Predictive Model Evaluating Risk of Hemorrhage in Intracranial Aneurysms: Analysis from Prospectively Collected HEAT Trial Database

OBJECTIVE

We analyzed the data of patients enrolled in the Hydrogel Endovascular Aneurysm Treatment (HEAT) trial to develop and validate a model to predict the risk of aneurysmal hemorrhage.

METHODS

Analysis included data from 600 patients enrolled for the HEAT trial and included single saccular aneurysms of 3-14 mm size. Baseline characteristics were compared between patients with ruptured and unruptured aneurysms. Regression analysis was performed in the training set to identify significant risk factors and was validated in the validation dataset. The complete dataset was used to formulate a scoring model in which positive and negative predictors were assigned 1 and -1 points, respectively.

RESULTS

Data from 593 patients were analyzed in which 169 (28.5%) patients had ruptured aneurysms. The training (n = 297) and validation dataset (n = 296) had a comparable proportion of ruptured aneurysms (29.3% and 27.7%). Dome-to-neck ratio >2.5 (odds ratio [OR] 3.66), irregular shape (OR 3.79), daughter sac (OR 5.89), and anterior and posterior communicating artery locations (OR 3.32 and 3.56, respectively) had a higher rupture rate. Use of aspirin was associated with lower risk of hemorrhage (OR 0.16). The area under the curve from the receiver operating curve analysis was 0.88, 0.87, and 0.87 in the training, validation, and combined data set, respectively. The scoring model created a score of -1 to 2, yielding an of aneurysmal hemorrhage probability from 1.5% (score -1) to 70% (score 2).

CONCLUSIONS

This prospective study identifies dome-to-neck ratio >2.5, irregular shape, presence of daughter sac, absence of aspirin use, and aneurysm location at anterior communicating and posterior communicating artery as factors associated with increased risk of hemorrhagic presentation in small- to medium-sized intracranial aneurysms. Our model provides an estimate of rupture risk based on the presence or absence of these factors.

A comparison of treating physician versus independent core lab assessments of post-aneurysm treatment imaging outcomes: an analysis of prospectively collected data from a randomized trial

OBJECTIVE

Aneurysm occlusion has been used as surrogate marker of aneurysm treatment efficacy. Aneurysm occlusion scales are used to evaluate the outcome of endovascular aneurysm treatment and to monitor recurrence. These scales, however, require subjective interpretation of imaging data, which can reduce the utility and reliability of these scales and the validity of clinical studies regarding aneurysm occlusion rates. Use of a core lab with independent blinded reviewers has been implemented to enhance the validity of occlusion rate assessments in clinical trials. The degree of agreement between core labs and treating physicians has not been well studied with prospectively collected data.

METHODS

In this study, the authors analyzed data from the Hydrogel Endovascular Aneurysm Treatment (HEAT) trial to assess the interrater agreement between the treating physician and the blinded core lab. The HEAT trial included 600 patients across 46 sites with intracranial aneurysms treated with coiling. The treating site and the core lab independently reviewed immediate postoperative and follow-up imaging (3-12 and 18-24 months, respectively) using the Raymond-Roy occlusion classification (RROC) scale, Meyer scale, and recanalization survey. A post hoc analysis was performed to calculate interrater reliability using Cohen's kappa. Further analysis was performed to assess whether degree of agreement varied on the basis of various factors, including scale used, timing of imaging, size of the aneurysm, imaging modality, location of the aneurysm, dome-to-neck ratio, and rupture status.

RESULTS

Minimal interrater agreement was noted between the core lab reviewers and the treating physicians for assessing aneurysm occlusion using the RROC grading scale (k = 0.39, 95% CI 0.38-0.40) and Meyer scale (k = 0.23, 95% CI 0.14-0.38). The degree of agreement between groups was slightly better but still weak for assessing recanalization (k = 0.45, 95% CI 0.38-0.52). Factors that significantly improved degree of agreement were scales with fewer variables, greater time to follow-up, imaging modality (digital subtraction angiography), and wide-neck aneurysms.

CONCLUSIONS

Assessment of aneurysm treatment outcome with commonly used aneurysm occlusion scales suffers from risk of poor interrater agreement. This supports the use of independent core labs for validation of outcome data to minimize reporting bias. Use of outcome tools with fewer point categories is likely to provide better interrater reliability. Therefore, the outcome assessment tools are ideal for clinical outcome assessment provided that they are sensitive enough to detect a clinically significant change.

The Hydrogel Endovascular Aneurysm Treatment Trial (HEAT): A Randomized Controlled Trial of the Second-Generation Hydrogel Coil

BACKGROUND

Aneurysm recurrence after coiling has been associated with aneurysm growth, (re)hemorrhage, and a greater need for follow-up. The second-generation HydroCoil Embolic System (HES; MicroVention, Inc) consists of a platinum core with integrated hydrogel and was developed to reduce recurrence through enhancing packing density and healing within the aneurysm.

OBJECTIVE

To compare recurrence between the second-generation HES and bare platinum coil (BPC) in the new-generation Hydrogel Endovascular Aneurysm Treatment Trial (HEAT).

METHODS

HEAT is a randomized, controlled trial that enrolled subjects with ruptured or unruptured 3- to 14-mm intracranial aneurysms amenable to coiling. The primary endpoint was aneurysm recurrence using the Raymond-Roy scale. Secondary endpoints included minor and major recurrence, packing density, adverse events related to the procedure and/or device, mortality, initial complete occlusion, aneurysm retreatment, hemorrhage from target aneurysm during follow-up, aneurysm occlusion stability, and clinical outcome at final follow-up.

RESULTS

A total of 600 patients were randomized (HES, n = 297 and BPC, n = 303), including 28% with ruptured aneurysms. Recurrence occurred in 11 (4.4%) subjects in the HES arm and 44 (15.4%) subjects in the BPC arm (P = .002). While the initial occlusion rate was higher with BPC, the packing density and both major and minor recurrence rates were in favor of HES. Secondary endpoints including adverse events, retreatment, hemorrhage, mortality, and clinical outcome did not differ between arms.

CONCLUSION

Coiling of small-to-medium aneurysms with second-generation HES resulted in less recurrence when compared to BPC, without increased harm. These data further support the use of the second-generation HES for the embolization of intracranial aneurysms.

VIDEO ABSTRACT

Quality of Life of Patients with Unruptured Intracranial Aneurysms Before and After Endovascular Coiling: A HEAT Trial Secondary Study and Systematic Review of the Literature

BACKGROUND

The study of quality of life (QOL) in patients with asymptomatic diseases receiving interventional treatment provides an essential metric for the assessment of procedural benefits in the surgical patient population. In this study, we analyzed QOL data collected from patients with unruptured intracranial aneurysms (UIAs) before and after endovascular coiling in the HEAT Trial, alongside a systematic review on QOL in unruptured brain aneurysms.

METHODS

HEAT was a randomized controlled trial comparing recurrence rates in aneurysms treated with either bare platinum coils or hydrogel coils. Patients enrolled in this trial completed a short form-36 (SF-36) QOL questionnaire before treatment and at the 3- to 12- and 18- to 24-month follow-ups. The change in QOL before and after treatment was assessed. Regression analysis evaluated the effect of select baseline characteristics on QOL change.

RESULTS

A total of 270 patients were eligible for analysis. There was an increase in the role physical (P = 0.043), vitality (P = 0.022), and emotional well-being (P < 0.001) QOL components at the 18- to 24-month follow-up compared with baseline scores. Regression analysis showed that age younger than 60 and absence of serious adverse events were associated with improved social functioning and vitality. The literature review showed a mixed effect of intervention on QOL in patients with UIAs.

CONCLUSIONS

Our analysis has revealed that patients with 3- to 14-mm UIAs had improvements in some physical and emotional components of QOL at 18-24 months following aneurysm coiling in the HEAT study. The literature remains indeterminate on this issue. Further studies are needed to better understand the effects of the diagnosis of UIAs and their treatment on QOL.

Endovascular Embolization of a Lateral Sacral Fistula: 2-Dimensional Operative Video

Spinal dural arteriovenous fistulas are the most common vascular malformations of the spine. They are localized in the sacral spine in 5% to 14% of the cases. They can be fed by the median or the lateral sacral arteries. These lesions present with nonspecific symptoms such as radiculopathy and/or myelopathy, which often leads to a delay in diagnosis. In this video, we present the case of a 65-yr-old gentleman with a lateral sacral dural arteriovenous fistula. The patient was referred to our institution after the outside facility workup was nondiagnostic. He presented with spastic paraparesis and bilateral radiculopathy. After patient informed consent was obtained, we performed a spinal diagnostic angiogram with catheterization and angiography of the internal iliac artery, which revealed the fistula. Onyx (Medtronic, Dublin, Ireland) embolization was performed, which led to a complete occlusion of the fistula. The patient had complete neurological recovery, and at 2-yr follow-up, imaging remained negative for a fistula. In this video, we discuss the nuances and key points related to the epidemiology, diagnosis, and treatment of lateral sacral fistulas.1-3.

Use of Pheno Room, Augmented Reality, and 3-Rod Technique for 3-Dimensional Correction of Adolescent Idiopathic Scoliosis

This is a surgical video that showcases the surgical repair of a young male patient with idiopathic scoliosis in a hybrid operating room with the utilization of a new imaging modality Advanced Radar Target Identification System (ARTIS) PHENO (Siemens Medical Solutions, Pennsylvania, USA) and augmented reality (Video 1). A 17-year-old male patient with idiopathic scoliosis underwent scoliosis repair in a hybrid operating room with segment reality surgical planning. The use of augmented reality helped in visualization of proper screw trajectory, and the use of ARTIS PHENO helped in identification of correct screw placement and rod fixation. Intraoperative use of new imaging modalities as augmented reality imaging and ARTIS PHENO can decrease surgical complication and time.

Surgical correction of proximal junctional kyphosis

This 3D video showcases the surgical techniques for patients with proximal junctional kyphosis. The surgical repair for patients with proximal junctional kyphosis is an individualized approach depending on patient history and imaging with adequate surgical measurements. This video will shed light on two cases with proximal junctional kyphosis and the method taken for their repair. The first case is of an 11-year-old female known to have osteogenesis imperfecta and status post T5–L3 posterior spinal fusion with segmental instrumentation. The patient underwent change of older instruments and scoliosis repair, with full correction on postoperative x-ray. The second patient is a 16-year-old male known to have cerebral palsy and kyphoscoliosis status post spinal fusion. The patient underwent scoliosis repair surgery with replacement of old instrumentation and scoliosis correction.

The video can be found here: https://youtu.be/f5iLwqbU26Q.

The Use of 5-Aminolevulinic Acid in Low-Grade Glioma Resection: A Systematic Review

BACKGROUND

For optimizing high-grade glioma resection, 5-aminolevulinic acid is a reliable tool. However, its efficacy in low-grade glioma resection remains unclear.

OBJECTIVE

To study the role of 5-aminolevulinic acid in low-grade glioma resection and assess positive fluorescence rates and the effect on the extent of resection.

METHODS

A systematic review of PubMed, Google Scholar, and Cochrane was performed from the date of inception to February 1, 2019. Studies that correlated 5-aminolevulinic acid fluorescence with low-grade glioma in the setting of operative resection were selected. Studies with biopsy only were excluded. Positive fluorescence rates were calculated. The quality index of the selected papers was provided. No patient information was used, so Institutional Review Board approval and patient consent were not required.

RESULTS

A total of 12 articles met the selection criteria with 244 histologically confirmed low-grade glioma patients who underwent microsurgical resection. All patients received 20 mg/kg body weight of 5-aminolevulinic acid. Only 60 patients (n = 60/244; 24.5%) demonstrated visual intraoperative 5-aminolevulinic acid fluorescence. The extent of resection was reported in 4 studies; however, the data combined low- and high-grade tumors. Only 2 studies reported on tumor location. Only 3 studies reported on clinical outcomes. The Zeiss OPMI Pentero microscope was most commonly used across all studies. The average quality index was 14.58 (range: 10-17), which correlated with an overall good quality.

CONCLUSION

There is an overall low correlation between 5-aminolevulinic acid fluorescence and low-grade glioma. Advances in visualization technology and using standardized fluorescence quantification methods may further improve the visualization and reliability of 5-aminolevulinic acid fluorescence in low-grade glioma resection.

Vascular Transposition of the Superior Cerebellar Artery Using a Fenestrated Clip and Fibrin Glue in Trigeminal Neuralgia: 2-Dimensional Operative Video

This is the case of an 86-yr-old gentleman who presented with left facial pain exacerbated by eating, drinking, chewing, and shaving (distribution: V2, V3). The patient was diagnosed with trigeminal neuralgia and was refractory to medications. Imaging showed a superior cerebellar artery (SCA) loop adjacent to the trigeminal nerve root entry zone and a decision to perform a microvascular decompression of the fifth nerve was presented to the patient. After patient informed consent was obtained, a standard 3 cm × 3 cm retrosigmoid craniotomy was performed with the patient in a supine head turned position and in reverse Trendelenburg. The arachnoid bands tethering the SCA to the trigeminal nerve were sharply divided. A slit was then made in the tentorium and a 3 mm fenestrated clip was then used to secure the transposed SCA away from the trigeminal nerve. The SCA proximal to this was slightly patulous in its course so a small amount of a fibrin glue was also used to secure the more proximal SCA to the tentorium. The patient was symptom-free postoperatively and no longer required medical therapy. Additionally, imaging was consistent with adequate separation of the nerve from adjacent vessels.1-5

Microsurgical Treatment of Foramen Magnum Cognard Type V Dural Arteriovenous Fistula: 2-Dimensional Operative Video

Cognard type V dural fistulas represent a rare and unique entity, and present clinically with myelopathy. They are frequently located around the foramen magnum and are most commonly fed by dural branches of the vertebral and external carotid artery. Detection requires meticulous angiography to define the angioarchitecture of the fistula, which in turn defines the treatment modality. We present the case of a 63 yr old woman, after informed consent was obtained, with prolonged, severe and progressive lower extremity myelopathy for 6 yr, with T2-weighted signal changes in the thoracic spinal cord on magnetic resonance imaging (MRI). Cervical MRI was unremarkable. Following computed tomography (CT), angiography of the spinal canal that revealed tortuous and dilated veins on the thoracic spinal cord surface, catheter angiography was performed. This demonstrated a fistula in relation to a dural branch of left vertebral artery with a characteristic single draining vein coursing caudally to the thoracic level, with delayed outflow suggestive of venous hypertension. Given the fact that the dural feeder was tortuous and relatively small, thus, precluding distal microcatheter access, and with presence of a single accessible draining vein, microsurgical treatment was preferred. Following a midline suboccipital craniotomy in prone position, a limited vertical dural opening was performed. Careful microsurgical arachnoid dissection revealed the arterialized draining vein with the aid of Indocyanine Green angiography. The draining vein was clipped, coagulated, and disconnected. Postoperative recovery was uneventful and the patient is undergoing rehabilitation therapy. Follow-up angiography showed complete elimination of the fistula. Salient teaching points are narrated at conclusion.

Is Intraoperative Ultrasound a Valuable Tool for Brain Arteriovenous Malformation Diagnosis and Treatment? A Case Report

The localization of arteriovenous malformations (AVMs) intraoperatively in the setting of an acute intracerebral hemorrhage (ICH) is crucial to avoid damage of delicate vascular structures that may even further exacerbate the bleed. Currently, surgical mapping using preoperative angiographic is the standard of practice. We report the use of intraoperative ultrasound for the diagnosis and localization of an AVM in the case of a 61-year-old female with reported iodine contrast allergy and previous severe reaction, in a setting with limited resources, without other imaging options or timely transfer to another facility readily available. Immediate surgical care was warranted to avoid further deterioration of the patient; intraoperative diagnosis and localization of the suspected underlying lesion were done using ultrasound. The ultrasound display showed tubular anechoic intertwined structures that demonstrated bidirectional flow, which is suggestive of an AVM. The intraoperative diagnosis allowed the surgeon to avoid an inadvertent approach to the vascular malformation nidus or vessels, which could have further complicated the case. We believe that intraoperative ultrasound may be valuable for the neurosurgeons today in many settings. Despite the fact that this case occurred in a scenario with limited resources and no other imaging method (such as magnetic resonance imaging (MRI), magnetic resonance angiography (MRA)) available, we advise readers not to rely solely on intraoperative ultrasound.

Roberts Bartholow: the progenitor of human cortical stimulation and his contentious experiment

Roberts Bartholow, a physician, born and raised in Maryland, was a surgeon and Professor in Medicine who had previously served the Union during the Civil War. His interest in scientific research drove him to perform the first experiment that tested the excitability of the human brain cortex. His historical experiment on one of his patients, Mary Rafferty, with a cancerous ulcer on the skull, was one of his great accomplishments. His inference from this experiment and proposed scientific theory of cortical excitation and localization in humans was one of the most critically acclaimed topics in the medical community, which attracted the highest commendation for the unique discovery as well as criticism for possible ethical violations. Despite that criticism, his theory and methods of cortical localization are the cornerstone of modern brain mapping and have, in turn, led to countless medical innovations.

Tulip Giant Aneurysm Amputation and "Shingle Clip Cut Clip" Technique for Microsurgical Reconstruction of a Giant Thrombosed Middle Cerebral Artery Aneurysm

In this video, we present the case of a 61-year-old female who was brought to the emergency department after she had partial complex seizures. Computed tomography and magnetic resonance imaging of the brain revealed a right temporal lobe mass, which was initially thought to be a tumor. The patient was therefore referred to us for further management. The round nature of the lesion raised suspicion for an aneurysm. Computed tomography angiography was performed, followed by a diagnostic conventional cerebral angiogram, and confirmed the presence of a giant thrombosed aneurysm. Giant aneurysms represent 3%-5% of all cerebral aneurysms.¹ They are more common in females with a ratio of 2:1 to 3:1.¹ They have a high risk of rupture up to 50% in the posterior circulation and 40% in the anterior circulation over 5 years according to the International Study of Unruptured Intracranial Aneurysms Investigators.^2,3 Their treatment can be complex and treacherous. Treatment options vary widely from parent artery sacrifice in select cases to clip reconstruction to an array of endovascular approaches such as flow diversion. In some cases a combination of both open and endovascular approaches might be necessary.^4-8 In our case, we opted for an open surgical clip reconstruction. A superior temporal artery-middle cerebral artery bypass was attempted to allow for trapping of the aneurysm without risking ischemic complication distal to it. Unfortunately, the patient's vessels were too atherosclerotic to maintain patency. A strategy was then devised, which consisted of cutting the dome of the aneurysm and clearing the distal two thirds of the clot ("tulip technique") and then completing thrombus resection under temporary occlusion. Once clot removal was completed, the aneurysm was clipped using the "shingle clip cut clip" technique (Video 1). The patient's postoperative course was uneventful, and the patient remained seizure free.

Thrombectomy for a Patient with Concomitant Acute Cervical Internal Carotid and Middle Cerebral Artery Occlusion: Video Case

We present the case of a 62-yr-old female who presented with ground-level fall and new onset of left-sided weakness of 30 min duration. CT angiogram revealed right ICA pseudo-occlusion and thrombus filling the right proximal M1 segment of the right MCA. On detailed neurological exam patient was noted to have NIHSS of 25. Patient was started on IV TPA infusion and was taken to interventional angiography suite after an informed consent was obtained. Diagnostic angiography was performed which demonstrated critical stenosis of the right proximal internal carotid artery. Right carotid artery stenting and balloon angioplasty of the carotid stent with distal embolic protection device was performed. Post carotid stent angiogram once again confirmed proximal right M1 pseudo-occlusion in the right MCA distribution. The clot was removed using a stent retriever, thus achieving complete recanalization (TICI 3) of the right cerebral hemisphere. The patient returned to baseline neurological status and a 1 mo follow-up diagnostic angiogram revealed patent carotid stent. Following the case presentation, we present the nuances of acute ischemic stroke management of large vessel occlusion with an emphasis on technical nuances, recent published guidelines1 and the literature.2-8.

Lateral supracerebellar infratentorial approach for pontomesencephalic cavernous malformations

Cavernomas at the posterolateral pontomesencephalic surface can be approached from a lateral infratentorial supracerebellar corridor. In this surgical video, we demonstrate two cases of brainstem cavernomas resected through a lateral supracerebellar infratentorial approach. A supine position with lateral turn of the head was used along with significant reverse Trendelenburg to allow the cerebellum to fall away with gravity from the tentorium. After exposure of the posterior surface of the brainstem between the tentorium and the superior cerebellar surface with aid of neuronavigation, the cavernomas were safely resected.

The video can be found here: https://youtu.be/fUDdaprg26Y.

Treatment Strategy of a Patient With a Brain Arteriovenous Malformation and Cranial Dural Fistula: 2-Dimensional Operative Video

We present the case of a 56-yr-old right-handed male, after informed consent was obtained, who presented with acute confusion and agitation, on the background of a remote history of an uncomplicated resection of a left parietal grade 2 glioma. Imaging revealed a large, acute right temporal intracerebral hemorrhage (ICH). Standard vascular workup for the cause of the ICH included catheter angiography. No direct cause of the hemorrhage was revealed; however, a high grade parasagittal dural arteriovenous fistula (DAVF) with cortical venous reflux was noted close to the prior craniotomy site. The venous reflux was towards the left hemisphere, but it was hypothesized that similar reflux on the right side may have been present and was not presently evident due to thrombosis. The DAVF was embolized by endovascular means, followed by evacuation of the hematoma. Follow-up angiogram 7 mo later revealed a high-flow, right superior temporal cortical arteriovenous malformation (AVM). The DAVF unfortunately had also progressed. Endovascular occlusion of both lesions was attempted but was not successful. Subsequently, microsurgical resection for both the vascular malformations was performed with careful pre- and intraoperative planning to obtain a successful clinical and angiographic result. In this video, we summarize diagnostic and therapeutic nuances that have broad implications for the workup of ICH and the strategic management of a unique scenario involving a brain AVM and high-grade cranial dural fistula in the same patient. Prior to each procedure, informed consent was obtained from the patient, which includes consent for publication.

Extended Lateral Orbital Craniotomy: Anatomic Study and Initial Clinical Series of a Novel Minimally Invasive Pterional Approach

Background  Of the minimally invasive "keyhole" alternatives to the pterional region, the supraorbital eyebrow approach is the most widely adopted. Yet it can prove disadvantageous when a more direct lateral microsurgical trajectory of attack to the Sylvian fissure and anterior middle fossa are needed. Objective  The extended lateral orbital (XLO) approach was designed to be direct and minimally invasive, with the sphenoid ridge at the center of exposure. Methods  Five injected cadaver heads were used for anatomic study of the XLO approach. The anatomic course of the frontalis branch of facial nerve was studied in relation to the XLO incision. Following XLO incision, the bone exposure was measured. The intracranial microsurgical exposure was assessed subjectively. Application of the technique in representative clinical operative cases is provided. Results  The frontalis nerve was protected in the subgaleal fat pad, with an average minimum distance of 2.3 cm from the XLO incision. The mean calvarial area exposure was 4.95 cm ² and consistently centered on the sphenoid ridge. Excellent access to ipsilateral Sylvian's fissure, perisylvian regions, and supra-/parasellar structures was possible. The main limitations related to exposure of the posterior Sylvian fissure and the expected limitations of microsurgical instrument manipulation from a smaller craniotomy. Conclusions  The XLO approach is a minimally invasive keyhole approach to the pterional region that affords a unique lateral trajectory via a craniotomy centered on the sphenoid ridge. Excellent exposure to properly selected lesions is possible. The incision is at a safe distance from the frontalis branch and shows excellent cosmetic healing.