of impending perfusion deficits by intraoperative computed tomography (iCT) in aneurysm surgery of the anterior circulation. Acta Neurochir (Wien) 2021; 163:3501-3514. [PMID: 34643806 PMCID: PMC8599411 DOI: 10.1007/s00701-021-05022-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/02/2021] [Indexed: 11/22/2022]
Abstract
Background The aim of our study was to evaluate the additional benefit of intraoperative computed tomography (iCT), intraoperative computed tomography angiography (iCTA), and intraoperative computed tomography perfusion (iCTP) in the intraoperative detection of impending ischemia to established methods (indocyanine green videoangiography (ICGVA), microDoppler, intraoperative neuromonitoring (IONM)) for initiating timely therapeutic measures. Methods Patients with primary aneurysms of the anterior circulation between October 2016 and December 2019 were included. Data of iCT modalities compared to other techniques (ICGVA, microDoppler, IONM) was recorded with emphasis on resulting operative conclusions leading to inspection of clip position, repositioning, or immediate initiation of conservative treatment strategies. Additional variables analyzed included patient demographics, aneurysm-specific characteristics, and clinical outcome. Results Of 194 consecutive patients, 93 patients with 100 aneurysms received iCT imaging. While IONM and ICGVA were normal, an altered vessel patency in iCTA was detected in 5 (5.4%) and a mismatch in iCTP in 7 patients (7.5%). Repositioning was considered appropriate in 2 patients (2.2%), where immediate improvement in iCTP could be documented. In a further 5 cases (5.4%), intensified conservative therapy was immediately initiated treating the reduced CBP as clip repositioning was not considered causal. In terms of clinical outcome at last FU, mRS0 was achieved in 85 (91.4%) and mRS1-2 in 7 (7.5%) and remained mRS4 in one patient with SAH (1.1%). Conclusions Especially iCTP can reveal signs of impending ischemia in selected cases and enable the surgeon to promptly initiate therapeutic measures such as clip repositioning or intraoperative onset of maximum conservative treatment, while established tools might fail to detect those intraoperative pathologic changes.
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da Silva Júnior NR, Trivelato FP, Nakiri GS, Rezende MTS, de Castro-Afonso LH, Abud TG, Vanzin JR, Manzato LB, Ulhôa AC, Abud DG, Giannetti AV. Endovascular treatment of residual or recurrent intracranial aneurysms after surgical clipping. J Cerebrovasc Endovasc Neurosurg 2021; 23:221-232. [PMID: 34470100 PMCID: PMC8497721 DOI: 10.7461/jcen.2021.e2021.03.001] [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: 03/16/2020] [Accepted: 04/19/2021] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Total aneurysm occlusion is crucial for the prevention of rebleeding of a ruptured aneurysm or to avoid rupture of an unruptured lesion. Both surgical and endovascular embolization fail to achieve complete aneurysm occlusion in all the cases. The objective of the study was to establish the safety and efficacy of endovascular treatment for previously clipped residual or recurrent aneurysms. METHODS This was an observational, retrospective study of patients harboring incompletely occluded intracranial aneurysms after clipping who underwent endovascular treatment. Patients were treated using 4 different techniques: (1) simple coiling, (2) balloon remodeling, (3) stent-assisted coiling, and (4) flow diversion. Analyses were performed to identify predictors of total aneurysm occlusion, recanalization and complications. RESULTS Between May 2010 and September 2018, 70 patients harboring incompletely occluded intracranial aneurysms after clipping met the inclusion criteria in 5 centers. The mean residual aneurysm size was 7.5 mm. Fifty-nine aneurysms were unruptured. Total aneurysm occlusion was achieved in 75.3% of the aneurysms after 1 year. All aneurysms treated with flow diversion revealed complete occlusion according to control angiography. Recanalization was observed in 14.5%. Permanent morbidity and mortality occurred in 2.9% and 1.4% of the patients, respectively. CONCLUSIONS Endovascular treatment of recurrent or residual aneurysms after surgical clipping was safe and efficacious. Flow diversion seems to be associated with better anatomical results. A more rigid study, a larger group of patients, and longterm follow-up are required to provide stronger conclusions about the best approach for residual clipped aneurysms.
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Affiliation(s)
| | - Felipe Padovani Trivelato
- Division of Interventional Neuroradiology, Felício Rocho Hospital, Belo Horizonte, Minas Gerais, Brazil
| | - Guilherme Seizem Nakiri
- Division of Interventional Neuroradiology, Hospital das Clínicas, Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | | | - Luís Henrique de Castro-Afonso
- Division of Interventional Neuroradiology, Hospital das Clínicas, Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Thiago Giansante Abud
- Division of Interventional Neuroradiology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - José Ricardo Vanzin
- Division of Interventional Neuroradiology, Hospital de Clínicas, Passo Fundo, Rio Grande do Sul, Brazil
| | - Luciano Bambini Manzato
- Division of Interventional Neuroradiology, Hospital de Clínicas, Passo Fundo, Rio Grande do Sul, Brazil
| | - Alexandre Cordeiro Ulhôa
- Division of Interventional Neuroradiology, Felício Rocho Hospital, Belo Horizonte, Minas Gerais, Brazil
| | - Daniel Giansante Abud
- Division of Interventional Neuroradiology, Hospital das Clínicas, Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Alexandre Varella Giannetti
- Department of Neurosurgery, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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Marbacher S, Halter M, Vogt DR, Kienzler JC, Magyar CTJ, Wanderer S, Anon J, Diepers M, Remonda L, Fandino J. Value of 3-Dimensional Digital Subtraction Angiography for Detection and Classification of Intracranial Aneurysm Remnants After Clipping. Oper Neurosurg (Hagerstown) 2021; 21:63-72. [PMID: 33861324 PMCID: PMC8279834 DOI: 10.1093/ons/opab087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/24/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The current gold standard for evaluation of the surgical result after intracranial aneurysm (IA) clipping is two-dimensional (2D) digital subtraction angiography (DSA). While there is growing evidence that postoperative 3D-DSA is superior to 2D-DSA, there is a lack of data on intraoperative comparison. OBJECTIVE To compare the diagnostic yield of detection of IA remnants in intra- and postoperative 3D-DSA, categorize the remnants based on 3D-DSA findings, and examine associations between missed 2D-DSA remnants and IA characteristics. METHODS We evaluated 232 clipped IAs that were examined with intraoperative or postoperative 3D-DSA. Variables analyzed included patient demographics, IA and remnant distinguishing characteristics, and 2D- and 3D-DSA findings. Maximal IA remnant size detected by 3D-DSA was measured using a 3-point scale of 2-mm increments. RESULTS Although 3D-DSA detected all clipped IA remnants, 2D-DSA missed 30.4% (7 of 23) and 38.9% (14 of 36) clipped IA remnants in intraoperative and postoperative imaging, respectively (95% CI: 30 [ 12, 49] %; P-value .023 and 39 [23, 55] %; P-value = <.001), and more often missed grade 1 (< 2 mm) clipped remnants (odds ratio [95% CI]: 4.3 [1.6, 12.7], P-value .005). CONCLUSION Compared with 2D-DSA, 3D-DSA achieves a better diagnostic yield in the evaluation of clipped IA. Our proposed method to grade 3D-DSA remnants proved to be simple and practical. Especially small IA remnants have a high risk to be missed in 2D-DSA. We advocate routine use of either intraoperative or postoperative 3D-DSA as a baseline for lifelong follow-up of clipped IA.
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Affiliation(s)
- Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Matthias Halter
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Deborah R Vogt
- Department of Clinical Research, Clinical Trial Unit, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Jenny C Kienzler
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | | | - Stefan Wanderer
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Javier Anon
- Division of Neuroradiology, Department of Radiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Michael Diepers
- Division of Neuroradiology, Department of Radiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Luca Remonda
- Division of Neuroradiology, Department of Radiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Javier Fandino
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
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Lee HJ, Choi JH, Shin YS, Lee KS, Kim BS. Risk Factors for the Recurrence of Posterior Communicating Artery Aneurysm: The Significance of Fetal-Type Posterior Cerebral artery. J Stroke Cerebrovasc Dis 2021; 30:105821. [PMID: 33915389 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105821] [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: 03/15/2021] [Revised: 03/27/2021] [Accepted: 04/04/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES The purpose of this study was to investigate the risk factors associated with recurrence of posterior communicating artery aneurysms after treatment and to evaluate the significance of fetal-type posterior cerebral artery as an independent risk factor for recurrence of posterior communicating artery aneurysms. MATERIALS AND METHODS The clinical and radiological findings of 220 posterior communicating artery aneurysms treated between January 2009 and December 2016 in a single tertiary institute were retrospectively reviewed. Univariate and multivariate analyses were performed to evaluate the association between clinical and radiological variables and recurrence. RESULTS Of 220 posterior communicating artery aneurysms, 148 aneurysms were unruptured and 82 aneurysms were treated with surgery. Forty-six out of 220 aneurysms (20.9%) were associated with fetal-type posterior cerebral artery. Overall recurrence rate was 19% (42 out of 220 aneurysms) during mean 54.6 ± 29.8 months follow-up. Multivariate logistic regression analysis showed that size (OR=1.238; 95% CI, 1.087-1.409, p = 0.001), ruptured status (OR=2.699; 95% CI, 1.179-6.117, p = 0.019), endovascular treatment (OR=3.803; 95% CI, 1.330-10.875, p = 0.013), incomplete occlusion (OR=4.699; 95% CI, 1.999-11.048, p = <0.001) and fetal-type posterior cerebral artery (OR=3.533; 95% CI, 1.373-9.089, p = 0.009) were significantly associated with recurrence after treatment. CONCLUSIONS The results demonstrated that fetal-type posterior cerebral artery may be an independent risk factor for the recurrence of posterior communicating artery aneurysms. Therefore, fetal-type posterior cerebral artery can be considered as an important risk factor for the recurrence of posterior communicating artery aneurysms, along with other known risk factors such as size, ruptured status, endovascular treatment, and incomplete occlusion.
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Affiliation(s)
- Hyeong Jin Lee
- Department of Neurosurgery, Chuncheon Army Hospital, Chuncheon, Gangwon, South Korea.
| | - Jai Ho Choi
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, South Korea.
| | - Yong Sam Shin
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, South Korea.
| | - Kwan Sung Lee
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, South Korea.
| | - Bum Soo Kim
- Department of Radiology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, South Korea.
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Piao J, Luan T, Qu L, Yu J. Intracranial post-clipping residual or recurrent aneurysms: Current status and treatment options (Review). MEDICINE INTERNATIONAL 2021; 1:1. [PMID: 36698683 PMCID: PMC9855273 DOI: 10.3892/mi.2021.1] [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: 02/14/2021] [Accepted: 04/08/2021] [Indexed: 01/28/2023]
Abstract
Following the clipping of intracranial aneurysms, post-clipping residual or recurrent aneurysms (PCRRAs) can occur. In recent years, the incidence of PCRRAs has increased due to a prolonged follow-up period and advanced imaging techniques. However, several aspects of intracranial PCRRAs remain unclear. Therefore, the present study performed an in-depth review of the literature on PCRRAs. Herein, a summary of PCRRAs that can be divided into the following two categories is presented: i) Those occurring after the incomplete clipping of an aneurysm, where the residual aneurysm regrows into a PCRRA; and ii) those occurring after the complete clipping of an aneurysm, in which a de novo aneurysm occurs at the original aneurysm site. Currently, digital subtracted angiography remains the gold standard for the imaging diagnosis of PCRRAs as it can eliminate metallic clip artifacts. Intracranial symptomatic PCRRAs should be actively treated, particularly those that have ruptured. A number of methods are currently available for the treatment of intracranial PCRRAs; these mainly include re-clipping, endovascular treatment (EVT) and bypass surgery. Currently, re-clipping remains the most effective method used to treat PCRRAs; however, it is a very difficult procedure to perform. EVT can also be used to treat intracranial PCRRAs. EVT methods include coiling (stent- or balloon-assisted) and flow-diverting stents (or coiling-assisted). Bypass surgery can be selected for difficult-to-treat, complex PCRRAs. On the whole, following appropriate treatment, the majority of intracranial PCRRAs achieve a high occlusion rate and a good prognosis.
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Affiliation(s)
- Jianmin Piao
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Tengfei Luan
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Lai Qu
- Department of Intensive Care, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China,Correspondence to: Dr Jinlu Yu, Department of Neurosurgery, The First Hospital of Jilin University, 1 Xinmin Avenue, Changchun, Jilin 130021, P.R. China
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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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17
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Świątnicki W, Szymański J, Szymańska A, Komuński P. Predictors of Intraoperative Aneurysm Rupture, Aneurysm Remnant, and Brain Ischemia following Microsurgical Clipping of Intracranial Aneurysms: Single-Center, Retrospective Cohort Study. J Neurol Surg A Cent Eur Neurosurg 2021; 82:410-416. [PMID: 33583011 DOI: 10.1055/s-0040-1721004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND STUDY AIMS Complete microsurgical clip occlusion of an aneurysm is one of the most important challenges in cerebrovascular surgery. Incorrect position of clip blades as well as intraoperative aneurysm rupture can expose the patient to serious complications such as rebleeding in case of aneurysm remnant and cerebral ischemia in case of occlusion of branching arteries or perforators. The aim of this study was to identify independent predictors of surgery-derived complications (aneurysm remnant and brain ischemia) as well as intraoperative aneurysm rupture in an institutional series of patients. MATERIAL AND METHODS This is a single-institution, retrospective cohort study including 147 patients with 162 aneurysms that were selected for microsurgical clipping due to intracranial aneurysm in a 5-year period. Bivariate and multivariate analyses were performed to identify independent predictors among demographic, clinical, and radiographic factors. RESULTS Increasing aneurysm size with a cutoff value at 9 mm (p = 0.009; odds ratio [OR]: 0.644) and irregular dome shape (p = 0.003; OR: 4.242) were independently associated with brain ischemia and aneurysm remnants that occurred in 13.6 and 17.3% of patients in our group, respectively. Intraoperative rupture was encountered in 27% of patients and its predictors were patient's age (p = 0.002; OR: 1.073) and increasing aneurysm size with a cutoff value at 7 mm (p = 0.003; OR: 1.205). CONCLUSION Aneurysm size, patient's age, and irregular dome shape were the most important risk factors of aneurysm remnant, brain ischemia, and intraoperative aneurysm rupture in our series of patients. We were not able to define a cutoff value for patient's age, but our results showed that with increasing age the risk of intraoperative aneurysm rupture increased.
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Affiliation(s)
| | - Jarosław Szymański
- University of Lodz Faculty of Economics and Sociology, Economic and Social Statistics, Lodz, Poland
| | - Anna Szymańska
- University of Lodz Faculty of Economics and Sociology, Economic and Social Statistics, Lodz, Poland
| | - Piotr Komuński
- Maria Sklodowska-Curie Hospital, Neurosurgery Zgierz, Lodz, Poland
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18
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Obermueller K, Hostettler I, Wagner A, Boeckh-Behrens T, Zimmer C, Gempt J, Meyer B, Wostrack M. Frequency and risk factors for postoperative aneurysm residual after microsurgical clipping. Acta Neurochir (Wien) 2021; 163:131-138. [PMID: 33216209 PMCID: PMC7778624 DOI: 10.1007/s00701-020-04639-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 10/27/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Aneurysm residuals after clipping are a well-known problem, but the course of aneurysm remnants in follow-up is not well studied. No standards or follow-up guidelines exist for treatment of aneurysm remnants. The aim of this study was to evaluate the risk factors for postoperative aneurysm remnants and their changes during follow-up. METHODS We performed a retrospective analysis of 666 aneurysms treated via clipping in our hospital from 2006 to 2016. Postoperative and follow-up angiographic data were analyzed for aneurysm remnants and regrowth. Clinical parameters and aneurysm-specific characteristics were correlated with radiological results. RESULTS The frequency of aneurysm residuals was 12% (78/666). Aneurysms located in the middle cerebral artery (p = 0.02) showed a significantly lower risk for incomplete aneurysm occlusion. Larger aneurysms with a diameter of 11-25 mm (p = 0.005) showed a significantly higher risk for incomplete aneurysm occlusion. Five patients underwent re-clipping during the same hospital stay. Remnants were stratified based on morphological characteristics into "dog ears" (n = 60) and "broad based" (n = 13). The majority of the "dog ears" stayed stable, decreased in size, or vanished during follow-up. Broad-based remnants showed a higher risk of regrowth. CONCLUSIONS A middle cerebral artery location seems to lower the risk for the incomplete clip occlusion of an aneurysm. Greater aneurysm size (11-25 mm) is associated with a postoperative aneurysm remnant. The majority of "dog-ear" remnants appear to remain stable during follow-up. In these cases, unnecessarily frequent angiographic checks could be avoided. By contrast, broad-based residuals show a higher risk of regrowth that requires close imaging controls if retreatment cannot be performed immediately.
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Affiliation(s)
- Kathrin Obermueller
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Straße 22, 81675, Munich, Germany.
| | - Isabel Hostettler
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Arthur Wagner
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Tobias Boeckh-Behrens
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Claus Zimmer
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Straße 22, 81675, Munich, Germany
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Pilipenko YV, Eliava SS, Pronin IN, Okishev DN, Abramyan AA. [Completeness of brain aneurysm exclusion according to CT angiography]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2020; 84:76-85. [PMID: 33306302 DOI: 10.17116/neiro20208406176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To develop a classification of the completeness of brain aneurysm exclusion according to CT angiography for determining further diagnostic and curative strategy. MATERIAL AND METHODS The study included 138 patients who had 164 brain aneurysms. Clipping was carried out at the Burdenko Neurosurgery Center in 2013-2017. Titanium clips were used in 111 cases, cobalt clips - in 53 patients. RESULTS Completeness of brain aneurysm exclusion was assessed in 149 cases using CT angiography. In 15 cases, artifacts from cobalt clips impaired assessment. Total exclusion was achieved in 136 (91.3%) cases, subtotal (a remainder of residual neck) - in 10 (6.7%) cases, complete exclusion of the body and bottom (patent neck) - 2 (1.3%) patients, partial exclusion (partially patent bottom) - 1 patient (0.7%). In this series, a clip prevented complete contrast enhancement of brain aneurysm bottom in all cases. CONCLUSION CTA is a reliable method for assessing the quality of exclusion of brain aneurysm in patients with implanted titanium clips. In case of cobalt clips, stratification depending on severity of CT artifacts should be performed for data interpretation. In some cases, artifacts impair visualization of the vessels adjacent to the clips. In these patients, direct cerebral angiography or dual-energy computed tomography scanners with metal artifact suppression programs should be recommended. Follow-up is recommended for patients with remnants of residual cervix. Redo surgery is indicated for completely patent neck, as well as partial or complete contrast enhancement of aneurysm bottom.
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Affiliation(s)
| | | | - I N Pronin
- Burdenko Center of Neurosurgery, Moscow, Russia
| | - D N Okishev
- Burdenko Center of Neurosurgery, Moscow, Russia
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20
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de Aguiar GB, Kormanski MK, Corrêa CJT, Batista AVDS, Conti MLM, Veiga JCE. Residual lesions in patients undergoing microsurgical clipping of cerebral aneurysms in a reference university hospital. Clinics (Sao Paulo) 2020; 75:e1973. [PMID: 33146358 PMCID: PMC7561064 DOI: 10.6061/clinics/2020/e1973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 08/13/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES This study aimed to analyze the incidence and epidemiological, angiographic, and surgical aspects associated with incomplete clipping of brain aneurysms in a cohort of patients undergoing microsurgical treatment. METHODS The medical record data of patients who underwent microsurgery for cerebral aneurysm treatment and postoperative digital subtraction angiography, treated at the same teaching hospital between 2014 and 2019, were retrospectively analyzed. The studied variables involved epidemiological and clinical data, as well as neurological status and findings on neuroimaging. The time elapsed between hemorrhage and microsurgical treatment, data on the neurosurgical procedure employed for aneurysm occlusion, and factors associated with the treated aneurysm, specifically location and size, were also evaluated. RESULTS One hundred and seventeen patients were submitted to 139 neurosurgical procedures, in which 167 aneurysms were clipped. The overall rate of residual injury was 23%. Smoking (odds ratio [OR]: 3.38, 95% confidence interval [CI95%]: 1.372-8.300, p=0.008), lesion size >10 mm (OR: 5.136, CI95%: 2.240-11.779, p<0.001) and surgery duration >6 h (OR: 8.667, CI95%: 2.713-27.681, p<0.001) were found to significantly impact incomplete aneurysm occlusion in the univariate analyses. CONCLUSION Incomplete microsurgical aneurysm occlusion is associated with aneurysm size, complexity, and current smoking status. Currently, there is no consensus on postoperative assessment of clipped aneurysms, hindering the correct assessment of treatment outcomes.
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Dawod G, Henkel ND, Salahuddin H, Castonguay AC, Koneru S, Mugge L, Khuder SA, Medhkour A, Jumaa MA. Outcomes of treatment modalities for ruptured intracranial aneurysms based on age - A meta-analysis. J Stroke Cerebrovasc Dis 2020; 29:105039. [PMID: 32807451 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105039] [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: 04/11/2020] [Revised: 05/17/2020] [Accepted: 06/07/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Data comparing the effect of age on outcomes of patients who underwent either endovascular coiling (EVC) or neurosurgical clipping (NSC) for ruptured intracranial aneurysms remains limited. OBJECTIVE To better elucidate the preferred intervention for ruptured aneurysm management by presenting the results of our systematic review of the literature that evaluated the potential advantages of the two interventions between different age groups. METHODS Systematic review of PubMed and Embase was performed (2002 - June 10, 2019) following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2013 guidelines. Median ages of EVC and NSC cohorts were 54 and 56, respectively. Ages below the median were used in our "younger" cohort; ages above the median were used in our "older" cohort. RESULTS We reviewed 13 studies on 7,137 patients. In the younger cohort, there were 2840 (EVC: 1412, NSC: 1428) patients. In the older cohort, there were 4297 (EVC: 2552, NSC: 1745) patients. Overall, there was a significant difference in functionality between EVC (77.70%) and NSC (69.23%) (OR=1.69; 95% C.I.: 1.10-2.60, p = 0.0212). In our younger cohort, functionality was significantly different between EVC (77%) and NSC (69%) (OR=1.54; 95% C.I.: 1.29-1.84, p < 0.001). For the older cohort, there was no significant difference in functionality, complications, or efficacy. CONCLUSIONS We have highlighted the importance of considering age prior to deciding which intervention is most appropriate for ruptured aneurysms, with higher morbidity and mortality with NSC versus EVC in the younger population.
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Affiliation(s)
- Giana Dawod
- Neurological Surgery, The University of Toledo Medical Center, Toledo, OH, USA.
| | - Nicholas D Henkel
- Neurological Surgery, The University of Toledo Medical Center, Toledo, OH, USA.
| | - Hisham Salahuddin
- Neurology, The University of Toledo Medical Center, Toledo, OH, USA.
| | | | | | - Luke Mugge
- Neurological Surgery, Inova Neuroscience and Spine Institute, Falls Church, VA, USA.
| | - Sadik A Khuder
- Department of Medicine, Department of Public Health, The University of Toledo Medical Center, Toledo, OH, USA.
| | - Azedine Medhkour
- Neurological Surgery, The University of Toledo Medical Center, Toledo, OH, USA.
| | - Mouhammad A Jumaa
- Neurology, The University of Toledo Medical Center, Toledo, OH, USA; Neurology, Promedica Toledo Hospital, Toledo, OH, USA.
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22
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Jang CK, Chung J, Lee JW, Huh SK, Son NH, Park KY. Recurrence and retreatment of anterior communicating artery aneurysms after endovascular treatment: a retrospective study. BMC Neurol 2020; 20:287. [PMID: 32727591 PMCID: PMC7389810 DOI: 10.1186/s12883-020-01871-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 07/26/2020] [Indexed: 11/16/2022] Open
Abstract
Background Surgical treatment of anterior communicating artery (Acom) aneurysm is challenging due to anatomic complexity. We aimed to describe our experiences with endovascular treatment (EVT) of Acom aneurysms, and to evaluate the incidence and risk factors of recurrence and retreatment. Methods The study comprised 260 patients who were treated at a single center between January 2010 and December 2018. Patients who had EVT, including stent-assisted coiling of Acom aneurysms, were included. All medical records were retrospectively reviewed. The incidence and risk factors of recurrence and retreatment were evaluated. Univariate and multivariate analysis were conducted. Results Recurrence of Acom aneurysms occurred in 38 (14.6%) patients. Mean follow-up duration was 27 months (range 1–110). Multivariate logistic regression indicated that ruptured aneurysm (odds ratio [OR] 3.55, P = 0.001), dome direction (anterior) (OR 3.86, P = 0.002), maximal diameter (OR 1.19, P = 0.02), and mean age (OR 0.96, P = 0.02) were independent risk factors for aneurysm recurrence. Of 38 cases of recurrence, 10 (3.8%) patients underwent retreatment. Ruptured aneurysm (OR 14.7, P = 0.004), maximal diameter (OR 1.56, P = 0.02), inflow angle (OR 1.04, P = 0.03), and Raymond-Roy classes II and III (OR 6.19, P = 0.03) showed significant relation to retreatment in multivariate logistic regression analysis. Conclusions In our study, recurrence rate of Acom aneurysms after EVT was 14.6%. Rupture, anterior dome direction, maximal diameter, and mean age were significantly associated with recurrence. Retreatment rate of recurrent Acom aneurysms after EVT was 3.8%. Patients with Acom aneurysms with large inflow, rupture, large size, or incomplete occlusion may be at a high risk of retreatment of recurring aneurysm.
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Affiliation(s)
- Chang Ki Jang
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Joonho Chung
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.,Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae Whan Lee
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Seung Kon Huh
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.,Department of Neurosurgery, Muhas Academic Medical Center, Dar es Salaam, United Republic of Tanzania
| | - Nak-Hoon Son
- Medical Research Supporting Section, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Gyeonggi-do, Republic of Korea
| | - Keun Young Park
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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23
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Aguiar GBD, Kormanski MK, Batista AVDS, Conti MLM, Veiga JCE. Residual lesions in patients who underwent microsurgical clipping of cerebral aneurysms. Rev Assoc Med Bras (1992) 2020; 66:701-705. [PMID: 32638977 DOI: 10.1590/1806-9282.66.5.701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 10/10/2019] [Indexed: 11/22/2022] Open
Abstract
Microsurgical clipping is currently the main method of treating cerebral aneurysms, even with the improvement of endovascular therapy techniques in recent years. Treatment aims at complete occlusion of the lesion, which is not always feasible. Although appearing superior to endovascular treatment, microsurgical clipping may present varying percentages of incomplete occlusion. Such incidence may be reduced with the use of intraoperative vascular study. Some classifications were elaborated in an attempt to standardize the characteristics of residual lesions, but the classification criteria and terminology used in the studies remain vague and poorly documented, and there is no consensus for a uniform classification. Thus, there is also no agrément on which residual aneurysms should be treated. The aim of this study is to review the literature on residual lesions after microsurgery to treat cerebral aneurysms and how to proceed with them.
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24
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Mohammad F, Horiguchi T, Mizutani K, Yoshida K. Clipping versus coiling in unruptured anterior cerebral circulation aneurysms. Surg Neurol Int 2020; 11:50. [PMID: 32257576 PMCID: PMC7110064 DOI: 10.25259/sni_1_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 03/01/2020] [Indexed: 02/06/2023] Open
Abstract
Background: Unruptured intracranial aneurysms (UIAs) are not uncommon, especially in Japan. Treatment strategy for UIAs has evolved in the past decades in Western countries with the increased use of endovascular treatment as the primary option, but in Japan, clipping still has the upper hand. Methods: This study retrospectively included 200 patients treated by clipping or coiling for UIAs located in the anterior cerebral circulation. Postoperative angiographic and clinical outcomes were evaluated. Results: Of 200 UIAs, 147 and 53 were treated by surgery and coiling, respectively. The average follow-up duration was 30.2 ± 18.8 months for clipping and 29.3 ± 17.6 months for coiling. Complete occlusion was greater in the surgery group (78.9%) than the endovascular group (18.8%). Regrowth occurred in 1.4% of the clipping group and 13.2% of the coiling group. Ischemic events were encountered in both groups; asymptomatic ones were higher in the coiling group (24.5%) than in the clipping group (2%), while symptomatic ischemic complications were equal (7.5%) in both groups. The deterioration of modified Rankin scale was detected totally in 13 UIAs (6.5%) with no statistical difference between groups. Postoperative hospital period was longer in clipping (P = 0.01). Conclusion: Clipping and coiling were both safe and feasible in the treatment of unruptured aneurysms. The clipping was advantageous in durability, while the rate of morbidity was lower, and hospitalization period was shorter in the coiling group. The clipping and coiling should coexist while complementing each other by understanding the advantages and disadvantages of both.
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Affiliation(s)
- Farrag Mohammad
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan.,Department of Neurosurgery, Faculty of Medicine, Assiut University, Markaz El-Fath, Assiut Governorate, Egypt
| | - Takashi Horiguchi
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Katsuhiro Mizutani
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Kazunari Yoshida
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
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25
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Delayed Progression to Major Recanalization in Coiled Aneurysms with Minor Recanalization at 36-Month Follow-up : Incidence and Related Risk Factors. Clin Neuroradiol 2020; 31:401-408. [PMID: 32144482 DOI: 10.1007/s00062-020-00887-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 02/07/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The aim was to monitor aneurysms that show imaging evidence of minor recanalization 36 months after coil embolization and to determine the rate and related risk factors of major recanalization during more prolonged observation. METHODS A total of 54 patients with 55 aneurysms showing minor recanalization at 36-month follow-up imaging between 2011 and 2013 were retrospectively reviewed. Medical records and radiological data accumulating in the course of extended monitoring (mean 83.9 ± 21.5 months) were assessed. Incidence and average annual risk of progression to major recanalization were then calculated. Univariate and multivariate regression analyses were applied to determine possible risk factors for progression to major recanalization. RESULTS In the 55 aneurysms studied 26 showed sustained minor recanalization since month 6 of follow-up, whereas minor recanalization of 29 completely occluded coiled lesions appeared in follow-up images after 6-24 months. Only 8 coiled aneurysms (14.5%) with minor recanalization at 36 months progressed to major recanalization during 219.3 aneurysm-years of observation (3.6% per aneurysm-year), 2 surfacing within 72 months and 6 developing thereafter. Additional embolization was performed in six of these patients. By multivariate analysis, no clinical or anatomic factors were statistically linked to such progression, but younger age showed marginal significance (hazard ratio, HR = 1.076; p = 0.099). CONCLUSION Most coiled aneurysms (85.5%) showing minor recanalization at 36 months postembolization proved to be stable in extended observation. Given the low probability but seriousness of delayed major recanalization, careful monitoring is still warranted in this setting but at less frequent intervals (every 2-3 years) beyond 36 months.
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26
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Kim JJ, Cho KC, Suh SH, Chung J, Jang CK, Joo JY, Kim YB. Evaluation of the angiographic outcomes after clipping of intracranial aneurysms: determination of predisposing factors for occurrence of aneurysm remnants. Neurol Res 2020; 42:354-360. [PMID: 32100635 DOI: 10.1080/01616412.2020.1732594] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objectives: Aneurysm remnants after microsurgical clipping have a risk of regrowth and rupture and have not been validated in the era of three-dimensional angiography. Therefore, this study aimed to evaluate the angiographic outcome using three-dimensional rotational images and determine the predictors for remnants after microsurgical clipping.Methods: Between January 2014 and May 2017, 139 aneurysms in 106 patients who were treated with microsurgical clipping, were eligible for this study. For the determination of aneurysm remnants after microsurgical clipping, the angiographic outcomes were evaluated using follow-up digital subtraction angiography within 7 days for unruptured aneurysms or within 2 weeks for ruptured aneurysms. According to the Sindou classification, the aneurysm remnants were dichotomized, and subgroup analysis was performed to identify the predictors of aneurysm remnants after clipping with various imaging parameters and clinical information.Results: The overall rate of aneurysm remnants was 29.5% (41/139), in which retreatments were needed in 6.5% (9/139). The neck size and maximum diameter of aneurysms were independent predisposing factors for the aneurysm remnants that need retreatment (OR: 2.30; p < 0.001; OR: 1.38; p < 0.001, respectively).Conclusions: This study demonstrated a low incidence of aneurysm remnants after microsurgical clipping which need to retreatment. However, selective postoperative angiography could provide us clear information of surgical result and evidence for long-term follow-up for some aneurysms with larger neck size (>5.7 mm) and maximum diameter (>7.1 mm).
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Affiliation(s)
- Jung-Jae Kim
- Department of Neurosurgery, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul, South Korea
| | - Kwang-Chun Cho
- Department of Neurosurgery, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, South Korea
| | - Sang Hyun Suh
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Joonho Chung
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Chang Ki Jang
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jin-Yang Joo
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Yong Bae Kim
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
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27
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Fingerlin TJ, Rychen J, Roethlisberger M, Taub E, Mariani L, Guzman R, Zumofen DW. Long-term aneurysm recurrence and de novo aneurysm formation after surgical treatment of unruptured intracranial aneurysms: a cohort study and systematic review. Neurol Res 2020; 42:338-345. [PMID: 32048571 DOI: 10.1080/01616412.2020.1726587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: There is a relative lack of literature on long-term aneurysm recurrence and de novo aneurysm formation following surgical treatment of unruptured intracranial aneurysms. This retrospective single-center cohort study, therefore, analyzes the incidence of aneurysm recurrence, and the incidence of de novo aneurysms formation in patients with at least 10yrs of radiological follow-up. The data are put into the context of a systematic review of the literature.Methods: Patients that underwent surgical treatment of an unruptured intracranial aneurysm at the Basel University Hospital were retrospectively identified. The rate of recurrent or de novo aneurysm formation was assessed for all patients with imaging follow-up ≥10yrs. A systematic review including studies with a mean follow-up period of ≥10yrs was then performed.Results: A total of 95 patients had undergone surgical treatment of an unruptured intracranial aneurysm between 1994 and 2008. Twenty-one patients (22.1%) had available imaging follow-up ≥10yrs (mean: 13.1yrs). In these patients, aneurysm recurrence and de novo aneurysm formation were equally found in 23.8% (n = 5; 1.8%/yr). There was no case of aneurysm rupture from a recurrent or a de novo aneurysm. The systematic literature review covered a combined cohort of 1778 patients over a mean follow-up period of 14.0yrs. In this cohort, the aneurysm recurrence rate was 16.4% (0.7%/yr), and the rate of de novo aneurysm formation was 6.2% (0.4%/yr).Discussion: Despite some discrepancy regarding the incidence, both cohorts show a non-negligible long-term risk of aneurysm recurrence and de novo aneurysm formation, which warrants life-long imaging follow-up.Abbreviations: SD: standard deviation; DSA: digital subtraction angiography; CTA: computed tomography angiography; MRA: magnetic resonance angiography; MCA: middle cerebral artery; ACA: anterior cerebral artery; ACommA: anterior communicating artery; ICA: internal carotid artery; ADPKD: autosomal dominant polycystic kidney disease; MeSH: Medical Subject Headings.
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Affiliation(s)
- Tamara J Fingerlin
- Department of Neurosurgery, Basel University Hospital, University of Basel, Basel, Switzerland
| | - Jonathan Rychen
- Department of Neurosurgery, Basel University Hospital, University of Basel, Basel, Switzerland
| | - Michel Roethlisberger
- Department of Neurosurgery, Basel University Hospital, University of Basel, Basel, Switzerland
| | - Ethan Taub
- Department of Neurosurgery, Basel University Hospital, University of Basel, Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, Basel University Hospital, University of Basel, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, Basel University Hospital, University of Basel, Basel, Switzerland
| | - Daniel W Zumofen
- Department of Neurosurgery, Basel University Hospital, University of Basel, Basel, Switzerland.,Division of Neurosurgery, Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
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28
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Spiessberger A, Vogt DR, Fandino J, Marbacher S. Formation of intracranial de novo aneurysms and recurrence after neck clipping: a systematic review and meta-analysis. J Neurosurg 2020; 132:456-464. [PMID: 30797217 DOI: 10.3171/2018.10.jns181281] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 10/26/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Incidence rates of de novo aneurysm formation and recurrence after clip ligation remain controversial. In this meta-analysis, the authors provide data on pooled annual incidence rates and the association of patient characteristics with time to formation of de novo aneurysms and time to recurrence after clipping. METHODS A search of the literature up to June 15, 2016, on PubMed and a systematic review were performed. The association of age, aneurysm rupture status, aneurysm multiplicity, and anatomical location with time to recurrence or formation of de novo aneurysm was estimated using multivariable Cox proportional-hazards models. Kaplan-Meier estimates (event-free survival curves) are shown. Pooled annualized incidence rates of recurrent and de novo aneurysms were estimated using Poisson regression. Proportions of aneurysms and average follow-up times are displayed as bubble plots with LOESS smoothers weighted for study size. RESULTS Of the 7606 articles screened, 92 were included in the study. Case reports on 101 patients with recurrent aneurysms and 132 patients with de novo aneurysms were analyzed. Long-term follow-up studies on de novo aneurysm formation included 13,723 patients with 101,378 patient-years of follow-up; studies on aneurysm recurrence included 5922 patients with 31,055 patient-years of follow-up. Mean time to recurrence was 12.9 ± 6.6 years (mean ± standard deviation), and mean time to de novo formation was 9.3 ± 6.1 years. No association with sex, aneurysm location, and initial rupture could be shown. De novo aneurysms occurred later in patients with multiplicity of aneurysms at diagnosis (HR 0.63, p = 0.03) and in patients with increasing age (HR per 10 yrs 0.88, p = 0.06). Pooled annualized incidence rates were 0.35% for de novo aneurysms and 0.13% for recurrent aneurysms. CONCLUSIONS Despite low reported annual incidence rates, the cumulative risk of 9.6%-22% for aneurysm recurrence or de novo formation 20 years after clip ligation warrants lifelong follow-up. Screening at 5, 10, and 20 years would detect 30.8% (95% CI 23.3%-37.6%), 64.2% (95% CI 55.9%-70.9%), and 95.9% (95% CI 90.9%-97.9%) of de novo aneurysms. Screening for recurrent aneurysms at 10, 15, and 20 years would detect 36.6% (95% CI 26.5%-45.4%), 65.3% (95% CI 54.7%-73.5%), and 95.1% (95% CI 85.8%-96.6%) of lesions.
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Affiliation(s)
| | - Deborah R Vogt
- 2Clinical Trial Unit, Department of Clinical Research, University of Basel, University Hospital Basel, Switzerland
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29
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Smith TR, Gupta S. Response by Smith and Gupta to Letter Regarding Article, “Computed Tomography Angiography Versus Digital Subtraction Angiography for Postclipping Aneurysm Obliteration Detection: A Meta-Analysis”. Stroke 2019; 50:e159. [DOI: 10.1161/strokeaha.119.025359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Timothy R. Smith
- Computational Neurosciences Outcomes Center Department of Neurosurgery, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA
| | - Saksham Gupta
- Computational Neurosciences Outcomes Center Department of Neurosurgery, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA
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30
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Satoh T, Hishikawa T, Hiramatsu M, Sugiu K, Date I. Visualization of Aneurysmal Neck and Dome after Coiling with 3D Multifusion Imaging of Silent MRA and FSE-MR Cisternography. AJNR Am J Neuroradiol 2019; 40:802-807. [PMID: 30948372 DOI: 10.3174/ajnr.a6026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 03/11/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Our aim was to visualize the precise configuration of the aneurysmal neck and dome with/without remnants combined with a coiled dome after coiling treatment for cerebral aneurysms. We developed 3D multifusion imaging of silent MRA and FSE-MR cisternography. MATERIALS AND METHODS We examined 12 patients with 3D multifusion imaging by composing 3D images reconstructed from TOF-MRA, silent MRA, and FSE-MR cisternography. The influence of magnetic susceptibility artifacts caused by metal materials affecting the configuration of the aneurysmal complex with coiling was assessed in a single 3D image. RESULTS In all cases, TOF-MRA failed to depict the aneurysmal neck complex precisely due to metal artifacts, whereas silent MRA delineated the neck and parent arteries at the coiled regions without serious metal artifacts. FSE-MR cisternography depicted the shape of the coiled aneurysmal dome and parent artery complex together with the brain parenchyma. With the 3D multifusion images of silent MRA and FSE-MR cisternography, the morphologic status of the coiled neck and parent arteries was clearly visualized with the shape of the dome in a single 3D image. CONCLUSIONS Silent MRA is a non-contrast-enhanced form of MRA. It depicts the coiled neck complex without serious metal artifacts. FSE-MR cisternography can delineate the shape of the coiled dome. In this small feasibility study, 3D multifusion imaging of silent MRA and FSE-MR cisternography allowed good visualization of key features of coiled aneurysms. This technique may be useful in the follow-up of coiled aneurysms.
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Affiliation(s)
- T Satoh
- From the Department of Neurological Surgery (T.S.), Ryofukai Satoh Neurosurgical Hospital, Fukuyama, Hiroshima, Japan
| | - T Hishikawa
- Department of Neurological Surgery (T.H., M.H., K.S., I.D.), Okayama University Graduate School of Medicine, Okayama, Okayama, Japan
| | - M Hiramatsu
- Department of Neurological Surgery (T.H., M.H., K.S., I.D.), Okayama University Graduate School of Medicine, Okayama, Okayama, Japan
| | - K Sugiu
- Department of Neurological Surgery (T.H., M.H., K.S., I.D.), Okayama University Graduate School of Medicine, Okayama, Okayama, Japan
| | - I Date
- Department of Neurological Surgery (T.H., M.H., K.S., I.D.), Okayama University Graduate School of Medicine, Okayama, Okayama, Japan
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31
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Marbacher S, Spiessberger A, Diepers M, Remonda L, Fandino J. Early Intracranial Aneurysm Recurrence after Microsurgical Clip Ligation: Case Report and Review of the Literature. J Neurol Surg Rep 2018; 79:e93-e97. [PMID: 30534511 PMCID: PMC6286179 DOI: 10.1055/s-0038-1676454] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 09/20/2018] [Indexed: 12/25/2022] Open
Abstract
Microsurgical clip ligation is considered a definitive treatment for intracranial aneurysms (IAs), resulting in low rates of local recurrence that range from 0.2 to 0.5% and a latency period that averages about a decade. Our case report describes an early asymptomatic recurrence (i.e., without sentinel headache or seizure) less than 1 year after this 20-year-old woman underwent clip ligation of a ruptured anterior communicating artery (AComA) aneurysm. At recurrence, the patient underwent coiling of the regrowth; follow-up imaging at 6 and 18 months demonstrated complete IA occlusion. To review the putative risk factors of this rare phenomenon, the authors searched the PubMed database using the keywords "intracranial aneurysm," "recurrence," and "clipping" in various combinations. In the seven cases identified, all occurred in initially ruptured IA, which was often at the AComA, and six of seven patients were younger than 50 years old. Although most IA remnants grow slowly, early recurrence may represent a more aggressive biological behavior that warrants special attention in younger patients, positive rupture status, and unintended remnant of any size. In such a constellation, early imaging follow-up within the first 6 months may be warranted to rule out early IA recurrence.
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Affiliation(s)
- Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau (KSA), Aarau, Switzerland
| | | | - Michael Diepers
- Division of Neuroradiology, Department of Radiology, Kantonsspital Aarau (KSA), Aarau, Switzerland
| | - Luca Remonda
- Division of Neuroradiology, Department of Radiology, Kantonsspital Aarau (KSA), Aarau, Switzerland
| | - Javier Fandino
- Department of Neurosurgery, Kantonsspital Aarau (KSA), Aarau, Switzerland
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32
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Dimitriadis S, Qeadan F, Taylor CL, Yonas H, Carlson AP. Middle Cerebral Artery Aneurysm "Neck Overhang": Decreased Postclipping Residual Using the Intersecting Clipping Technique. Oper Neurosurg (Hagerstown) 2018. [PMID: 29529311 DOI: 10.1093/ons/opx278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Middle cerebral artery (MCA) aneurysms continue to be viewed by many as primarily surgical entities. OBJECTIVE To introduce a new, easily measurable dimension termed "neck overhang," defined as the amount of the aneurysm that extends proximal to the 2 dimensionally defined "neck" and to evaluate the utility of the intersecting clipping technique (use of straight clip and intersecting fenestrated clip) to adapt to this overhanging segment's specific dimensions and achieve better obliteration of the MCA aneurysms. METHODS We reviewed retrospectively 100 MCA aneurysms treated surgically over the last 10 yr at our institution. We identified the clipping technique that was performed (intersecting vs "standard" technique) and we evaluated the presence of a postoperative remnant. We then correlated these with the aneurysm's overhanging neck length. RESULTS Forty-three aneurysms were treated with the intersecting clipping technique. The overall rate of remnant was 16%. In the standard group, the rate of remnant was 23%, whereas with intersecting clipping that was 7% (P = .029). Within the standard clipping group, we found that the optimum threshold for length of the neck overhang was ≥1.9 mm in order to predict the occurrence of residual. Applying this threshold to the intersecting clipping technique group resulted in a reduction in remnant from 35% in the standard group to 9%. CONCLUSION Neck overhang >1.9 mm is associated with a higher chance of postclipping residual aneurysm in MCA aneurysms. The intersecting clipping technique is a versatile technique that can conform to various aneurysms' geometry and can reduce the rate of post clipping residual for aneurysms with high neck overhang.
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Affiliation(s)
- Stavros Dimitriadis
- Department of Neurological Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Fares Qeadan
- Department of Internal Medicine, division of Epidemiology, Biostatistics and Preventive Medicine University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Christopher L Taylor
- Department of Neurological Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Howard Yonas
- Department of Neurological Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Andrew P Carlson
- Department of Neurological Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
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Safety and Efficacy of Endovascular Treatment of Previously Clipped Aneurysms: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 114:e137-e150. [DOI: 10.1016/j.wneu.2018.02.103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 02/16/2018] [Accepted: 02/17/2018] [Indexed: 01/04/2023]
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AlMatter M, Bhogal P, Aguilar Pérez M, Hellstern V, Bäzner H, Ganslandt O, Henkes H. Evaluation of safety, efficacy and clinical outcome after endovascular treatment of aneurysmal subarachnoid hemorrhage in coil-first setting. A 10-year series from a single center. J Neuroradiol 2018; 45:349-356. [PMID: 29544998 DOI: 10.1016/j.neurad.2018.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 01/20/2018] [Accepted: 02/24/2018] [Indexed: 10/17/2022]
Abstract
INTRODUCTION The endovascular treatment (EVT) of ruptured cerebral aneurysms has been widely adopted after the publication of the International Subarachnoid Aneurysm Trial. In this study, we sought to evaluate the safety and efficacy of the EVT for ruptured aneurysms based on 10-year series from a single center with coil-first strategy. METHODS All patients with aneurysmal subarachnoid hemorrhage (aSAH) treated between 2007 and 2016 were retrospectively reviewed and divided according to initial treatment into an EVT and a microsurgical clipping (MSC) group. Clinical and radiological findings at presentation, treatment modalities and procedural complications were recorded. The angiographic and clinical outcome was compared between the two groups. RESULTS A total of 587 patients with aSAH were reviewed (452 EVT, 135 MSC). There were no significant differences in mean age or the Hunt and Hess grades. Parenchymal hemorrhage (PH) was more frequent in the MSC. Procedure related complications of the acute treatment were recorded in 5.5% and 32% in the EVT and MSC, respectively. The rate of retreatment was 21.9% in the EVT and 5.9% in the MSC. Late rehemorrhage was not observed in either group. There was no significant difference in the clinical outcome between the two treatment groups after adjustment for other prognostic factors. CONCLUSION The majority of ruptured intracranial aneurysms can be managed via an endovascular approach in the acute phase with excellent safety profile and good efficacy. Despite the high rate of reperfusion after primary endovascular approach, retreatment has a very low rate of complications and the rate of recurrent hemorrhage is very low.
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Affiliation(s)
| | | | | | | | | | | | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, Germany; Medizinische Fakultät, Universitätsklinikum Essen, Essen, Germany
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Abstract
Objective Surgical clipping of the cerebral aenurysm is considered as a standard therapy with endovascular coil embolization. The surgical clipping is known to be superior to the endovascular coil embolization in terms of recurrent rate. However, a recurrent aneurysm which is initially treated by surgical clipping is difficult to handle. The purpose of this study was to research the management of the recurrent cerebral aneurysm after a surgical clipping and how to overcome them. Methods From January 1996 to December 2015, medical records and radiologic findings of 14 patients with recurrent aneurysm after surgical clipping were reviewed retrospectively. Detailed case-by-case analysis was performed based on preoperative, postoperative and follow-up radiologic examinations and operative findings. All clinical variables including age, sex, aneurysm size and location, type and number of applied clips, prognosis, and time to recurrence are evaluated. All patients are classified by causes of the recurrence. Possible risk factors that could contribute to those causes and overcoming ways are comprehensively discussed. Results All recurrent aneurysms after surgical clipping were 14 of 2364 (0.5%). Three cases were males and 11 cases were females. Mean age was 52.3. At first treatment, nine cases were ruptured aneurysms, four cases were unruptured aneurysms, and one case was unknown. Locations of recurrent aneurysm were determined; anterior communicating artery (A-com) (n=7), posterior communicating artery (P-com) (n=3), middle cerebral artery (n=2), anterior cerebral artery (n=1) and basilar artery (n=1). As treatment of the recurrence, 11 cases were treated by surgical clipping and three cases were treated by endovascular coil embolization. Three cases of all 14 cases occurred in a month after the initial treatment. Eleven cases occurred after a longer interval, and three of them occurred after 15 years. By analyzing radiographs and operative findings, several main causes of the recurrent cerebral aneurysm were found. One case was incomplete clipping, five cases were clip slippage, and eight cases were fragility of vessel wall near the clip edge. Conclusion This study revealed main causes of the recurrent aneurysm and contributing risk factors to be controlled. To manage those risk factors and ultimately prevent the recurrent aneurysm, neurosurgeons have to be careful in the technical aspect during surgery for a complete clipping without a slippage. Even in a perfect surgery, an aneurysm may recur at the clip site due to a hemodynamic change over years. Therefore, all patients must be followed up by imaging for a long period of time.
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Affiliation(s)
- Pius Kim
- Department of Neurosurgery, College of Medicine, Chosun University, Gwangju, Korea
| | - Suk Jung Jang
- Department of Neurosurgery, College of Medicine, Chosun University, Gwangju, Korea
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Vascular assessment after clipping surgery using four-dimensional CT angiography. Neurosurg Rev 2018; 42:107-114. [PMID: 29502322 DOI: 10.1007/s10143-018-0962-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 02/08/2018] [Accepted: 02/26/2018] [Indexed: 12/29/2022]
Abstract
Recent advances in computed tomography angiography (CTA) enable repeated imaging follow up for post-clipping surgery. The purpose of this study was to clarify the critical volume and configuration of the aneurysmal clip in the postoperative evaluation using volume rendering (VR) imaging, and present four-dimensional (4D)-CTA for these larger metal artifacts. A total of 44 patients with cerebral aneurysm, treated using clipping surgery, were included in this study. The metal artifact volume was assessed using CTA and the association between the type of clips and its metal artifact volume was analyzed. A VR image and a 4D-CTA were then produced, and the diagnostic accuracy of arteries around the clip or residual aneurysm on these images was evaluated. In the receiver operating characteristic (ROC) curve analysis, the cutoff value for metal artifacts was 2.32 mm3 as determined through a VR image. Patients were divided into two groups. Group 1 included patients with a simple and small clip, and group 2 included patients with multiple, large or fenestrated clips. The metal artifact volume was significantly larger in group 2, and the group incorporated the cutoff value. Post-clipping status on the VR image was significantly superior in group 1 compared with group 2. In group 2, the imaging quality of post-clipping status on 4D-CTA was superior in 92.9% of patients. The metal artifact volume was dependent on the number, size, or configuration of the clip used. In group 2, evaluation using a 4D-CTA eliminated the effect of the metal artifacts.
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Secondary coiling after incomplete surgical clipping of cerebral aneurysms: a rescue strategy or a treatment option for complex cases? Institutional series and systematic review. Neurosurg Rev 2018; 42:337-350. [DOI: 10.1007/s10143-018-0950-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 01/13/2018] [Accepted: 01/24/2018] [Indexed: 12/23/2022]
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Hospital-Based Study of the Frequency and Risk Factors of Stroke Recurrence in Two Years in China. J Stroke Cerebrovasc Dis 2017; 26:2494-2500. [PMID: 28939046 DOI: 10.1016/j.jstrokecerebrovasdis.2017.05.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 04/24/2017] [Accepted: 05/17/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Stroke causes death and disability throughout the world and recurrent stroke events are more likely to be disabling or fatal. We conducted a hospital-based study to investigate the frequency and influence factors of stroke recurrence in China. METHODS Data from patients hospitalized with stroke between January 2007 and December 2010 of 109 tertiary hospitals in China were used. Stroke recurrence and associated factors were ascertained. The zero-inflated model was used to evaluate the factors of recurrence. RESULTS Of 101,926 discharged patients, the cumulative 2-year stroke recurrence rate was 3.80% for subarachnoid hemorrhage (SAH), 5.31% for intracerebral hemorrhage (ICH), and 8.71% for ischemic stroke (IS), respectively. Among patients with stroke recurrence, 54.11% with SAH, 60.42% with ICH, and 92.92% with IS relapsed for the same type of the first-onset stroke. For discharged patients with SAH with middle cerebral artery aneurysm clipping or artery aneurysm embolization, it was less likely to stroke relapse, but the times of recurrence would increase if 1 recurrence appeared. Cerebral artery aneurysms and hypertension were risk factors for recurrence frequency. For ICH, protective factors for recurrence were trepanation and drainage of intracranial hematoma, cerebral angiography, puncture and drainage of intracranial hematoma, and length of stay (LOS). But rheumatic heart disease and atrial fibrillation would further the relapse frequency. For IS, age and LOS were protective factors, but recurrence frequency would increase if the first recurrence happened. Cervical spondylopathy, male gender, and diabetes were risk factors for frequency of relapse. CONCLUSIONS Associated factors were different for recurrence frequency among different stroke types.
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Dellaretti M, da Silva Martins WC, Dourado JC, Faglioni W, Quadros RS, de Souza Moraes VV, de Souza Filho CBA. Angiographic and epidemiological characteristics associated with aneurysm remnants after microsurgical clipping. Surg Neurol Int 2017; 8:198. [PMID: 28904825 PMCID: PMC5590350 DOI: 10.4103/sni.sni_109_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 06/06/2017] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Despite new techniques for the treatment of cerebral aneurysms, the percentage of aneurysm remnants after surgical intervention seems to be relatively constant. The objective of this study was to assess angiographic and epidemiological features associated with aneurysm remnants after microsurgical clipping. METHODS This study was conducted from February 2009 to August 2012 on a series of 90 patients with 105 aneurysms referred to the Santa Casa of Belo Horizonte who were surgically treated and angiographically controlled. RESULTS Surgical clipping was considered incomplete in 13.3% of the aneurysms. The mean age of cases with an aneurysm remnant was 57.5 years, whereas the mean age without aneurysm remnant was 49.7 years (P = 0.02). Aneurysm remnants were detected more frequently on the internal carotid artery, nevertheless, no statistically significant differences were verified when comparing the locations. Aneurysm size in the preoperative angiography verified that the mean size of aneurysms operated was 6.56 mm, such that in cases showing a postoperative remnant, the mean size was 9.7 mm and in cases with complete clipping it was 6.08 mm (P = 0.02). Postoperative angiography showed that, in cases with residual aneurysm, the number of clips used was higher - a mean of 1.8 for complete clipping and 3.1 for incomplete clipping (P < 0.001). CONCLUSIONS Aneurysm size and patient age showed significant correlations with residual intracranial aneurysm. The mean number of clips used was higher in cases with incomplete occlusion.
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Affiliation(s)
- Marcos Dellaretti
- Department of Neurosurgery, Santa Casa de Misericórdia de Belo Horizonte, Belo Horizonte, Minas Gerais, Brazil.,Department of Neurosurgery, Hospital Mater Dei, Belo Horizonte, Minas Gerais, Brazil.,Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.,Department of Neurosurgery, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | | | - Jules Carlos Dourado
- Department of Neurosurgery, Santa Casa de Misericórdia de Belo Horizonte, Belo Horizonte, Minas Gerais, Brazil
| | - Wilson Faglioni
- Department of Neurosurgery, Santa Casa de Misericórdia de Belo Horizonte, Belo Horizonte, Minas Gerais, Brazil.,Department of Neurosurgery, Hospital Mater Dei, Belo Horizonte, Minas Gerais, Brazil.,Department of Neurosurgery, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Ricardo Souza Quadros
- Department of Neurosurgery, Santa Casa de Misericórdia de Belo Horizonte, Belo Horizonte, Minas Gerais, Brazil.,Department of Neurosurgery, Hospital Mater Dei, Belo Horizonte, Minas Gerais, Brazil
| | | | - Carlos Batista Alves de Souza Filho
- Department of Neurosurgery, Santa Casa de Misericórdia de Belo Horizonte, Belo Horizonte, Minas Gerais, Brazil.,Department of Neurosurgery, Hospital Mater Dei, Belo Horizonte, Minas Gerais, Brazil.,Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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Dammann P, Jägersberg M, Kulcsar Z, Radovanovic I, Schaller K, Bijlenga P. Clipping of ruptured intracranial aneurysms in a hybrid room environment-a case-control study. Acta Neurochir (Wien) 2017; 159:1291-1298. [PMID: 28516365 DOI: 10.1007/s00701-017-3212-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 05/05/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Hybrid room treatment (HRT) provides the surgeon immediate intraoperative angiography control of aneurysm occlusion and vessel patency. Since it is relatively resource demanding, in clinical routine HRT is reserved for elective cases. However, since its introduction in our department in 2008, several random cases of ruptured intracranial aneurysms (IAs) have been treated in the HR. This study aims to compare the clinical and radiological outcomes of these cases with cases treated conventionally using a matched pair analysis. METHODS Twenty (20%) consecutive patients with ruptured IA treated by microsurgical clipping in the HR between 2009 and 2015 were retrospectively matched with "conventionally" (C) treated patients (overall n = 101). Clinical and radiological outcome variables were assessed and compared. RESULTS Despite a trend in favor of the HR group, no significant difference between both matched groups (HR vs. C) could be demonstrated regarding the functional outcome (upper/lower good recovery 16/20 vs. 17/20, p > 0.05), frequency of clipping-related vascular insults on CT scans (0/20 vs. 3/20, p > 0.05), aneurysm remnant rate on postoperative angiography (1/20 vs. 4/20, p > 0.05) and retreatment rate (0/20 vs. 1/20, p > 0.05). When cumulating all outcome events by a scoring system, however, the HR cohort showed a significantly lower occurrence of events (p < 0.05). In three cases co-treatment by an endovascular approach was performed in the HR cohort. CONCLUSION In this relatively small cohort, a matched pair analysis revealed a discrete but not significant tendency toward a lower frequency of aneurysm remnants and clipping-related vascular insults in the HR cohort. However, HR cohort patients benefited from direct endovascular co-treatment in selected cases.
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Affiliation(s)
- Philipp Dammann
- Department of Neurosurgery, University Hospital of Geneva, Rue Gabrielle Perret-Gentil 4, 1211, Genève 14, Suisse.
- Department of Neurosurgery, University Hospital of Essen, Essen, Germany.
| | - Max Jägersberg
- Department of Neurosurgery, University Hospital of Geneva, Rue Gabrielle Perret-Gentil 4, 1211, Genève 14, Suisse
| | - Zsolt Kulcsar
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Geneva, Geneva, Suisse
| | - Ivan Radovanovic
- Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Karl Schaller
- Department of Neurosurgery, University Hospital of Geneva, Rue Gabrielle Perret-Gentil 4, 1211, Genève 14, Suisse
| | - Philippe Bijlenga
- Department of Neurosurgery, University Hospital of Geneva, Rue Gabrielle Perret-Gentil 4, 1211, Genève 14, Suisse
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Catapano G, Sgulò F, Laleva L, Columbano L, Dallan I, de Notaris M. Multimodal use of indocyanine green endoscopy in neurosurgery: a single-center experience and review of the literature. Neurosurg Rev 2017; 41:985-998. [PMID: 28477043 PMCID: PMC6133047 DOI: 10.1007/s10143-017-0858-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 04/13/2017] [Indexed: 12/28/2022]
Abstract
During the last 10 years, microscope-integrated indocyanine green fluorescence (m-ICG) has been widely used for assessing real-time blood flow during aneurysm surgery. More recently, an endoscope-integrated indocyanine green fluorescence (e-ICG) has been adopted as a versatile tool during different endoscopic neurosurgical procedures. The purpose of the present report is to evaluate multimodal applications of e-ICG during different endonasal, intraventricular, aneurysm and brain tumor surgeries and provide technical nuances. In addition, we reviewed the literature and identified and compare several overlapping case series of patients treated via an endoscopic integrated indocyanine green fluorescence technique. A total of 40 patients were retrospectively evaluated. Patients were divided into four main groups: (1) endoscopic endonasal approaches (n = 14); (2) ventricular endoscopic approach including patients undergoing third ventriculostomy (n = 8) and tumor biopsy (n = 1); (3) aneurysms surgery (n = 9); and (4) brain parenchymal tumors (n = 8). All patients were successfully treated using the e-ICG dynamic endoscopic visualization, and there were no perioperative complications. Such unique features open up a promising field of applications beyond the use of m-ICG in different surgical field due to the longer duration of e-ICG fluorescence up to 35 ± 7 min. E-ICG represents a new and effective technique for longer real-time visualization of vascular structures preserving normal tissues and functions during different transcranial and endonasal approaches. As the technology and e-ICG resolution improves, the technique has the potential to become a critical tool for different applications in neurosurgery.
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Affiliation(s)
- Giuseppe Catapano
- Department of Neuroscience, Neurosurgery Operative Unit, "G. Rummo" Hospital, Via Pacevecchia no. 53, 82100, Benevento, Italy
| | - Francesco Sgulò
- Division of Neurosurgery, Department of Neurological Sciences, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Lili Laleva
- Department of Neurosurgery, Tokuda Hospital Sofia, Sofia, Bulgaria
| | - Laura Columbano
- Department of Neuroscience, Neurosurgery Operative Unit, "G. Rummo" Hospital, Via Pacevecchia no. 53, 82100, Benevento, Italy
| | - Iacopo Dallan
- First Otorhinolaryngologic Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Matteo de Notaris
- Department of Neuroscience, Neurosurgery Operative Unit, "G. Rummo" Hospital, Via Pacevecchia no. 53, 82100, Benevento, Italy.
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Abdulazim A, Rubbert C, Reichelt D, Mathys C, Turowski B, Steiger HJ, Hänggi D, Etminan N. Dual- versus Single-Energy CT-Angiography Imaging for Patients Undergoing Intracranial Aneurysm Repair. Cerebrovasc Dis 2017; 43:272-282. [PMID: 28319953 DOI: 10.1159/000464356] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 02/20/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The invasiveness and risk of thromboembolic complications of catheter angiography underline the need for alternative imaging modalities in patients following intracranial aneurysm (IA) repair. However, the overall image quality of existing noninvasive imaging modalities, such as single-energy CT angiography (SE-CTA), compromises its value in this respect. OBJECTIVE We prospectively investigated the value of a novel dual-energy CTA (DE-CTA) scanner and algorithm for assessing the degree of occlusion and parent vessel patency in patients following IA repair. METHODS A prospective cohort of 17 patients underwent DE-CTA imaging following surgical or endovascular IA repair. This dataset was matched with an identical historical cohort of 17 patients, who underwent IA repair and SE-CTA imaging. Beam-hardening artifacts, as a measure for objective imaging quality were analyzed based on the volume of a prolate ellipsoid, whereas subjective imaging quality at the IA site and corresponding parent vessels was rated by 2 independent neuroradiologists on a scale from 4 (excellent, no artifacts) to 1 (poor, severe artifacts). RESULTS Objective DE-CTA image quality was markedly higher, compared to SE-CTA in patients undergoing surgical (0.77 ± 0.23 vs. 10.91 ± 1.88 mL, respectively; p < 0.001) or endovascular (32.36 ± 10.62 vs. 107.63 ± 24.51 mL, respectively; p = 0.026) IA repair. Subjective image quality for DE-CTA was significantly improved compared to SE-CTA in the surgical group but not in the endovascular group. The calculated dose values for DE-CTA in our study remain markedly below the legally required radiation dose limits. CONCLUSION The imaging quality of DE-CTA, especially for patients undergoing surgical IA repair, is distinctly superior, compared to SE-CTA imaging. Therefore, DE-CTA may serve as a noninvasive alternative for assessing the IA occlusion rate and parent vessel patency.
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Affiliation(s)
- Amr Abdulazim
- Department of Neurosurgery, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
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Jabbarli R, Wrede KH, Pierscianek D, Dammann P, El Hindy N, Özkan N, Müller O, Stolke D, Forsting M, Sure U. Outcome After Clipping of Unruptured Intracranial Aneurysms Depends on Caseload. World Neurosurg 2015; 89:666-671.e1. [PMID: 26732965 DOI: 10.1016/j.wneu.2015.12.043] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 12/08/2015] [Accepted: 12/10/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Although most neurovascular centers currently have a coil first policy, the percentage of coiled versus clipped aneurysms, as well as treatment outcomes, varies strongly between these centers. This study evaluates the impact of an increase in clipping caseload on treatment outcome in a large single-center series. METHODS All consecutive patients who underwent microsurgical clipping of unruptured intracranial aneurysms between January 2003 and April 2014 in our department were analyzed retrospectively. According to the change of the chairman in the neurosurgical department (1 September 2008) with a subsequent increase in the clipping volume, the entire cohort was divided into 2 groups with equal time intervals (historic and current cohorts). RESULTS There were 94 clipped unruptured intracranial aneurysms in the historic cohort and 252 in the current cohort. Unfavorable outcome at 6 months postoperatively (defined as modified Rankin Score >2) was observed in 8 cases (8.5%) in the historic cohort and 7 cases (2.8%) in the current cohort (P < 0.0001). The surgical mortality decreased from 3.2% to 0%. Cerebral infarction on postoperative computed tomography scan was observed in 25 cases (26.6%) in the historic cohort and 19 cases (7.5%) in the current cohort (P < 0.0001). Within the current cohort, there was a progressive improvement of surgical outcome over the time. CONCLUSIONS The improvement of the surgical outcome after increasing the clipping caseload underlines the importance of sufficient surgical volume for maintenance of competitive treatment results.
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Affiliation(s)
- Ramazan Jabbarli
- Department of Neurosurgery, University Hospital of Essen, Essen, Germany.
| | - Karsten H Wrede
- Department of Neurosurgery, University Hospital of Essen, Essen, Germany
| | | | - Philipp Dammann
- Department of Neurosurgery, University Hospital of Essen, Essen, Germany
| | - Nicolai El Hindy
- Department of Neurosurgery, University Hospital of Essen, Essen, Germany
| | - Neriman Özkan
- Department of Neurosurgery, University Hospital of Essen, Essen, Germany
| | - Oliver Müller
- Department of Neurosurgery, University Hospital of Essen, Essen, Germany
| | - Dietmar Stolke
- Department of Neurosurgery, University Hospital of Essen, Essen, Germany
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology, University Hospital of Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery, University Hospital of Essen, Essen, Germany
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