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Wu Q, Yao J, Qi J, Bi Y, Chen A, Yang Z, Ai C, Chen L, Zhang B, Xu S, Li Z, Shi H, Wu P. Microsurgical clipping versus endovascular therapy for treating patients with middle cerebral artery aneurysms presenting with neurological ischemic symptoms. Neurosurg Rev 2024; 47:318. [PMID: 38995460 DOI: 10.1007/s10143-024-02559-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 05/05/2024] [Accepted: 07/07/2024] [Indexed: 07/13/2024]
Abstract
Studies comparing different treatment methods in patients with middle cerebral artery (MCA) aneurysms in different subgroups of onset symptoms are lacking. It is necessary to explore the safety and efficacy of open surgical treatment and endovascular therapy in patients with MCA aneurysms in a specific population. This study aimed to compare microsurgical clipping versus endovascular therapy regarding complication rates and outcomes in patients with MCA aneurysms presenting with neurological ischemic symptoms. This was a retrospective cohort study in which 9656 patients with intracranial aneurysms were screened between January 2014 and July 2022. Further, 130 eligible patients were enrolled. The primary outcome was the incidence of serious adverse events (SAEs) within 30 days of treatment, whereas secondary outcomes included postprocedural target vessel-related stroke, disabling stroke or death, mortality, and aneurysm occlusion rate. Among the 130 included patients, 45 were treated with endovascular therapy and 85 with microsurgical clipping. The primary outcome of the incidence of SAEs within 30 days of treatment was significantly higher in the clipping group [clipping: 23.5%(20/85) vs endovascular: 8.9%(4/45), adjusted OR:4.05, 95% CI:1.20-13.70; P = 0.024]. The incidence of any neurological complications related to the treatment was significantly higher in the clipping group [clipping:32.9%(28/85) vs endovascular:15.6%(7/45); adjusted OR:3.49, 95%CI:1.18-10.26; P = 0.023]. Postprocedural target vessel-related stroke, disabling stroke or death, mortality rate, and complete occlusion rate did not differ significantly between the two groups. Endovascular therapy seemed to be safer in treating patients with MCA aneurysms presenting with neurological ischemic symptoms compared with microsurgical clipping, with a significantly lower incidence of SAEs within 30 days of treatment and any neurological complications related to the treatment during follow-up.
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Affiliation(s)
- Qiaowei Wu
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng Road No.23, Harbin, 150000, Heilongjiang, China
| | - Jinbiao Yao
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng Road No.23, Harbin, 150000, Heilongjiang, China
| | - Jingtao Qi
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng Road No.23, Harbin, 150000, Heilongjiang, China
| | - Yuange Bi
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Aixia Chen
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng Road No.23, Harbin, 150000, Heilongjiang, China
| | - Zhonghui Yang
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng Road No.23, Harbin, 150000, Heilongjiang, China
| | - Changsi Ai
- Department of Neurosurgery, Hongda Hospital of Jiamusi University, Jiamusi, Heilongjiang, China
| | - Lining Chen
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng Road No.23, Harbin, 150000, Heilongjiang, China
| | - Bohan Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng Road No.23, Harbin, 150000, Heilongjiang, China
| | - Shancai Xu
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng Road No.23, Harbin, 150000, Heilongjiang, China
| | - Zhentao Li
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng Road No.23, Harbin, 150000, Heilongjiang, China
| | - Huaizhang Shi
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng Road No.23, Harbin, 150000, Heilongjiang, China.
| | - Pei Wu
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng Road No.23, Harbin, 150000, Heilongjiang, China.
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2
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Stroh N, Stefanits H, Maletzky A, Kaltenleithner S, Thumfart S, Giretzlehner M, Drexler R, Ricklefs FL, Dührsen L, Aspalter S, Rauch P, Gruber A, Gmeiner M. Machine learning based outcome prediction of microsurgically treated unruptured intracranial aneurysms. Sci Rep 2023; 13:22641. [PMID: 38114635 PMCID: PMC10730905 DOI: 10.1038/s41598-023-50012-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 12/14/2023] [Indexed: 12/21/2023] Open
Abstract
Machine learning (ML) has revolutionized data processing in recent years. This study presents the results of the first prediction models based on a long-term monocentric data registry of patients with microsurgically treated unruptured intracranial aneurysms (UIAs) using a temporal train-test split. Temporal train-test splits allow to simulate prospective validation, and therefore provide more accurate estimations of a model's predictive quality when applied to future patients. ML models for the prediction of the Glasgow outcome scale, modified Rankin Scale (mRS), and new transient or permanent neurological deficits (output variables) were created from all UIA patients that underwent microsurgery at the Kepler University Hospital Linz (Austria) between 2002 and 2020 (n = 466), based on 18 patient- and 10 aneurysm-specific preoperative parameters (input variables). Train-test splitting was performed with a temporal split for outcome prediction in microsurgical therapy of UIA. Moreover, an external validation was conducted on an independent external data set (n = 256) of the Department of Neurosurgery, University Medical Centre Hamburg-Eppendorf. In total, 722 aneurysms were included in this study. A postoperative mRS > 2 was best predicted by a quadratic discriminant analysis (QDA) estimator in the internal test set, with an area under the receiver operating characteristic curve (ROC-AUC) of 0.87 ± 0.03 and a sensitivity and specificity of 0.83 ± 0.08 and 0.71 ± 0.07, respectively. A Multilayer Perceptron predicted the post- to preoperative mRS difference > 1 with a ROC-AUC of 0.70 ± 0.02 and a sensitivity and specificity of 0.74 ± 0.07 and 0.50 ± 0.04, respectively. The QDA was the best model for predicting a permanent new neurological deficit with a ROC-AUC of 0.71 ± 0.04 and a sensitivity and specificity of 0.65 ± 0.24 and 0.60 ± 0.12, respectively. Furthermore, these models performed significantly better than the classic logistic regression models (p < 0.0001). The present results showed good performance in predicting functional and clinical outcomes after microsurgical therapy of UIAs in the internal data set, especially for the main outcome parameters, mRS and permanent neurological deficit. The external validation showed poor discrimination with ROC-AUC values of 0.61, 0.53 and 0.58 respectively for predicting a postoperative mRS > 2, a pre- and postoperative difference in mRS > 1 point and a GOS < 5. Therefore, generalizability of the models could not be demonstrated in the external validation. A SHapley Additive exPlanations (SHAP) analysis revealed that this is due to the most important features being distributed quite differently in the internal and external data sets. The implementation of newly available data and the merging of larger databases to form more broad-based predictive models is imperative in the future.
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Affiliation(s)
- Nico Stroh
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Harald Stefanits
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria.
| | | | | | | | | | - Richard Drexler
- Department of Neurosurgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Franz L Ricklefs
- Department of Neurosurgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Lasse Dührsen
- Department of Neurosurgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Aspalter
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Philip Rauch
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Andreas Gruber
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Matthias Gmeiner
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
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3
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Aydin K, Berdikhojayev M, Cay F, Barburoglu M, Nurzhan S, Aygun S, Sencer S, Arat A. Safety, Efficacy, and Durability of Stent-Assisted Coiling Treatment of M2 (Insular) Segment MCA Aneurysms. AJNR Am J Neuroradiol 2022; 43:560-567. [PMID: 35301223 PMCID: PMC8993191 DOI: 10.3174/ajnr.a7461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/17/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Most distal MCA aneurysms are located within the insular segment, which lies between the limen insulae and circular sulcus. However, experience is limited in the microsurgical and endovascular management of insular segment MCA aneurysms. In this multicenter retrospective case series, we aimed to investigate the safety, efficacy, and durability of stent-assisted coiling for treatment of insular segment MCA aneurysms. MATERIALS AND METHODS A retrospective review was performed to identify patients with insular MCA aneurysms that were treated with stent-assisted coiling. The technical success of the procedures and the initial and follow-up clinical and angiographic outcomes were assessed. Periprocedural and delayed complications were reviewed. RESULTS Twenty-seven aneurysms in 27 patients with a mean age of 53.3 (SD,11.3) years were included. The mean size of the aneurysms was 6.3 (SD 2.6) mm. Endovascular procedures were successfully performed in all patients. Immediate postprocedural angiography revealed complete aneurysm occlusions in 81.5%. Periprocedural complications developed in 7.4% without causing permanent morbidity. A delayed thromboembolic complication resulted in a minor permanent morbidity in 1 patient (3.7%). There was no mortality. The mean duration of angiographic follow-up was 19.5 (SD, 9.8) months. The last follow-up examinations showed complete occlusion in 92.6%. During the follow-up period, none of the treated aneurysms showed recanalization. CONCLUSIONS The results of this study demonstrate that stent-assisted coiling with a low-profile self-expandable stent is a feasible and relatively safe technique for endovascular treatment of insular segment complex MCA aneurysms. Additionally, it provides an effective and durable treatment for insular MCA aneurysms.
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Affiliation(s)
- K Aydin
- From the Department of Interventional Neuroradiology (K.A., S.A.), Koç University Hospital, Topkapi, Istanbul, Turkey
- Department of Neuroradiology (K.A., M. Barburoglu, S.S.), Istanbul Faculty of Medicine, Capa, Istanbul University, Istanbul, Turkey
| | - M Berdikhojayev
- Department of Neurosurgery (M. Berdikhojayev, S.N.), JSC Central Hospital, Almaty City, Kazakhstan
| | - F Cay
- Department of Radiology (F.C., A.A.), Hacettepe University Medical School, Hacettepe Hospitals, Sihhiye, Ankara, Turkey
| | - M Barburoglu
- Department of Neuroradiology (K.A., M. Barburoglu, S.S.), Istanbul Faculty of Medicine, Capa, Istanbul University, Istanbul, Turkey
| | - S Nurzhan
- Department of Neurosurgery (M. Berdikhojayev, S.N.), JSC Central Hospital, Almaty City, Kazakhstan
| | - S Aygun
- From the Department of Interventional Neuroradiology (K.A., S.A.), Koç University Hospital, Topkapi, Istanbul, Turkey
| | - S Sencer
- Department of Neuroradiology (K.A., M. Barburoglu, S.S.), Istanbul Faculty of Medicine, Capa, Istanbul University, Istanbul, Turkey
| | - A Arat
- Department of Radiology (F.C., A.A.), Hacettepe University Medical School, Hacettepe Hospitals, Sihhiye, Ankara, Turkey
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Sriamornrattanakul K, Akharathammachote N, Wongsuriyanan S. Early Exposure of the Dorsal Surface of M1 Segment via the Distal Transsylvian Approach for Clipping of Anteroinferior-Projecting Middle Cerebral Artery Bifurcation Aneurysms. Asian J Neurosurg 2022; 17:23-30. [PMID: 35873836 PMCID: PMC9298598 DOI: 10.1055/s-0042-1749177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Abstract
Background Middle cerebral artery bifurcation (MCAB) aneurysms are common intracranial aneurysms. Anteroinferior-projecting MCAB aneurysms, with M1 segment usually embedded into the deep part of the Sylvian fissure, cause some surgical challenges. The distal transsylvian approach (DTSA) allows M1 exposure from the dorsal surface for proximal control in the early step. Therefore, this study aimed to demonstrate the efficacy and safety of DTSA for clipping anteroinferior-projecting MCAB aneurysms.
Methods Among 97 patients with MCA aneurysms, 13 with anteroinferior-projecting MCAB aneurysms who underwent aneurysm clipping via the DTSA between June 2018 and January 2021 were retrospectively evaluated for the aneurysm obliteration rate, surgical complications, and outcomes.
Results Ten patients (76.9%) had ruptured MCAB aneurysms and three (23.1%) had incidentally discovered unruptured MCAB aneurysms. Favorable outcome was achieved in 100% of patients with good grade. The complete aneurysm obliteration rate was 100% without intraoperative lenticulostriate artery injury. Twelve (92.3%) patients had early identified distal M1 segment for proximal control, and one (7.7%) patient had premature rupture of aneurysm that achieved favorable outcome at 3 months postoperatively. Difficult M1 exposure and premature rupture occurred in the patient with MCAB located above the Sylvian fissure line. Permanent postoperative neurological deficit was detected in one patient due to severe vasospasm.
Conclusion DTSA, which simplify the early exposure of the dorsal surface of distal M1, is safe and effective for clipping anteroinferior-projecting MCAB aneurysms without extensive Sylvian fissure dissection. High-positioned MCAB requires careful dissection of the aneurysm neck with consideration of tentative clipping preparation.
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Affiliation(s)
- Kitiporn Sriamornrattanakul
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Nasaeng Akharathammachote
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Somkiat Wongsuriyanan
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
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5
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Diestro JDB, Adeeb N, Dibas M, Boisseau W, Harker P, Brinjikji W, Xiang S, Joyce E, Shapiro M, Raz E, Parra-Farinas C, Pickett G, Alotaibi NM, Regenhardt RW, Bernstock JD, Spears J, Griessenauer CJ, Burkhardt JK, Hafeez MU, Kan P, Grandhi R, Taussky P, Nossek E, Hong T, Zhang H, Rinaldo L, Lanzino G, Stapleton CJ, Rabinov JD, Patel AB, Marotta TR, Roy D, Dmytriw AA. Flow Diversion for Middle Cerebral Artery Aneurysms: An International Cohort Study. Neurosurgery 2021; 89:1112-1121. [PMID: 34624100 DOI: 10.1093/neuros/nyab365] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 08/06/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Open surgery has traditionally been preferred for the management of bifurcation middle cerebral artery (MCA) aneurysms. Flow diverting stents present a novel endovascular strategy for aneurysm treatment. OBJECTIVE To add to the limited literature describing the outcomes and complications in the use of flow diverters for the treatment of these complex aneurysms. METHODS This is a multicenter retrospective review of MCA bifurcation aneurysms undergoing flow diversion. We assessed post-treatment radiological outcomes and both thromboembolic and hemorrhagic complications. RESULTS We reviewed the outcomes of 54 aneurysms treated with flow diversion. Four (7.4%) of the aneurysms had a history of rupture (3 remote and 1 acute). Fourteen (25.9%) of the aneurysms already underwent either open surgery or coiling prior to flow diversion. A total of 36 out of the 45 aneurysms (80%) with available follow-up data had adequate aneurysm occlusion with a median follow-up time of 12 mo. There were no hemorrhagic complications but 16.7% (9/54) had thromboembolic complications. CONCLUSION Flow diverting stents may be a viable option for the endovascular treatment of complex bifurcation MCA aneurysms. However, compared to published series on the open surgical treatment of this subset of aneurysms, flow diversion has inferior outcomes and are associated with a higher rate of complications.
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Affiliation(s)
- Jose Danilo Bengzon Diestro
- Division of Diagnostic & Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital (Unity Health), University of Toronto, Toronto, Ontario, Canada.,Département de Radiologie, Radio-oncologie et Médecine Nucléaire, Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Nimer Adeeb
- Departments of Neurosurgery & Interventional Neuroradiology, LSU Shreveport School of Medicine, Shreveport, Louisiana, USA
| | - Mahmoud Dibas
- Departments of Neurosurgery & Interventional Neuroradiology, LSU Shreveport School of Medicine, Shreveport, Louisiana, USA
| | - William Boisseau
- Département de Radiologie, Radio-oncologie et Médecine Nucléaire, Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Pablo Harker
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Waleed Brinjikji
- Departments of Radiology & Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sishi Xiang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Evan Joyce
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Maksim Shapiro
- Departments of Radiology and Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Eytan Raz
- Departments of Radiology and Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Carmen Parra-Farinas
- Division of Diagnostic & Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital (Unity Health), University of Toronto, Toronto, Ontario, Canada
| | - Gwynedd Pickett
- Department of Neurosurgery, Queen Elizabeth II Health Science Centre, Dalhousie Medical School, Halifax, Nova Scotia, Canada
| | - Naif M Alotaibi
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Robert W Regenhardt
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua D Bernstock
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Julian Spears
- Division of Diagnostic & Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital (Unity Health), University of Toronto, Toronto, Ontario, Canada
| | - Christoph J Griessenauer
- Department of Neurosurgery, Geisinger, Danville, Pennsylvania, USA.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria.,Department of Neurosurgery, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Muhammad U Hafeez
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Houston, Texas, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Philipp Taussky
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Erez Nossek
- Departments of Radiology and Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Tao Hong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Lorenzo Rinaldo
- Departments of Radiology & Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Giuseppe Lanzino
- Departments of Radiology & Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Christopher J Stapleton
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - James D Rabinov
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aman B Patel
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas R Marotta
- Division of Diagnostic & Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital (Unity Health), University of Toronto, Toronto, Ontario, Canada
| | - Daniel Roy
- Département de Radiologie, Radio-oncologie et Médecine Nucléaire, Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Adam A Dmytriw
- Division of Diagnostic & Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital (Unity Health), University of Toronto, Toronto, Ontario, Canada.,Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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6
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Salem MM, Khorasanizadeh M, Lay SV, Renieri L, Kuhn AL, Sweid A, Massari F, Moore JM, Tjoumakaris SI, Jabbour P, Puri AS, Ogilvy CS, Jankowitz BT, Burkhardt JK, Kan P, Limbucci N, Cognard C, Thomas AJ. Endoluminal flow diverting stents for middle cerebral artery bifurcation aneurysms: multicenter cohort. J Neurointerv Surg 2021; 14:1084-1089. [PMID: 34732531 DOI: 10.1136/neurintsurg-2021-018224] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 10/20/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Data regarding the safety and efficacy of flow diverting stents (FDS) in the treatment of middle cerebral artery (MCA) bifurcation aneurysms are scarce and limited to small single center series, with particular concern for increased risk of ischemic complications with jailing one of the M2 branches. METHODS Prospectively-maintained databases at six North American and European centers were queried for patients harboring MCA bifurcation aneurysms undergoing treatment with FDS (2011-2018). The pertinent clinical and radiographic data were collected and analyzed. RESULTS 87 patients (median age 60 years, 69% females) harboring 87 aneurysms were included. The majority of aneurysms were unruptured (79%); 75.9% were saccular with a median maximal diameter of 8.5 mm. Radiographic imaging follow-up was available in 88.5% of cases at a median of 16.3 months post-treatment, showing complete occlusion in 59% and near complete occlusion (90-99%) in 18% of aneurysms. The overall rate of ischemic and hemorrhagic complications was 8% and 1.1%, respectively. Symptomatic and permanent complications were encountered in 5.7% and 2.3% of patients respectively, with retreatment pursued in 2.3% of patients. Jailed branch occlusion was detected in 11.5% of cases, with clinical sequelae in 2.3%. Last follow-up modified Rankin Scale of 0-2 was noted in 96.8% of patients. On multivariate analysis, male sex was the only independent predictor of aneurysmal persistence at last follow-up imaging (p=0.019). CONCLUSION FDS treatment for MCA bifurcation aneurysms is feasible, with comparable safety and efficacy profiles to other available endovascular options when utilized in carefully selected aneurysms. Jailing of M2 branches was not associated with a higher risk of post-procedural ischemic complications.
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Affiliation(s)
- Mohamed M Salem
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Mirhojjat Khorasanizadeh
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Sovann V Lay
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France
| | - Leonardo Renieri
- Department of Interventional Neuroradiology, University of Florence, Florence, Italy
| | - Anna L Kuhn
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Ahmad Sweid
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Francesco Massari
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Justin M Moore
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Ajit S Puri
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Christopher S Ogilvy
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Nicola Limbucci
- Department of Interventional Neuroradiology, University of Florence, Florence, Italy
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France
| | - Ajith J Thomas
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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7
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Pierot L, Szikora I, Barreau X, Holtmannspoetter M, Spelle L, Herbreteau D, Fiehler J, Costalat V, Klisch J, Januel AC, Weber W, Liebig T, Stockx L, Berkefeld J, Moret J, Molyneux A, Byrne J. Aneurysm treatment with WEB in the cumulative population of two prospective, multicenter series: 3-year follow-up. J Neurointerv Surg 2021; 13:363-368. [PMID: 32532858 PMCID: PMC7982938 DOI: 10.1136/neurintsurg-2020-016151] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 05/06/2020] [Accepted: 05/07/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND WEB treatment is an endovascular approach for wide-neck bifurcation aneurysms that has demonstrated high safety and good efficacy in mid-term follow-up. While evaluating safety in the long term is important to determine if delayed adverse events occur affecting late morbidity and mortality, the most important point to evaluate is the long-term stability of aneurysm occlusion. The current analysis reports the 3-year clinical and anatomical results of WEB treatment in the combined population of two European trials (WEBCAST (WEB Clinical Assessment of Intrasaccular Aneurysm Therapy) and WEBCAST-2). METHODS Aneurysm occlusion was evaluated using a 3-grade scale: complete occlusion, neck remnant, and aneurysm remnant. RESULTS The safety population comprised 79 patients. The efficacy population comprised 61 aneurysms. Aneurysm locations were middle cerebral artery in 32/61 aneurysms (52.5%), anterior communicating artery in 13/61 (21.3%), basilar artery in 9/61 (14.8%), and internal carotid artery terminus in 7/61 (11.5%). No adverse events related to the device or procedure occurred between 2 and 3 years. At 3 years, complete occlusion was observed in 31/61 (50.8%) aneurysms, neck remnant in 20/61 (32.8%), and aneurysm remnant in 10/61 (16.4%). Between 1 year and 3 years, aneurysm occlusion was improved or stable in 53/61 (86.9%) aneurysms and worsened in 8/61 (13.1%). Worsening was mostly from complete occlusion to neck remnant in 6/61 (9.8%) aneurysms. The retreatment rate at 3 years was 11.4%. CONCLUSIONS This analysis confirms the high safety profile of WEB. Moreover, evidence demonstrates the great stability of aneurysm occlusion with adequate occlusion (complete occlusion or neck remnant) in 83.6% of aneurysms. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. WEBCAST and WEBCAST-2: Unique identifier: NCT01778322.
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Affiliation(s)
| | - Istvan Szikora
- Neurointerventions, National Institute of Clinical Neurosciences, Budapest, Budapest, Hungary
| | | | - Markus Holtmannspoetter
- Neuroradiology Department, Nuremberg General Hospital, Paracelsius Medical University, Nürnberg, Germany
| | - Laurent Spelle
- Interventional Neuroradiology, CHU Bicêtre, Le Kremlin-Bicetre, Île-de-France, France
| | | | - Jens Fiehler
- Department of Neuroradiology, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Hamburg, Germany
| | - Vincent Costalat
- Neuroradiology, CHU Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Joachim Klisch
- Institute of Diagnostic and Intervenional Radiology and Neuroradiology, HELIOS Klinikum Erfurt Klinik für Frauenheilkunde und Geburtshilfe, Erfurt, Thuringia, Germany
| | | | - Werner Weber
- Radiology and Neuroradiology, Ruhr-Universitat Bochum, Bochum, Nordrhein-Westfalen, Germany
| | - Thomas Liebig
- Neuroradiology, University Hospital Munich, Munchen, Bayern, Germany
| | - Luc Stockx
- Neuroradiology, Ziekenhuis Oost-Limburg, Genk, Limburg, Belgium
| | - Joachim Berkefeld
- Neuroradiology, Goethe University Frankfurt, Frankfurt am Main, Hessen, Germany
| | - Jacques Moret
- Interventional Neuroradiology, Hopital Bicetre, Le Kremlin-Bicetre, Île-de-France, France
| | - Andy Molyneux
- Neurovascular and Neuroradiology Research Unit, Oxford University, Oxford, Oxfordshire, UK
| | - James Byrne
- Department of Neuroradiology, Nuffield Department of Surgical Sciences, Oxford University, Oxford, Oxfordshire, UK
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8
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Pflaeging M, Kabbasch C, Schlamann M, Pennig L, Juenger ST, Grunz JP, Timmer M, Brinker G, Goldbrunner R, Krischek B, Goertz L. Microsurgical Clipping versus Advanced Endovascular Treatment of Unruptured Middle Cerebral Artery Bifurcation Aneurysms After a "Coil-First" Policy. World Neurosurg 2021; 149:e336-e344. [PMID: 33607288 DOI: 10.1016/j.wneu.2021.02.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Although intracranial aneurysms are increasingly treated endovascularly, microsurgical clipping has been the standard approach for middle cerebral artery (MCA) aneurysms. We compared microsurgical clipping and state-of-the-art endovascular treatment of unruptured MCA bifurcation aneurysms treated at a neurovascular center following a "coil-first" policy. METHODS This single-center study included 148 patients treated for 160 unruptured MCA bifurcation aneurysms. Technical success, complications, clinical outcome, and angiographic results were retrospectively compared. RESULTS Microsurgical clipping was performed for 120 MCA aneurysms (75%) and endovascular treatment for 40 (25%; conventional coiling: 8, stent-assisted coiling: 16, balloon-assisted coiling: 3, and flow-disruption: 13). Technical treatment success was higher in the clipping group (100%) than in the endovascular group (92.5%, P = 0.015). Overall, complications occurred in 16.7% for clipping and in 20.0% for endovascular treatment (P = 0.631). Major ischemic stroke rates were 4.2% in the clipping group and 7.5% in the endovascular group (P = 0.414). At 6 months, a favorable outcome was obtained by 99.2% after clipping and 95.0% after endovascular treatment (P = 0.154). The 6-month complete aneurysm occlusion rates were by trend higher in the clipping group (89.2%) than in the endovascular group (75.9%, P = 0.078). CONCLUSIONS Microsurgical clipping was associated with a higher technical success rate and tendentially higher complete occlusion than endovascular treatment, with no additional morbidity and similar clinical outcome. On the basis of these results, clipping proves to be the standard treatment option for MCA bifurcation aneurysms. However, endovascular treatment represents a safe and efficient alternative treatment option for patients.
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Affiliation(s)
- Muriel Pflaeging
- Center for Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Christoph Kabbasch
- Department of Neuroradiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Marc Schlamann
- Department of Neuroradiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Lenhard Pennig
- Department of Neuroradiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Stephanie Theresa Juenger
- Center for Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Jan-Peter Grunz
- Institute for Diagnostic and Interventional Radiology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Marco Timmer
- Center for Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Gerrit Brinker
- Center for Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Roland Goldbrunner
- Center for Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Boris Krischek
- Center for Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Department of Neurosurgery, Hôpitaux Robert Schuman, Luxembourg, Luxembourg
| | - Lukas Goertz
- Center for Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Department of Neuroradiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.
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9
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Clinical features of ischemic complications after unruptured middle cerebral artery aneurysm clipping: patients and radiologically related factors. Neurosurg Rev 2021; 44:2819-2829. [PMID: 33462782 DOI: 10.1007/s10143-021-01475-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 12/17/2020] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
Postoperative ischemic complication results in neurological sequelae and longer hospitalization after unruptured middle cerebral artery (MCA) aneurysm clipping surgery. We evaluated the radiological and patient-related factors associated with ischemic complications after unruptured MCA aneurysm clipping surgery. Patient demographics, radiological findings, and intraoperative factors were compared between patients with and without postoperative ischemic complications. The clinical courses and outcomes of postoperative ischemic complications were compared according to the types of ischemic complication. Forty-two out of 2227 patients (1.9%) developed postoperative ischemic complications after MCA aneurysm clipping. Multivariate analysis revealed that diabetes mellitus (DM) was a patient-related factor. Intraarterial (IA) calcification of the distal internal carotid artery (ICA), preoperative M1 stenosis, and M1 aneurysm were radiological factors that increased the risk of postoperative ischemic complications. DM was significantly associated with divisional branch territory infarction (P = 0.04). The time to first presentation of ischemic complication was significantly longer in divisional branch territory infarction than perforator territory infarction (67.8 ± 75.9 h vs. 22 ± 20.7, P = 0.023). Twelve out of 42 patients with ischemic complications (28.6%) had unfavorable outcome (mRS > 3). Perforator territory infarction was significantly associated with an unfavorable outcome (mRS > 3, P = 0.019). IA calcification of the distal ICA, M1 stenosis and aneurysms, and DM were significantly associated with postoperative ischemic complications after unruptured MCA aneurysm clipping. Patients with DM should be closely monitored postoperatively to detect delayed occurrence of divisional branch infarction. Trial registration number: 2019-1002, Date of registration: January 1, 2005, "retrospectively registered".
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10
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Berro DH, L'Allinec V, Pasco-Papon A, Emery E, Berro M, Barbier C, Fournier HD, Gaberel T. Clip-first policy versus coil-first policy for the exclusion of middle cerebral artery aneurysms. J Neurosurg 2020; 133:1124-1131. [PMID: 31597117 DOI: 10.3171/2019.5.jns19373] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 05/07/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Middle cerebral artery (MCA) aneurysms are a particular subset of intracranial aneurysms that can be excluded by clipping or coiling. A comparison of the results between these two methods is often limited by a selection bias in which wide-neck and large aneurysms are frequently treated with surgery. Here, the authors report the results of two centers using opposing policies in the management of MCA aneurysms: one center used a clip-first policy while the other used a coil-first policy, which limited the selection bias and ensured a good comparison of these two treatment modalities. METHODS All patients treated for either ruptured or unruptured MCA aneurysms at one of two institutions between January 2012 and December 2015 were eligible for inclusion in this study. At one center a clip-first policy was applied, whereas the other applied a coil-first policy. The authors retrospectively reviewed the medical records of these patients and compared their clinical and radiological outcomes. RESULTS A total of 187 aneurysms were treated during the inclusion period; 88 aneurysms were treated by coiling and 99 aneurysms by clipping. The baseline patient and radiological characteristics were similar between the two groups, but the clinical presentation of the ruptured aneurysm cohort differed slightly. In the ruptured cohort (n = 90), although patients in the coiling group had a higher rate of additional surgery, the complication rate, functional outcome, and risk of death were similar between the two treatment groups. In the unruptured cohort (n = 97), the complication rate, functional outcome, and risk of death were also similar between the two treatment groups, although the risk of discomfort related to the temporal muscle atrophy was higher in the surgical group. Overall, the rate of complete occlusion was higher in the clipping group (84.2%) than in the coiling group (31%), which led to a higher risk in the coiling group of aneurysm retreatment within the first 2 years (p = 0.04). CONCLUSIONS Clipping and coiling for MCA aneurysm treatment provide the same clinical outcome for ruptured and unruptured aneurysms. However, clipping provides higher short- and long-term rates of complete exclusion, which in turn decreases the risk of aneurysm retreatment. Whether this lower occlusion rate can have a clinical impact in the long-term must be further evaluated.
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Affiliation(s)
- David Hassanein Berro
- 1CHU de Caen, Department of Neurosurgery, Caen
- 2Université Caen Normandie, Medical School, Caen
- 3Normandie Université, UNICAEN, CEA, CNRS, ISTCT/CERVOxy Group, GIP Cyceron, Caen
| | | | | | - Evelyne Emery
- 1CHU de Caen, Department of Neurosurgery, Caen
- 2Université Caen Normandie, Medical School, Caen
- 5INSERM, UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), GIP Cyceron, Caen
| | - Mada Berro
- 2Université Caen Normandie, Medical School, Caen
- 6CHU de Caen, Department of Neurology, Caen
| | | | | | - Thomas Gaberel
- 1CHU de Caen, Department of Neurosurgery, Caen
- 2Université Caen Normandie, Medical School, Caen
- 5INSERM, UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), GIP Cyceron, Caen
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11
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Pierot L. In Reply: Aneurysm Treatment With Woven EndoBridge in the Cumulative Population of 3 Prospective, Multicenter Series: 2-Year Follow-up. Neurosurgery 2020; 87:E78-E79. [DOI: 10.1093/neuros/nyaa089] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Laurent Pierot
- Department of Neuroradiology Hôpital Maison-Blanche Université Reims-Champagne-Ardenne Reims, France
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12
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Nussbaum ES, Kallmes KM. Contralateral approach for the treatment of a distal supraclinoid aneurysm: a technical case report. Br J Neurosurg 2019:1-4. [PMID: 31364870 DOI: 10.1080/02688697.2019.1648754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: When treating intracranial aneurysms with open microsurgery, rare cases arise in which an ipsilateral approach leads to poor visualization, lack of proximal control, or potential damage to nearby vital structures due to the anatomy of the aneurysm. Case Description: We describe a patient with a small, unruptured aneurysm arising from the medial aspect of the distal supraclinoid internal carotid artery (ICA), just below the ICA bifurcation. A contralateral surgical approach was chosen because our view of the aneurysm from an ipsilateral approach would have been obstructed by the ICA. The contralateral approach provided excellent exposure of the aneurysm and allowed for precise clip placement without complications. Conclusions: Contralateral approaches may be a good option for some small medially pointing aneurysm of large proximal cerebral arteries.
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Affiliation(s)
- Eric S Nussbaum
- a Department of Neurosurgery, National Brain Aneurysm & Tumor Center, United Hospital , St. Paul , MN , USA
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13
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Hagen F, Maurer CJ, Berlis A. Endovascular Treatment of Unruptured MCA Bifurcation Aneurysms Regardless of Aneurysm Morphology: Short- and Long-Term Follow-Up. AJNR Am J Neuroradiol 2019; 40:503-509. [PMID: 30765382 DOI: 10.3174/ajnr.a5977] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 01/04/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE The optimal treatment of unruptured middle cerebral aneurysms is still under debate. Although today almost any aneurysm can be treated endovascularly, there is a lack of data comparing endovascular and microsurgical repair of MCA aneurysms. The aim of our analysis is to provide data on the efficacy, clinical outcome, complications and re-treatment rates of endovascular treatment of this subtype of aneurysms. MATERIALS AND METHODS Between May 2008 and July 2017, endovascular treatment of 1184 aneurysms in 827 patients was performed in our department. Twenty-four percent of these aneurysms were located at the MCA, and 150 unruptured MCA bifurcation aneurysms treated with coiling, stent-assisted-coiling, or endovascular flow diverter (WEB device) were identified for this retrospective data analysis. Ninety-six percent of all aneurysms, ruptured and unruptured, were treated by an endovascular approach, which yields a low selection bias for aneurysms suitable for endovascular treatment. Follow-up examinations were performed after 12 and 36 months and then every 1-3 years after embolization. Procedures were analyzed for periprocedural complications, outcome, and retreatment rate of the WEB (n = 38) and coiling with (n = 45) or without stent assistance (n = 67). RESULTS The procedure-associated good clinical outcome (mRS ≦ 2) was 89.9%, and the mortality rate was 2.7%. Short-term follow-up good clinical outcome/mortality rates were 91.3%/0.7%. At discharge, 137 patients had an mRS of 0-2 (91.3%) and 13 had an mRS of 3-6 (8.7%). The retreatment rate was significantly higher in the WEB group (21.1%) compared with the coiling group with (5.9%) or without (2.2%) stent placement (P < .05). CONCLUSIONS Regardless of the architecture of MCA bifurcation aneurysms, the endovascular treatment can be performed with low morbidity/mortality rates. The higher retreatment rate in the WEB group correlates with the learning curve in choosing the right device size.
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Affiliation(s)
- F Hagen
- From the Department of Diagnostic and Interventional Neuroradiology, Klinikum Augsburg, Augsburg, Germany
| | - C J Maurer
- From the Department of Diagnostic and Interventional Neuroradiology, Klinikum Augsburg, Augsburg, Germany.
| | - A Berlis
- From the Department of Diagnostic and Interventional Neuroradiology, Klinikum Augsburg, Augsburg, Germany
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