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Kim M, Kim JH, Park W, Park JC, Ahn JS, Kwun BD, Lee SG, Hwang S, Kim M, Lee S. Risk of Cerebral Aneurysm Rupture After Liver Transplantation: Development and Validation of a Hemorrhagic Stroke Scoring Model. J Korean Med Sci 2024; 39:e88. [PMID: 38469964 PMCID: PMC10927392 DOI: 10.3346/jkms.2024.39.e88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/15/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Liver transplantation (LT) patients appear to be more prone to neurological events compared to individuals undergoing other types of solid-organ transplantation. The aims of the present study were to analyze the prevalence of unruptured intracranial aneurysms (UIAs) in patients undergoing liver transplantation (LT) and to examine the perioperative occurrence of subarachnoid hemorrhage (SAH). Also, it intended to systematically identify the risk factors of SAH and hemorrhagic stroke (HS) within a year after LT and to develop a scoring system which involves distinct clinical features of LT patients. METHODS Patients who underwent LT from January 2012 to March 2022 were analyzed. All included patients underwent neurovascular imaging within 6 months before LT. We conducted an analysis of prevalence and radiological features of UIA and SAH. The clinical factors that may have an impact on HS within one year of LT were also reviewed. RESULTS Total of 3,487 patients were enrolled in our study after applying inclusion and exclusion criteria. The prevalence of UIA was 5.4%. The incidence of SAH and HS within one year following LT was 0.5% and 1.6%, respectively. We developed a scoring system based on multivariable analysis to predict the HS within 1-year after LT. The variables were a poor admission mental status, the diagnosis of UIA, serum ammonia levels, and Model for End-stage Liver Disease (MELD) scores. Our model showed good discrimination among the development (C index, 0.727; 95% confidence interval [CI], 0.635-0.820) and validation (C index, 0.719; 95% CI, 0.598-0.801) cohorts. CONCLUSION The incidence of UIA and SAH was very low in LT patients. A poor admission mental status, diagnosis of UIA, serum ammonia levels, and MELD scores were significantly associated with the risk of HS within one year after LT. Our scoring system showed a good discrimination to predict the HS in LT patients.
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Affiliation(s)
- Minwoo Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Hyun Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Wonhyoung Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Cheol Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Sung Ahn
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byung Duk Kwun
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Gyu Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Korea
| | - Moinay Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Seungjoo Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Lee CH, Kwak HS, Kang HS, Jung KH, Jeong SK. Geometric versus Hemodynamic Indexes for Rupture-Destined Aneurysms: A Retrospective Cohort and a Repeated-Measures Study. Cerebrovasc Dis 2023; 53:327-334. [PMID: 37696264 DOI: 10.1159/000533167] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 07/13/2023] [Indexed: 09/13/2023] Open
Abstract
INTRODUCTION A proper stratification of intracranial aneurysms is critical in identifying rupture-destined aneurysms and unruptured intracranial aneurysms. We aimed to determine the utility of geometric and hemodynamic indexes in differentiating two types of aneurysms and to examine the characteristics of natural evolutionary changes of unruptured aneurysms. METHODS Rupture-destined aneurysm refers to an aneurysm that undergoes subsequent aneurysmal subarachnoid hemorrhage (SAH). On the other hand, an unruptured intracranial aneurysm is characterized by an aneurysm that does not experience rupture during serial time-of-flight magnetic resonance angiography (TOF-MRA). In addition to geometric indexes, signal intensity gradient (SIG), an in vivo approximated wall shear stress from TOF-MRA, was measured in aneurysms. The difference between the maximum and minimum values of SIG in an aneurysm compared to parent arterial values was designated as the delta-SIG ratio. RESULTS This study analyzed 20 rupture-destined aneurysms in 20 patients and 45 unruptured intracranial aneurysms in 41 patients with follow-up TOF-MRA. While geometric indexes did not show differences between the two groups, the delta-SIG ratio was higher in the rupture-destined aneurysms (1.5 ± 0.6 vs. 1.1 ± 0.3, p = 0.032). The delta-SIG ratio showed a higher area under the receiver operating characteristic curve for SAH than the size ratio (0.72 [95% CI, 0.58-0.87] vs. 0.56 [95% CI, 0.41-0.72], p = 0.033). The longitudinal re-examination of TOF-MRA in the unruptured intracranial aneurysms revealed evidence of aneurysmal growth, while concurrently exhibiting hemodynamic stability. CONCLUSION The delta-SIG ratio showed higher discriminatory results between the two groups compared to geometric indexes. Aneurysmal rupture risk should be assessed by considering both geometric and hemodynamic information. This study was registered on ClinicalTrials.gov (NCT05450939).
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Affiliation(s)
- Chan-Hyuk Lee
- Department of Neurology, Asan Medical Center, Seoul, Republic of Korea
- Department of Neurology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Hyo Sung Kwak
- Department of Radiology and Research Institute of Clinical Medicine of Jeonbuk National University, Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Republic of Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Keun-Hwa Jung
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seul-Ki Jeong
- Seul-Ki Jeong Neurology Clinic, Seoul, Republic of Korea
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Effects of Pulsatile Flow Rate and Shunt Ratio in Bifurcated Distal Arteries on Hemodynamic Characteristics Involved in Two Patient-Specific Internal Carotid Artery Sidewall Aneurysms: A Numerical Study. Bioengineering (Basel) 2022; 9:bioengineering9070326. [PMID: 35877376 PMCID: PMC9311626 DOI: 10.3390/bioengineering9070326] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/05/2022] [Accepted: 07/15/2022] [Indexed: 01/08/2023] Open
Abstract
The pulsatile flow rate (PFR) in the cerebral artery system and shunt ratios in bifurcated arteries are two patient-specific parameters that may affect the hemodynamic characteristics in the pathobiology of cerebral aneurysms, which needs to be identified comprehensively. Accordingly, a systematic study was employed to study the effects of pulsatile flow rate (i.e., PFR−I, PFR−II, and PFR−III) and shunt ratio (i.e., 75:25 and 64:36) in bifurcated distal arteries, and transient cardiac pulsatile waveform on hemodynamic patterns in two internal carotid artery sidewall aneurysm models using computational fluid dynamics (CFD) modeling. Numerical results indicate that larger PFRs can cause higher wall shear stress (WSS) in some local regions of the aneurysmal dome that may increase the probability of small/secondary aneurysm generation than under smaller PFRs. The low WSS and relatively high oscillatory shear index (OSI) could appear under a smaller PFR, increasing the potential risk of aneurysmal sac growth and rupture. However, the variances in PFRs and bifurcated shunt ratios have rare impacts on the time-average pressure (TAP) distributions on the aneurysmal sac, although a higher PFR can contribute more to the pressure increase in the ICASA−1 dome due to the relatively stronger impingement by the redirected bloodstream than in ICASA−2. CFD simulations also show that the variances of shunt ratios in bifurcated distal arteries have rare impacts on the hemodynamic characteristics in the sacs, mainly because the bifurcated location is not close enough to the sac in present models. Furthermore, it has been found that the vortex location plays a major role in the temporal and spatial distribution of the WSS on the luminal wall, varying significantly with the cardiac period.
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Chandra RV, Maingard J, Slater LA, Cheung NK, Lai LT, Gall SL, Thrift AG, Phan TG. A Meta-Analysis of Rupture Risk for Intracranial Aneurysms 10 mm or Less in Size Selected for Conservative Management Without Repair. Front Neurol 2022; 12:743023. [PMID: 35250788 PMCID: PMC8893017 DOI: 10.3389/fneur.2021.743023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 12/28/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Small unruptured intracranial aneurysms (UIAs) are considered to have low risk of rupture. The proportion of UIAs measuring 10 mm or less in size that rupture when selected for conservative management without repair is not well known. The aim of this study is to determine the proportion of UIAs that rupture by size threshold from ≤10 to ≤3 mm when selected for management without repair and to determine the level of precision and sources of heterogeneity in the rupture risk estimate. METHODS This study was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42019121522). The Ovid MEDLINE, EMBASE, Web of Science Core Collection, and the Cochrane Central Register of Controlled Trials were searched (inception to August 2020). Studies with longitudinal follow-up of patients with UIAs ( ≤10 mm to ≤3 mm) without endovascular or neurosurgical repair were eligible. We included studies, which provided details of aneurysm size and in which UIA rupture was reported as an outcome. The primary outcome of the pooled proportion of UIA rupture during follow-up was synthesized with random-effects meta-analysis; heterogeneity was explored using meta-regression. RESULTS A total of 31 studies that included 13,800 UIAs ≤10 mm in size were eligible for data synthesis. The pooled proportion of ≤10 mm UIAs that ruptured when managed without repair was 1.1% (95% CI 0.8-1.5; I 2 = 52.9%) over 3.7 years. Findings were consistent in sensitivity analyses at all the size stratified thresholds including ≤5 and ≤3 mm; rupture occurred in 1.0% (95% CI 0.8-1.3; I 2 = 0%) of 7,280 ≤5 mm UIAs and 0.8% (95% CI 0.4-1.5; I 2 = 0%) of 1,228 ≤3 mm UIAs managed without repair. In higher quality studies with lower risk of bias, rupture occurred in 1.8% (95% CI 1.5-2.0; I 2 = 0%) over 3.9 years. In meta-regression, aneurysm size, shape, anatomical location, and exposure to prior subarachnoid hemorrhage were not identified as sources of heterogeneity. CONCLUSION For every 1,000 UIAs that are 10 mm or less in size and selected for conservative management without repair, between 8 and 15 UIAs are estimated to rupture over 3.7 years. When stratified by size, these pooled rupture risk estimates are consistent and clinically applicable for ≤5 mm UIAs selected for management without repair. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/prospero/, identifier: CRD42019121522.
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Affiliation(s)
- Ronil V. Chandra
- NeuroInterventional Radiology, Monash Medical Centre, Monash Health, Melbourne, VIC, Australia
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
| | - Julian Maingard
- NeuroInterventional Radiology, Monash Medical Centre, Monash Health, Melbourne, VIC, Australia
| | - Lee-Anne Slater
- NeuroInterventional Radiology, Monash Medical Centre, Monash Health, Melbourne, VIC, Australia
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
| | - Nicholas K. Cheung
- NeuroInterventional Radiology, Monash Medical Centre, Monash Health, Melbourne, VIC, Australia
| | - Leon T. Lai
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
- Department of Neurosurgery, Monash Medical Centre, Monash Health, Melbourne, VIC, Australia
| | - Seana L. Gall
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
| | - Amanda G. Thrift
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
| | - Thanh G. Phan
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
- Department of Neurology, Monash Medical Centre, Monash Health, Melbourne, VIC, Australia
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Joo B, Choi HS, Ahn SS, Cha J, Won SY, Sohn B, Kim H, Han K, Kim HP, Choi JM, Lee SM, Kim TG, Lee SK. A Deep Learning Model with High Standalone Performance for Diagnosis of Unruptured Intracranial Aneurysm. Yonsei Med J 2021; 62:1052-1061. [PMID: 34672139 PMCID: PMC8542476 DOI: 10.3349/ymj.2021.62.11.1052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 07/29/2021] [Accepted: 08/30/2021] [Indexed: 02/07/2023] Open
Abstract
PURPOSE This study aimed to investigate whether a deep learning model for automated detection of unruptured intracranial aneurysms on time-of-flight (TOF) magnetic resonance angiography (MRA) can achieve a target diagnostic performance comparable to that of human radiologists for approval from the Korean Ministry of Food and Drug Safety as an artificial intelligence-applied software. MATERIALS AND METHODS In this single-center, retrospective, confirmatory clinical trial, the diagnostic performance of the model was evaluated in a predetermined test set. After sample size estimation, the test set consisted of 135 aneurysm-containing examinations with 168 intracranial aneurysms and 197 aneurysm-free examinations. The target sensitivity and specificity were set as 87% and 92%, respectively. The patient-wise sensitivity and specificity of the model were analyzed. Moreover, the lesion-wise sensitivity and false-positive detection rate per case were also investigated. RESULTS The sensitivity and specificity of the model were 91.11% [95% confidence interval (CI): 84.99, 95.32] and 93.91% (95% CI: 89.60, 96.81), respectively, which met the target performance values. The lesion-wise sensitivity was 92.26%. The overall false-positive detection rate per case was 0.123. Of the 168 aneurysms, 13 aneurysms from 12 examinations were missed by the model. CONCLUSION The present deep learning model for automated detection of unruptured intracranial aneurysms on TOF MRA achieved the target diagnostic performance comparable to that of human radiologists. With high standalone performance, this model may be useful for accurate and efficient diagnosis of intracranial aneurysm.
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Affiliation(s)
- Bio Joo
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Seok Choi
- Department of Radiology, Seoul Medical Center, Seoul, Korea
- Department of Radiology, Research Institute of Radiological Science and Center for Clinical Image Data Science, Yonsei University College of Medicine, Seoul, Korea.
| | - Sung Soo Ahn
- Department of Radiology, Research Institute of Radiological Science and Center for Clinical Image Data Science, Yonsei University College of Medicine, Seoul, Korea
| | - Jihoon Cha
- Department of Radiology, Research Institute of Radiological Science and Center for Clinical Image Data Science, Yonsei University College of Medicine, Seoul, Korea
| | - So Yeon Won
- Department of Radiology, Research Institute of Radiological Science and Center for Clinical Image Data Science, Yonsei University College of Medicine, Seoul, Korea
| | - Beomseok Sohn
- Department of Radiology, Research Institute of Radiological Science and Center for Clinical Image Data Science, Yonsei University College of Medicine, Seoul, Korea
| | - Hwiyoung Kim
- Department of Radiology, Research Institute of Radiological Science and Center for Clinical Image Data Science, Yonsei University College of Medicine, Seoul, Korea
| | - Kyunghwa Han
- Department of Radiology, Research Institute of Radiological Science and Center for Clinical Image Data Science, Yonsei University College of Medicine, Seoul, Korea
| | | | | | | | | | - Seung-Koo Lee
- Department of Radiology, Research Institute of Radiological Science and Center for Clinical Image Data Science, Yonsei University College of Medicine, Seoul, Korea
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Kwon HM, Jun IG, Kim KS, Moon YJ, Huh IY, Lee J, Song JG, Hwang GS. Rupture Risk of Intracranial Aneurysm and Prediction of Hemorrhagic Stroke after Liver Transplant. Brain Sci 2021; 11:brainsci11040445. [PMID: 33807191 PMCID: PMC8066281 DOI: 10.3390/brainsci11040445] [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: 03/03/2021] [Revised: 03/24/2021] [Accepted: 03/27/2021] [Indexed: 01/23/2023] Open
Abstract
Postoperative hemorrhagic stroke (HS) is a rare yet devastating complication after liver transplantation (LT). Unruptured intracranial aneurysm (UIA) may contribute to HS; however, related data are limited. We investigated UIA prevalence and aneurysmal subarachnoid hemorrhage (SAH) and HS incidence post-LT. We identified risk factors for 1-year HS and constructed a prediction model. This study included 3544 patients who underwent LT from January 2008 to February 2019. Primary outcomes were incidence of SAH, HS, and mortality within 1-year post-LT. Propensity score matching (PSM) analysis and Cox proportional hazard analysis were performed. The prevalence of UIAs was 4.63% (n = 164; 95% confidence interval (CI), 3.95–5.39%). The 1-year SAH incidence was 0.68% (95% CI, 0.02–3.79%) in patients with UIA. SAH and HS incidence and mortality were not different between those with and without UIA before and after PSM. Cirrhosis severity, thrombocytopenia, inflammation, and history of SAH were identified as risk factors for 1-year HS. UIA presence was not a risk factor for SAH, HS, or mortality in cirrhotic patients post-LT. Given the fatal impact of HS, a simple scoring system was constructed to predict 1-year HS risk. These results enable clinical risk stratification of LT recipients with UIA and help assess perioperative HS risk before LT.
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A review of hemodynamic parameters in cerebral aneurysm. INTERDISCIPLINARY NEUROSURGERY-ADVANCED TECHNIQUES AND CASE MANAGEMENT 2020. [DOI: 10.1016/j.inat.2020.100716] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Lee KS, Zhang JJY, Alalade AF, Vine R, Lanzino G, Park N, Roberts G, Gurusinghe NT. Radiological surveillance of small unruptured intracranial aneurysms: a systematic review, meta-analysis, and meta-regression of 8428 aneurysms. Neurosurg Rev 2020; 44:2013-2023. [PMID: 33094423 DOI: 10.1007/s10143-020-01420-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/08/2020] [Accepted: 10/12/2020] [Indexed: 11/26/2022]
Abstract
With the widespread use of imaging techniques, the possibility that an asymptomatic unruptured intracranial aneurysm (UIA) is detected has increased significantly. There is no established consensus regarding follow-up, duration, and frequency of such imaging surveillance. The objectives of this study include assessing the growth rate and rupture risk of small (less than 7mm) UIAs, identifying associated risk factors and providing an aneurysm surveillance protocol in appropriately selected patients. Systematic searches of Medline, Embase, and Cochrane Central were undertaken from database inception to March 2020 for published studies reporting the growth and rupture risks of small UIAs. Twenty-one studies reporting 8428 small UIAs were included in our meta-analysis. The pooled mean age was 61 years (95% CI: 55-67). The mean follow-up period for growth and rupture ranged from 11 to 108 months, with the pooled mean follow-up period across 14 studies being 42 months (95% CI: 33-51). Pooled overall growth rate was 6.0% (95% CI: 3.8-8.7). Pooled growth rates for aneurysms < 5mm and < 3 mm were 5.2% (95% CI: 3.0-7.9) and 0.8% (95% CI: 0.0-6.1), respectively. Pooled overall rupture rate was 0.4% (95% CI: 0.2-0.7). From the meta-regression analysis, having multiple aneurysms, smoking, hypertension, and personal history of SAH did not significantly predict growth, and a personal history of SAH, smoking, hypertension, and multiple aneurysms were not statistically significant predictors of rupture. Our findings suggest that small UIAs have low growth and rupture rates and very small UIAs have little or no risk for rupture. In the setting of incidental small UIAs, patients with multiple and/or posterior circulation aneurysms require more regular radiological monitoring.
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Affiliation(s)
- Keng Siang Lee
- Bristol Medical School, University of Bristol, Bristol, UK
| | - John J Y Zhang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Andrew Folusho Alalade
- Department of Neurosurgery, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, PR2 9HT, UK.
| | - Roanna Vine
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Giuseppe Lanzino
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Nicholas Park
- Department of Neurosurgery, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, PR2 9HT, UK
| | - Gareth Roberts
- Department of Neurosurgery, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, PR2 9HT, UK
| | - Nihal T Gurusinghe
- Department of Neurosurgery, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, PR2 9HT, UK
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A deep learning algorithm may automate intracranial aneurysm detection on MR angiography with high diagnostic performance. Eur Radiol 2020; 30:5785-5793. [DOI: 10.1007/s00330-020-06966-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 03/30/2020] [Accepted: 05/15/2020] [Indexed: 10/24/2022]
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Nam JS, Jeon SB, Jo JY, Joung KW, Chin JH, Lee EH, Chung CH, Choi IC. Perioperative rupture risk of unruptured intracranial aneurysms in cardiovascular surgery. Brain 2020; 142:1408-1415. [PMID: 30851103 DOI: 10.1093/brain/awz058] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 01/05/2019] [Accepted: 01/18/2019] [Indexed: 01/10/2023] Open
Abstract
Although unruptured intracranial aneurysms are increasingly being diagnosed incidentally, perioperative rupture risk of unruptured intracranial aneurysm in patients undergoing cardiovascular surgery remains unclear. Therefore, we conducted an observational study to assess the prevalence and perioperative rupture risk of unruptured intracranial aneurysm in patients undergoing cardiovascular surgery. Adult patients (n = 4864) who underwent cardiovascular surgery between January 2010 and December 2016 were included. We assessed the prevalence of unruptured intracranial aneurysms in these patients using preoperative neurovascular imaging. The incidence of postoperative 30-day subarachnoid haemorrhage from aneurysmal rupture was investigated in patients undergoing cardiovascular surgery with unruptured intracranial aneurysm. Postoperative outcomes were compared between patients with unruptured intracranial aneurysm and those without unruptured intracranial aneurysm. Of the 4864 patients (39.6% females; mean ± standard deviation age, 62.3 ± 11.3 years), 353 patients had unruptured intracranial aneurysms (prevalence rate, 7.26%; 95% confidence interval, 6.52-8.06%). Of these, eight patients received surgical or endovascular treatment before surgery and 345 patients underwent cardiovascular surgery with unruptured intracranial aneurysms. Within 30 days postoperatively, subarachnoid haemorrhage occurred only in one patient, and the cumulative postoperative 30-day subarachnoid haemorrhage incidence was 0.29% (95% confidence interval, 0.01% to 1.61%). The Kaplan-Meier estimated subarachnoid haemorrhage probabilities according to the unruptured intracranial aneurysm rupture risk scores were not higher than the previously reported risk in the general population. There were no significant differences in postoperative subarachnoid haemorrhage-free survival, haemorrhagic stroke-free survival, in-hospital mortality, and hospital length of stay between patients with unruptured intracranial aneurysm and those without unruptured intracranial aneurysm. In conclusion, the prevalence of unruptured intracranial aneurysm in patients undergoing cardiovascular surgery is higher than in the general population. However, incidentally detected unruptured intracranial aneurysms are not linked to an increased risk of subarachnoid haemorrhage or adverse postoperative outcomes. These findings may help determine the optimal management of unruptured intracranial aneurysms before cardiovascular surgery.
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Affiliation(s)
- Jae-Sik Nam
- Department of Anaesthesiology and Pain Medicine, Laboratory for Perioperative Outcomes Analysis and Research, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Beom Jeon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun-Young Jo
- Department of Anaesthesiology and Pain Medicine, Laboratory for Perioperative Outcomes Analysis and Research, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyoung-Woon Joung
- Department of Anaesthesiology and Pain Medicine, Laboratory for Perioperative Outcomes Analysis and Research, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji-Hyun Chin
- Department of Anaesthesiology and Pain Medicine, Laboratory for Perioperative Outcomes Analysis and Research, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun-Ho Lee
- Department of Anaesthesiology and Pain Medicine, Laboratory for Perioperative Outcomes Analysis and Research, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Cheol Hyun Chung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In-Cheol Choi
- Department of Anaesthesiology and Pain Medicine, Laboratory for Perioperative Outcomes Analysis and Research, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Kim M, Lee HS, Lee S, Park JC, Ahn JS, Kwon DH, Kwun BD, Park W. Pediatric Intracranial Aneurysms: Favorable Outcomes Despite Rareness and Complexity. World Neurosurg 2019; 125:e1203-e1216. [PMID: 30794975 DOI: 10.1016/j.wneu.2019.01.280] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 01/27/2019] [Accepted: 01/30/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Pediatric intracranial aneurysms (IAs) are rare and differ from their adult counterparts in terms of their aneurysmal characteristics, presentation, treatment, and outcomes. Their treatment is often more difficult and complex compared with that of adults. However, studies outlining the clinical effect of pediatric IAs remain sparse. METHODS We retrospectively reviewed the data from patients aged ≤18 years admitted to our hospital from 2000 to 2017 with a diagnosis of IAs. RESULTS From the sample of 8207 patients with an IA diagnosis, 26 patients with 33 IAs were involved. Our cohort included 17 males and 9 females, with a mean age of 12.5 years. The mean follow-up duration was 4 years and 3 months. Seven patients (26.92%) were assumed to have a traumatic origin for their IAs. Ruptured aneurysms were more common than unruptured ones (61.53% vs. 38.46%). Complex features were observed in 14 aneurysms (42.42%). Initially, microsurgical and endovascular treatment were both performed in 10 patients (38.46%). A good recovery was obtained in 16 patients (61.54%) as determined by the Glasgow outcome scale scores at the 6-month follow-up visits. The complete obliteration of aneurysms was observed in 17 patients (65.38%). Endovascular treatment was the initial treatment in 3 patients with incomplete obliteration. CONCLUSIONS The treatment of pediatric IAs is challenging and technically demanding owing to their discrete nature compared with adult IAs and the need for greater surgical skills. We found a male predominance, with internal carotid artery bifurcation as the most frequent location of the aneurysms. Despite the greater incidence of ruptured and complex aneurysm cases, many patients had experienced a good recovery at the 6-month follow-up examinations.
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Affiliation(s)
- Moinay Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Heui Seung Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seungjoo Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung Cheol Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Sung Ahn
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Do Hoon Kwon
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Byung Duk Kwun
- Department of Neurosurgery, School of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Wonhyoung Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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12
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Nagahiro S, Tada Y, Satomi J, Kinouchi T, Kuwayama K, Yagi K, Nakajima K, Matsushita N, Miyamoto T, Yamaguchi T, Shimada K, Korai M, Mure H, Okayama Y, Abe T, Harada M, Kitazato KT, Kanematsu Y. Treatment of Unruptured Cerebral Aneurysms with the Mineralocorticoid Receptor Blocker Eplerenone—Pilot Study. J Stroke Cerebrovasc Dis 2018; 27:2134-2140. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.03.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 02/06/2018] [Accepted: 03/13/2018] [Indexed: 11/25/2022] Open
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13
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Kim T, Kim CH, Kang SH, Ban SP, Kwon OK. Relevance of Antiplatelet Therapy Duration After Stent-Assisted Coil Embolization for Unruptured Intracranial Aneurysms. World Neurosurg 2018; 116:e699-e708. [PMID: 29778598 DOI: 10.1016/j.wneu.2018.05.071] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Revised: 05/09/2018] [Accepted: 05/10/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND The optimal duration of dual-antiplatelet therapy (DAPT) for preventing delayed thromboembolic events (DTEs) remains unclear. We aimed to determine whether longer DAPT provides improved protection against delayed DTEs. METHODS This retrospective cohort study included 507 stent-assisted coil embolization procedures using a single stent for unruptured intracranial aneurysms. We performed coarsened exact matching according to the duration of maintenance DAPT. DTEs were defined as any neurologic symptoms concerning the stented vascular territory and occurring at 1 month or later after the procedure. After stratification according to DAPT duration (short-term, <9 months; long-term, ≥9 months), the log-rank test and Z-analysis were performed to evaluate the efficacy of long-term DAPT for preventing DTEs. RESULTS Of 507 treated patients (median follow-up, 44 months), 25 (4.9%) experienced DTEs at 1 month after the procedure. Among all DTEs, 9 (1.8%) were infarctions confirmed on magnetic resonance imaging. Permanent neurologic deficit (modified Rankin Scale score ≥2) occurred in 2 (0.4%) patients. On procedure-to-event analysis, long-term DAPT was not superior for preventing DTEs. Most events occurred within 1 month of switching from DAPT to single-antiplatelet therapy, regardless of DAPT duration. The longest time from the procedure to DTE occurrence was 22 months. Age older than 54.5 years was identified as independent risk factor for DTE-stroke. CONCLUSIONS Compared with short-term DAPT, long-term DAPT delays the occurrence of DTEs but does not lower their incidence. Longer-term DAPT (>9 months) should be considered after stent-assisted coil embolization for unruptured intracranial aneurysms, although its efficacy remains to be clarified.
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Affiliation(s)
- Tackeun Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea; Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Hyeun Kim
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Si-Hyuck Kang
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Pil Ban
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea; Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - O-Ki Kwon
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea; Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea.
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14
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Schneider AM, Moore JM, Adeeb N, Gupta R, Griessenauer CJ, Winkler PA, Sieber S, Alturki AY, Ogilvy CS, Thomas AJ. Self-Reported Headaches in Patients with Unruptured Intracranial Aneurysms Treated with the Pipeline Embolization Device. World Neurosurg 2018; 113:e364-e372. [DOI: 10.1016/j.wneu.2018.02.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 02/05/2018] [Accepted: 02/06/2018] [Indexed: 11/28/2022]
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15
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Kim T, Kwon OK, Lee H, Cho MJ, Jeong HJ, Ban SP. Nationwide Mortality Data after Flow-Diverting Stent Implantation in Korea. J Korean Neurosurg Soc 2018. [PMID: 29526065 PMCID: PMC5853200 DOI: 10.3340/jkns.2017.0218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective To investigate nationwide statistics on flow-diverting stent usage for cerebral aneurysm treatment and related mortality data. Methods We requested data extraction from the National Health Insurance Service claims database using electronic data interchange codes (J3207064, J3207073). Patient and hospital information as well as death statistics were collected from the database. Results A total of 169 procedures were performed using flow-diverting stents for cerebral aneurysm treatment from November 2014 to December 2016 in Korea. The majority of primary diagnosis was unruptured intracranial aneurysm. During the study period, nine subjects died, including one patient initially diagnosed with subarachnoid hemorrhage. The crude mortality rate was 5.3%. Five patients died within one month after the procedure; therefore, the estimated periprocedural mortality rate was 3.0±1.3%. The mortality rate as of the last day of 2016 was 6.3±2.1%. Conclusion In a 171 person-year follow-up in a Korean series, nine deaths occurred after flow-diverting stent treatment. The crude mortality rate in Korea (5.3%) was higher than that reported in a previous meta-analysis (3.8%).
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Affiliation(s)
- Tackeun Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Seoul National University College of Medicine, Seoul, Korea
| | - O-Ki Kwon
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Seoul National University College of Medicine, Seoul, Korea
| | - Heeyoung Lee
- Seoul National University College of Medicine, Seoul, Korea.,Center for Preventive Medicine and Public Health, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Min Jai Cho
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Jean Jeong
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Seoul National University College of Medicine, Seoul, Korea
| | - Seung Pil Ban
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Seoul National University College of Medicine, Seoul, Korea
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16
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Lee MS, Park CG, Hughes TL, Jun SE, Whang K, Kim N. The predictive role of health-promoting behaviours and perceived stress in aneurysmal rupture. J Clin Nurs 2018; 27:e1068-e1077. [DOI: 10.1111/jocn.14149] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Mi-Sun Lee
- Kyungpook National University Hospital; Daegu Korea
- College of Nursing; Keimyung University; Daegu Korea
| | - Chang G Park
- College of Nursing; University of Illinois at Chicago; Chicago IL USA
| | - Tonda L Hughes
- School of Nursing and Department of Psychiatry; Columbia University; New York NY USA
| | - Sang-Eun Jun
- College of Nursing; Keimyung University; Daegu Korea
| | - Kum Whang
- Department of Neurosurgery; Wonju College of Medicine; Yonsei University; Wonju Korea
| | - Nahyun Kim
- College of Nursing; Keimyung University; Daegu Korea
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17
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Malhotra A, Wu X, Forman HP, Grossetta Nardini HK, Matouk CC, Gandhi D, Moore C, Sanelli P. Growth and Rupture Risk of Small Unruptured Intracranial Aneurysms: A Systematic Review. Ann Intern Med 2017; 167:26-33. [PMID: 28586893 DOI: 10.7326/m17-0246] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Small unruptured intracranial aneurysms (UIAs) are increasingly diagnosed. Management depends on growth and rupture risks, which may vary by aneurysm size. PURPOSE To summarize evidence about the growth and rupture risk of UIAs 7 mm and smaller and to explore differences in growth and rupture risks of very small (≤3 mm) and small (≤5 mm) aneurysms. DATA SOURCES MEDLINE, EMBASE, Scopus, and the Cochrane Library from inception to 2017 (with no language restrictions). STUDY SELECTION Published case series and observational studies that reported natural history data on UIAs 7 mm and smaller. DATA EXTRACTION 2 reviewers abstracted study information, evaluated study quality, and graded strength of evidence. DATA SYNTHESIS Of 26 studies, 5, 10, and 8 described the growth rate of aneurysms 3 mm and smaller, 5 mm and smaller, and 7 mm and smaller, respectively, whereas rupture rates were reported in 7, 11, and 13 studies for aneurysms 3 mm and smaller, 5 mm and smaller, and 7 mm and smaller, respectively. The annualized growth rate was less than 3% in all but 1 study for all 3 size categories. The annualized rupture rate was 0%, less than 0.5%, and less than 1% for the 3 size categories, respectively. Strength of evidence was very low quality for growth rates and low quality for rupture rates. LIMITATION Heterogeneous definitions of growth; heterogeneous and selective treatment and follow-up methods, particularly in high-risk patients. CONCLUSION Poor-quality evidence suggests that small UIAs have low growth and rupture rates and very small UIAs have little or no risk for rupture. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Ajay Malhotra
- From Yale School of Medicine and Yale University, New Haven, Connecticut; University of Maryland School of Medicine, Baltimore, Maryland; and Northwell Health, Manhasset, New York
| | - Xiao Wu
- From Yale School of Medicine and Yale University, New Haven, Connecticut; University of Maryland School of Medicine, Baltimore, Maryland; and Northwell Health, Manhasset, New York
| | - Howard P Forman
- From Yale School of Medicine and Yale University, New Haven, Connecticut; University of Maryland School of Medicine, Baltimore, Maryland; and Northwell Health, Manhasset, New York
| | - Holly K Grossetta Nardini
- From Yale School of Medicine and Yale University, New Haven, Connecticut; University of Maryland School of Medicine, Baltimore, Maryland; and Northwell Health, Manhasset, New York
| | - Charles C Matouk
- From Yale School of Medicine and Yale University, New Haven, Connecticut; University of Maryland School of Medicine, Baltimore, Maryland; and Northwell Health, Manhasset, New York
| | - Dheeraj Gandhi
- From Yale School of Medicine and Yale University, New Haven, Connecticut; University of Maryland School of Medicine, Baltimore, Maryland; and Northwell Health, Manhasset, New York
| | - Christopher Moore
- From Yale School of Medicine and Yale University, New Haven, Connecticut; University of Maryland School of Medicine, Baltimore, Maryland; and Northwell Health, Manhasset, New York
| | - Pina Sanelli
- From Yale School of Medicine and Yale University, New Haven, Connecticut; University of Maryland School of Medicine, Baltimore, Maryland; and Northwell Health, Manhasset, New York
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18
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Lee S, Gong TS, Lee YW, Kim HJ, Kweon CY. Results of Endovascular Coil Embolization Treatment for Small (≤ 5 mm) Unruptured Intracranial Aneurysms. J Cerebrovasc Endovasc Neurosurg 2016; 18:229-233. [PMID: 27847766 PMCID: PMC5104847 DOI: 10.7461/jcen.2016.18.3.229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 09/05/2016] [Accepted: 09/15/2016] [Indexed: 12/02/2022] Open
Abstract
Objective Researchers and clinicians have been unable to fully elucidate the natural course of and proper treatment for unruptured intracranial aneurysms (UIAs) smaller than or equal to 5 mm, particularly with regard to whether close observation or surgery is more appropriate. In this retrospective study, we evaluated the safety and efficacy of endovascular coil embolization of small (≤ 5 mm) asymptomatic UIAs by analyzing outcomes and complications associated with the procedure. Materials and Methods We analyzed data from 150 patients with small asymptomatic UIAs (≤ 5 mm) treated with coil embolization between January 2011 and December 2015. Three-dimensional angiography was used to measure aneurysm size. We evaluated procedure-related morbidity and mortality, immediate post-operative angiographic results, brain computed thomography follow-up results on post-operative day one, and clinical progress. Results UIAs occurred primarily in the anterior circulation area (142 cases, 94.67%), though eight patients exhibited UIAs of the posterior circulation. Following coil embolization, aneurysms with complete occlusion were observed in 137 cases (91.3%). Partial occlusion occurred in five cases (3.33%), while the procedure had failed in eight cases (5.33%). Procedure-related morbidity and mortality were five cases (3.33%) and zero cases, respectively. Conclusion The endovascular treatment of small asymptomatic UIAs is associated with good short-term outcomes without permanent neurologic complications as well as low overall complication and morbidity rates. Thus, the procedure should be considered for patients with smaller asymptomatic UIAs.
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Affiliation(s)
- Siwoo Lee
- Department of Neurosurgery, Presbyterian Medical Center, Jeonju, Korea
| | - Tae-Sik Gong
- Department of Neurosurgery, Presbyterian Medical Center, Jeonju, Korea
| | - Yong-Woo Lee
- Department of Neurosurgery, Presbyterian Medical Center, Jeonju, Korea
| | - Hyo-Joon Kim
- Department of Neurosurgery, Presbyterian Medical Center, Jeonju, Korea
| | - Chang-Young Kweon
- Department of Neurosurgery, Presbyterian Medical Center, Jeonju, Korea
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