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de Liyis BG, Surya SC, Tini K. Effectivity and safety of endovascular coiling versus microsurgical clipping for aneurysmal subarachnoid hemorrhage: A systematic review and meta-analysis. Clin Neurol Neurosurg 2024; 236:108058. [PMID: 38056041 DOI: 10.1016/j.clineuro.2023.108058] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 10/24/2023] [Accepted: 11/22/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND There is an ongoing lack of consensus among clinicians regarding on the optimal aneurysmal subarachnoid hemorrhage (aSAH) management approach between endovascular coiling and microsurgical clipping. METHODS Comprehensive literature search for randomized controlled trials (RCTs) was conducted in Medline and Cochrane databases until January 1st, 2023 without language constraints. Effectivity outcomes included one-year mortality, one-year poor outcomes, and one-year complete aneurysmal occlusion, while safety outcomes comprised the incidence of vasospasms, rebleeding, post-operative complications, and cerebral ischemia. RESULTS Eight RCTs, involving 3585 aSAH patients, underwent comprehensive quantitative analysis. Among them, 1792 underwent endovascular coiling and 1773 patients had microsurgical clipping. Regarding effectivity, the rates of one-year mortality (OR: 0.79, 95% CI: 0.61-1.03, p = 0.08) exhibited no significant difference. However, endovascular coiling demonstrated an inferior one-year complete aneurysmal occlusion rate (OR: 0.33, 95% CI: 0.21-0.53, p < 0.00001), although with significantly lower rates of poor outcomes (OR: 0.68, 95% CI: 0.57-0.81, p < 0.00001) compared to the microsurgical clipping group. As for safety, endovascular coiling group exhibited lower rates of vasospasm (OR: 0.58, 95% CI: 0.36-0.92, p = 0.02), post-operative complications (OR: 0.40, 95% CI: 0.23-0.71, p = 0.02), and cerebral ischemia (OR: 0.36, 95% CI: 0.20-0.63, p = 0.0004). No significant effect on the incidence of rebleeding was observed (OR: 1.09, 95% CI: 0.73-1.63, p = 0.68). CONCLUSIONS Endovascular coiling proves superior and safer for aSAH patients, but consideration of resources, patient condition, and surgeon preferences is crucial for selecting the optimal approach.
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Affiliation(s)
| | | | - Kumara Tini
- Department of Neurology, Universitas Udayana, Denpasar, Bali, Indonesia
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2
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Nisson PL, Palsma R, Barnard ZR, Schievink WI, Mamelak AN. Endoscopic endonasal transclival clipping of a cerebellar arteriovenous malformation feeding vessel and associated aneurysm; a 2D operative video. J Clin Neurosci 2023; 118:161-162. [PMID: 37944360 DOI: 10.1016/j.jocn.2023.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 10/30/2023] [Indexed: 11/12/2023]
Abstract
Positioned along the ventral surface of the pons, proximal superior cerebellar artery (SCA) aneurysms account for only 1.7% of all intracranial aneurysms [1]. Unlike more commonly encountered basilar artery aneurysms, patients often experience good outcomes when treated via endovascular coiling or surgical clipping [1,2]. These lesions frequently have a lateral projection and paucity of perforator arteries [2]. With further development of endoscopic endonasal techniques, access to this region is possible via a direct frontal exposure to the ventral brainstem, basilar artery and branching vessels. To date, there are only a limited number of reports describing an endoscopic endonasal transclival (EETC) approach for surgical clipping [3-5]. In this operative video, we detail the surgical clipping of a cerebellar arteriovenous malformation feeding vessel and an associated aneurysm using the EETC approach in a 59-year-old woman who presented with sudden onset of a severe headache. The feeding vessel and aneurysm's midline location, just below the take-off of the SCA made it a good candidate for this surgery. Major steps included in this video include 1) transsphenoidal exposure of and subsequent drilling of the clivus, 2) dural opening into the pre-pontine cistern and dissection of the aneurysm, 3) clipping of the aneurysm, and 4) multi-layered closure of the skull base defect. Overall, the patient tolerated the procedure well and was found to have no residual filling of the aneurysm or the AVM feeding vessel at 2-year follow-up. EETC is a viable surgical option for the treatment of aneurysm located along the midline of the pre-pontine cistern.
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Affiliation(s)
- Peyton L Nisson
- Department of Neurosurgery, Cedars-Sinai, Los Angeles, CA, United States
| | - Ryan Palsma
- Department of Neurosurgery, University of Arizona, Tucson, AZ, United States
| | - Zachary R Barnard
- Department of Neurosurgery, Cedars-Sinai, Los Angeles, CA, United States
| | - Wouter I Schievink
- Department of Neurosurgery, Cedars-Sinai, Los Angeles, CA, United States
| | - Adam N Mamelak
- Department of Neurosurgery, Cedars-Sinai, Los Angeles, CA, United States.
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3
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Yang K, Begley SL, Lynch D, Turpin J, Aminnejad M, Farrokhyar F, Dehdashti AR. Long-term outcomes of surgical clipping of saccular middle cerebral artery aneurysms: a consecutive series of 92 patients. Neurosurg Rev 2023; 46:271. [PMID: 37843680 DOI: 10.1007/s10143-023-02167-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/17/2023] [Accepted: 09/24/2023] [Indexed: 10/17/2023]
Abstract
Despite advances in endovascular treatment, microsurgical clipping of middle cerebral artery (MCA) aneurysms remains appropriate. We review the high occlusion rate and treatment durability seen with surgical clipping of MCA aneurysms. We retrospectively reviewed patients who underwent microsurgical clipping of saccular MCA aneurysms by a single surgeon. Outcomes included aneurysm occlusion rate and durability, modified Rankin scale (mRS), and postoperative neurological morbidities. Ninety-two patients with 92 saccular MCA aneurysms were included, 50% of which were ruptured aneurysms. The mean follow-up period was 59 months. Complete aneurysm occlusion was achieved in all except one patient (99%) with near-complete occlusion. MCA aneurysm clipping was durable, with only one patient (1%) requiring retreatment after 4 years due to regrowth. Of the cohort, 79.3% achieved mRS 0-2 at last follow-up, including all with unruptured aneurysms. Poor outcome at discharge was associated with age > 65 (p = .03), postoperative neurological morbidities (p = .006), and aneurysm rupture (p < .001). Older age remained the single correlate for poor long-term outcome (p = .04). For ruptured aneurysms, predictors of poor long-term outcome included hemiparesis on presentation (p = .017), clinical vasospasm requiring treatment (p = .026), and infarction related to vasospasm (p = .041). Older age (p = .046) and complex anatomy (p = .036) were predictors of new postoperative neurological morbidities in the unruptured group. MCA aneurysm clipping is safe, durable, and should be considered first-line treatment for patients with saccular MCA aneurysms, especially in centers with abundant surgical experience.
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Affiliation(s)
- Kaiyun Yang
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr Manhasset, Hempstead, NY, 11030, USA
- Community Neurosciences Institute, Community Health Partners, Fresno, CA, USA
| | - Sabrina L Begley
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr Manhasset, Hempstead, NY, 11030, USA
| | - Daniel Lynch
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr Manhasset, Hempstead, NY, 11030, USA
| | - Justin Turpin
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr Manhasset, Hempstead, NY, 11030, USA
| | - Minoo Aminnejad
- Department of Surgery, Department of Health, Evidence, Impact, McMaster University, Hamilton, ON, Canada
| | - Forough Farrokhyar
- Department of Surgery, Department of Health, Evidence, Impact, McMaster University, Hamilton, ON, Canada
| | - Amir R Dehdashti
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr Manhasset, Hempstead, NY, 11030, USA.
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Han J, Pan H, Yao L, Jin E, Pan W, Xiong L. Comparison of microsurgical clipping with intravascular interventional embolization in the treatment of ruptured aneurysms and risk factors for intraoperative rupture and bleeding. Am J Transl Res 2023; 15:3451-3459. [PMID: 37303682 PMCID: PMC10251033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 12/11/2022] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To investigate the effectiveness of microsurgical clipping compared with intravascular interventional embolization in the treatment of ruptured aneurysms and the risk factors for intraoperative rupture and bleeding. METHODS The data of 116 patients with ruptured aneurysms admitted to the People's Hospital of China Three Gorges University from January 2020 to March 2021 were collected for retrospective analysis. Among them, 61 cases with microsurgical clipping were classified as the control group (CG), and the rest 55 with intravascular interventional embolization were the observation group (OG), and the treatment effects in the two groups were compared. The general conditions of operation (operation time, postoperative hospital stay and intraoperative blood loss) were compared between the two groups. The intraoperative rupture of cerebral aneurysm during operation was counted, and the incidence of complications between the groups was compared. Risk factors affecting intraoperative rupture of cerebral aneurysms were analyzed by logistic regression. RESULTS The total clinical treatment efficiency was dramatically higher in the OG than that in the CG (P<0.05). The operative time, postoperative hospital stays, and intraoperative bleeding were all higher in the CG than those in the OG (all P<0.001). There was no statistical difference in the incidence of wound infection, hydrocephalus, and cerebral infarction between the two groups (all P>0.05). However, the incidence of intraoperative rupture was markedly higher in the CG than that in the OG (P<0.05). Multifactorial logistic regression analysis revealed that history of subarachnoid hemorrhage, history of hypertension, large diameter of aneurysm, irregular morphology, and anterior communicating artery aneurysm were independent risk factors for intraoperative rupture in patients. CONCLUSION Intravascular interventional embolization for middle cerebral artery aneurysm rupture is a less invasive procedure with faster recovery time, and history of subarachnoid hemorrhage, history of hypertension, large diameter of aneurysm, irregular morphology, and anterior communicating artery aneurysm are independent risk factors affecting patients with intraoperative rupture.
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Affiliation(s)
- Jing Han
- Department of Neurosurgery, The People’s Hospital of China Three Gorges UniversityYichang 443000, Hubei, China
| | - Haiyan Pan
- Department of Neurosurgery, Dangyang People’s HospitalYichang 444100, Hubei, China
| | - Longfei Yao
- Department of Neurosurgery, The People’s Hospital of China Three Gorges UniversityYichang 443000, Hubei, China
| | - Erliang Jin
- Department of Neurosurgery, The People’s Hospital of China Three Gorges UniversityYichang 443000, Hubei, China
| | - Wanxi Pan
- Department of Neurosurgery, The People’s Hospital of China Three Gorges UniversityYichang 443000, Hubei, China
| | - Lianlian Xiong
- Department of Neurosurgery, Dangyang People’s HospitalYichang 444100, Hubei, China
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Kranawetter B, Hernández S, Mielke D, Ernst MS, Malinova V, Rohde V. Microsurgical clipping as a retreatment strategy for previously ruptured aneurysms treated with the Woven EndoBridge (WEB) device: a mono-institutional case series. Acta Neurochir (Wien) 2023:10.1007/s00701-023-05596-5. [PMID: 37178247 DOI: 10.1007/s00701-023-05596-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 04/10/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Since its approval by the US Food and Drug Administration (FDA) in 2018, the flow disruptor Woven EndoBridge (WEB) device has become increasingly popular for the endovascular treatment of unruptured and ruptured cerebral aneurysms. However, the occlusion rates seem rather low and the retreatment rates rather high compared to other treatment methods. For initially ruptured aneurysms, a retreatment rate of 13 % has been reported. A variety of retreatment strategies has been proposed; however, there is a paucity of data concerning microsurgical clipping of WEB-pretreated aneurysms, especially previously ruptured ones. Thus, we present a single-center series of five ruptured aneurysms treated with the WEB device and retreated with microsurgical clipping. METHODS A retrospective study including all patients presenting with a ruptured aneurysm undergoing WEB treatment at our institution between 2019 and 2021 was performed. Subsequently, all patients with an aneurysm remnant or recurrence of the target aneurysm retreated with microsurgical clipping were identified. RESULTS Overall, five patients with a ruptured aneurysm treated with WEB and retreated with microsurgical clipping were included. Besides one basilar apex aneurysm, all aneurysms were located at the anterior communicating artery (AComA) complex. All aneurysms were wide-necked with a mean dome-to-neck ratio of 1.5. Clipping was feasible and safe in all aneurysms, and complete occlusion was achieved in 4 of 5 aneurysms. CONCLUSIONS Microsurgical clipping for initially ruptured WEB-treated aneurysms is a feasible, safe, and effective treatment method in well-selected patients.
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Affiliation(s)
- B Kranawetter
- Department of Neurosurgery, University Medical Center, Georg-August University Göttingen, Göttingen, Germany.
| | - S Hernández
- Department of Neurosurgery, University Medical Center, Georg-August University Göttingen, Göttingen, Germany
| | - D Mielke
- Department of Neurosurgery, University Medical Center, Georg-August University Göttingen, Göttingen, Germany
| | - M S Ernst
- Department of Neuroradiology, University Medical Center, Georg-August University Göttingen, Göttingen, Germany
| | - V Malinova
- Department of Neurosurgery, University Medical Center, Georg-August University Göttingen, Göttingen, Germany
| | - V Rohde
- Department of Neurosurgery, University Medical Center, Georg-August University Göttingen, Göttingen, Germany
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Yang Y, He K, Liu L, Li F, Zhang G, Xie B, Liang F. Risk Factors for Cerebral Infarction After Microsurgical Clipping of Hunt-Hess Grade 0-2 Single Intracranial Aneurysm: A Retrospective Study. World Neurosurg 2023; 171:e186-e194. [PMID: 36503119 DOI: 10.1016/j.wneu.2022.11.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 11/26/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The study aimed to explore risk factors for cerebral infarction after microsurgical clipping in patients with Hunt-Hess grade 0-2 single intracranial aneurysms. METHODS A total of 137 patients with Hunt-Hess grade 0-2 single intracranial aneurysms treated with microsurgical clipping between March 2017 and December 2020 were retrospectively enrolled. Patients were divided into 2 groups on the basis of the occurrence of cerebral infarction after surgery. RESULTS Of 137 enrolled patients, 14 (10.22%) showed cerebral infarction symptoms after surgery. Univariate analysis indicated that ruptured aneurysm status, aneurysm rupture during surgery, history of transient ischemic attack (TIA)/stroke, aneurysm size ≥7 mm, temporary clipping, intraoperative systolic hypotension (IOH), and occurrences of intraoperative motor-evoked potentials change were significantly related to postoperative cerebral infarction (PCI). However, using multivariate regression, only history of TIA/stroke (odds ratio = 0.124; 95% confidence interval [CI] = 0.021-0.748, P = 0.023) and IOH (odds ratio = 0.032; 95% CI = 0.005-0.210, P < 0.001) were independent predictors for PCI. Receiver operating characteristic curve analysis showed that the critical duration of temporary clipping and IOH that minimized the risk of PCI was 5.5 minutes and 7.5 minutes, respectively. CONCLUSIONS Our study identified history of TIA/stroke and IOH as independent risk factors for cerebral infarction after microsurgical clipping.
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Affiliation(s)
- Yibing Yang
- Neurosurgery Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Kejun He
- Neurosurgery Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Linfeng Liu
- Neurosurgery Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Fanying Li
- Neurosurgery Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Guofeng Zhang
- Neurosurgery Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Baoshu Xie
- Neurosurgery Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Feng Liang
- Neurosurgery Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
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7
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Luzzi S, Giotta Lucifero A, Baldoncini M, Campero A, Galzio R, Lawton MT. Optic Foraminotomy versus Anterior Clinoidectomy for Small Superior-Projecting Paraclinoid Aneurysms: Visual and Angiographic Outcome Evaluation. World Neurosurg 2023; 170:e612-e621. [PMID: 36410704 DOI: 10.1016/j.wneu.2022.11.081] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/17/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Optic foraminotomy (OF) has been recently proposed as an alternative to anterior clinoidectomy (AC) for selected types of paraclinoid aneurysms. In this study, OF and AC were compared for small superior-projecting paraclinoid aneurysms assuming visual and angiographic results as outcome measures. Indications for OF are also discussed. METHODS Data of patients who underwent surgery for a paraclinoid aneurysm in the last 10 years were collected across 3 tertiary hospitals. Small to regular-size and superior projecting aneurysms were sorted. Multiple and complex aneurysms were excluded. Records of patients who went through OF were compared with those of patients who underwent AC. Neurologic outcome was reported as a modified Rankin Scale. Aneurysm complete occlusion rate and rate of approach-related worsened vision were selected as outcome measures of efficacy and safety, respectively, of the OF versus AC. Unpaired t test and χ2 test were used for numerical and categorical variables, respectively. A P value less than 0.05 was considered statistically significant. RESULTS OF and AC groups involved 18 and 25 patients, respectively. Complication rate, overall neurologic outcome, rate of approach-related worsened vision, and complete occlusion rate did not differ between the groups. The average follow-up was 51 ± 34 and 60 ± 41 months in the OF and AC groups, respectively. CONCLUSIONS Compared to AC, OF did not show either a higher rate of approach-related worsened vision or a lower aneurysm complete occlusion rate. OF can be considered a valid alternative to the AC for small superior-projecting dorsal ICA wall paraclinoid aneurysms.
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Affiliation(s)
- Sabino Luzzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy; Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Alice Giotta Lucifero
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Matias Baldoncini
- Department of Neurological Surgery, San Fernando Hospital, Buenos Aires, Argentina; Laboratory of Microsurgical Neuroanatomy, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Alvaro Campero
- Department of Neurological Surgery, Padilla Hospital, Tucumán, Argentina
| | - Renato Galzio
- Neurosurgery Unit, Maria Cecilia Hospital, Cotignola, Italy
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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Matsushige T, Hashimoto Y, Ogawa T, Makimoto G, Yoshiyama M, Hara T, Kobayashi S, Sakamoto S. The impact of high-resolution cone-beam CT findings on decision-making for the treatment of unruptured middle cerebral artery aneurysms. Neurosurg Rev 2022; 46:26. [PMID: 36575355 DOI: 10.1007/s10143-022-01933-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 11/24/2022] [Accepted: 12/21/2022] [Indexed: 12/29/2022]
Abstract
Even with the advent of endovascular treatment for intracranial aneurysms, microsurgical clipping continues to play a significant role in the treatment of middle cerebral artery (MCA) aneurysms. Securing perforators around unruptured intracranial aneurysms (UIAs) is essential for minimizing procedural risks in each treatment option. Therefore, we herein investigated whether the findings of high-resolution cone-beam computed tomography (HR-CBCT) have an impact on decision-making for the treatment of MCA UIAs. Patients with MCA UIAs between October 2017 and September 2021 were consecutively recruited for this study. All patients underwent HR-CBCT and 3D-DSA before treatment. The imaging quality of both modalities to visualize the microvasculature around aneurysms was evaluated. Specific findings on the microvasculature surrounding aneurysms on HR-CBCT were investigated to facilitate microsurgical clipping. Fifty-two MCA UIAs were treated, including 43 by microsurgical clipping and 9 by endovascular approaches. The overall imaging quality of HR-CBCT was superior to that of 3D-DSA. Regarding microsurgical insights, sensitivity and specificity for the visualization of small vessels around aneurysms were 79 and 100%, respectively, using HR-CBCT, and 57 and 93%, respectively, using 3D-DSA. The presence of a low-density band between adhesive vessels and aneurysm sacs was indicative of successful and safe microsurgical dissection between these structures. HR-CBCT enabled visualization of the intracranial microvasculature around MCA UIAs at the submillimeter level in vivo. In cases in which the tight adhesion of the microvasculature to the aneurysm sac is indicated by HR-CBCT, an endovascular approach may be considered in order to avoid the risks associated with securing perforators.
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Affiliation(s)
- Toshinori Matsushige
- Department of Neurosurgery and Interventional Neuroradiology, Hiroshima City North Medical Center Asa Citizens Hospital, 1-2-1 Kameyama-minami, Asakitaku, Hiroshima, 731 0293, Japan.
| | - Yukishige Hashimoto
- Department of Neurosurgery and Interventional Neuroradiology, Hiroshima City North Medical Center Asa Citizens Hospital, 1-2-1 Kameyama-minami, Asakitaku, Hiroshima, 731 0293, Japan
| | - Taichi Ogawa
- Department of Radiology, Hiroshima City North Medical Center Asa Citizens Hospital, Hiroshima, Japan
| | - Gosuke Makimoto
- Department of Radiology, Hiroshima City North Medical Center Asa Citizens Hospital, Hiroshima, Japan
| | - Michitsura Yoshiyama
- Department of Neurosurgery and Interventional Neuroradiology, Hiroshima City North Medical Center Asa Citizens Hospital, 1-2-1 Kameyama-minami, Asakitaku, Hiroshima, 731 0293, Japan
| | - Takeshi Hara
- Department of Neurosurgery and Interventional Neuroradiology, Hiroshima City North Medical Center Asa Citizens Hospital, 1-2-1 Kameyama-minami, Asakitaku, Hiroshima, 731 0293, Japan
| | - Shohei Kobayashi
- Department of Neurosurgery and Interventional Neuroradiology, Hiroshima City North Medical Center Asa Citizens Hospital, 1-2-1 Kameyama-minami, Asakitaku, Hiroshima, 731 0293, Japan
| | - Shigeyuki Sakamoto
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Xu R, Kalluri AL, Orlev A, Nair SK, Gonzalez LF, Tamargo RJ. Elongated, finger-like ophthalmic segment aneurysms: Implications for selection of treatment modality. Clin Neurol Neurosurg 2022; 224:107546. [PMID: 36495621 DOI: 10.1016/j.clineuro.2022.107546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Microsurgical treatment of ophthalmic segment aneurysms often requires anterior clinoidectomy and optic nerve mobilization prior to successful clipping. OBJECTIVE We hypothesize that ophthalmic segment aneurysms that are elongated and finger-like grow unconstrained, lateral to the optic nerve. We note that this avoids the need for clinoid resection and optic nerve mobilization. METHODS Three cases with up-pointing aneurysms were reviewed. Patient and aneurysm characteristics were collected. RESULTS The first two patients with elongated ophthalmic segment aneurysms were found to have aneurysms growing lateral to the optic nerve. This allowed for straightforward treatment via microsurgical clipping without anterior clinoidectomy or division of the falciform ligament. The third patient presented with distortion of the optic chiasm superiorly and medially by a giant ventral ICA aneurysm. A concomitant ophthalmic aneurysm in this patient exhibited elongated morphology, with a high-resolution MRI demonstrating the patient's optic nerve was located inferior and medial to the ophthalmic artery aneurysm dome. This supports our hypothesis that an overriding optic nerve normally impedes vertical growth of ophthalmic segment aneurysms. CONCLUSIONS Ophthalmic segment aneurysms may acquire a round morphology when their growth is constrained superiorly by the optic nerve. Elongated ophthalmic segment aneurysms may be the result of growth lateral to the optic nerve. For these aneurysms, an anterior clinoidectomy is not required, and microsurgical clipping represents a straightforward treatment option.
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Nia AM, Lall RR, Kan P, Srinivasan VM. Trends and Outcomes of Endovascular Embolization and Surgical Clipping for Ruptured Intracranial Aneurysms: A Propensity-Matched Study of 1332 Patients in the United States. World Neurosurg 2022; 161:e674-e681. [PMID: 35218963 PMCID: PMC9081193 DOI: 10.1016/j.wneu.2022.02.077] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe recent trends in treatment and outcomes of endovascular coil embolization and microsurgical clipping treatment strategies for ruptured intracranial aneurysms. METHODS Using International Classification of Diseases, Tenth Revision, codes, 1332 propensity-matched patients >18 years old who underwent coiling or clipping were identified. Patient demographics, baseline characteristics, comorbidities, and clinical outcomes were evaluated within 1 year postoperatively. Pooled and individual studies of the International Classification of Diseases codes investigated differences in clinical outcomes owing to aneurysm location. Outcomes were mortality, intensive care, surgical complications, hydrocephalus, and vasospasm. RESULTS After propensity matching for baseline characteristics and comorbidities, 666 patients were included in the coiling and clipping cohorts. There was no significant difference in 1-year mortality between cohorts. However, incidence of intensive care, surgical/medical complications, and vasospasm was significantly lower in the pooled coiling cohort (P = 0.02, P = 0.03, and P = 0.014) compared with the clipping cohort within 1 year postoperatively. Additionally, individual International Classification of Diseases code analysis revealed that coiling of anterior communicating artery aneurysms was associated with significantly fewer surgical/medical complications and hydrocephalus (P = 0.0008 and P = 0.015) and coiling of posterior communicating artery aneurysms was associated with substantially less vasospasm treatment (P = 0.034) compared with the respective clipping cohorts. CONCLUSIONS Analysis revealed no difference in 1-year mortality between coiling and clipping. Clinical outcomes, including intensive care, surgical complications, and vasospasm, favored coiling regardless of aneurysm location. Patients with coiling of anterior communicating artery aneurysms had significantly less hydrocephalus and patients with coiling of posterior communicating artery aneurysms had substantially less vasospasm treatment within 1 year compared with the clipping cohort.
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Affiliation(s)
- Anna M Nia
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA.
| | - Rishi R Lall
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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Ali A, Alrabayah T, Abdelhafez I, Salam A, Thakur M, Alrumaihi G, Ayyad A, Ahmed AZ, Own AM, Wu AW, Belkhair S. Patient-Reported Outcome for Endovascular Treatment versus Microsurgical Clipping in Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2021; 155:e695-703. [PMID: 34500096 DOI: 10.1016/j.wneu.2021.08.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 08/26/2021] [Accepted: 08/27/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Aneurysmal subarachnoid hemorrhage has a high mortality with significant impact on quality of life despite effective management strategies including endovascular treatment and/or microsurgical clipping. Although the modalities have undergone clinical comparison, they have not been evaluated on patient-reported outcomes (PROs). This study compared endovascular versus microsurgical treatment using a PRO measure. METHODS We conducted a cross-sectional telephonic survey of adult patients conducted at Hamad General Hospital, Doha, Qatar between 2017 and 2019. Candidate study participants were identified from procedure logs and hospital electronic health records for endovascular treatment (N = 32) versus microsurgical clipping (N = 32) of cerebral aneurysm. The primary outcome measure was the short version of the Stroke-Specific Quality of Life (SS-QoL) measure. The secondary outcome measure was the screened clinician-reported modified Rankin Scale (mRS) for all screened patients (n = 137). Mean scores were compared for the 2 treatment groups. RESULTS The SS-QoL mean score was 4.23 (standard deviation ± 0.77) in endovascular treatment and 4.19 ± 0.19 in surgical clipping (P = 0.90). In exploratory analysis, mean physical domain score was 3.17 ± 0.60 versus 2.98 ± 0.66 in endovascular treatment and surgical clipping groups, respectively. Mean psychosocial domain scores were 4.43 ± 0.85 versus 4.18 ± 0.0.92, respectively. In multivariable analysis, none of the clinical variables were significantly related to SS-QoL except vasospasm irrespective of intervention received. In secondary outcome analysis, modified Rankin Scale score was higher for endovascular treatment (P = 0.04). CONCLUSIONS Published evidence has supported clinical benefits of endovascular treatment for cerebral aneurysm treatment, but this study did not find any difference in PROs. Future studies of treatments should include PRO to identify potential differences from the patient's perspective.
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12
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Winkler EA, Lee A, Yue JK, Raygor KP, Rutledge WC, Rubio RR, Josephson SA, Berger MS, Raper DMS, Abla AA. Endovascular embolization versus surgical clipping in a single surgeon series of basilar artery aneurysms: a complementary approach in the endovascular era. Acta Neurochir (Wien) 2021; 163:1527-1540. [PMID: 33694012 PMCID: PMC8053658 DOI: 10.1007/s00701-021-04803-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 03/03/2021] [Indexed: 11/28/2022]
Abstract
Background Currently, most basilar artery aneurysms (BAAs) are treated endovascularly. Surgery remains an appropriate therapy for a subset of all intracranial aneurysms. Whether open microsurgery would be required or utilized, and to what extent, for BAAs treated by a surgeon who performs both endovascular and open procedures has not been reported. Methods Retrospective analysis of prospectively maintained, single-surgeon series of BAAs treated with endovascular or open surgery from the first 5 years of practice. Results Forty-two procedures were performed in 34 patients to treat BAAs—including aneurysms arising from basilar artery apex, trunk, and perforators. Unruptured BAAs accounted for 35/42 cases (83.3%), and the mean aneurysm diameter was 8.4 ± 5.4 mm. Endovascular coiling—including stent-assisted coiling—accounted for 26/42 (61.9%) treatments and led to complete obliteration in 76.9% of cases. Four patients in the endovascular cohort required re-treatment. Surgical clip reconstruction accounted for 16/42 (38.1%) treatments and led to complete obliteration in 88.5% of cases. Good neurologic outcome (mRS ≤ 2) was achieved in 88.5% and 75.0% of patients in endovascular and open surgical cohorts, respectively (p = 0.40). Univariate logistic regression analysis demonstrated that advanced age (OR 1.11[95% CI 1.01–1.23]) or peri-procedural adverse event (OR 85.0 [95% CI 6.5–118.9]), but not treatment modality (OR 0.39[95% CI 0.08–2.04]), was the predictor of poor neurologic outcome. Conclusions Complementary implementation of both endovascular and open surgery facilitates individualized treatment planning of BAAs. By leveraging strengths of both techniques, equivalent clinical outcomes and technical proficiency may be achieved with both modalities.
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Affiliation(s)
- Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Anthony Lee
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - John K Yue
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Kunal P Raygor
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - W Caleb Rutledge
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Roberto R Rubio
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - S Andrew Josephson
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Mitchel S Berger
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Daniel M S Raper
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.
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Atchley TJ, Laskay NMB, Estevez-Ordonez D, Fisher WS, Harrigan MR. "Seizure Prophylaxis in Unruptured Aneurysm Repair: A randomized controlled trial" by Daou et al. journal of stroke and cerebrovascular diseases, Vol. 29, No. 10 (October), 2020: 105171. J Stroke Cerebrovasc Dis 2021; 30:105694. [PMID: 33707129 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/16/2021] [Indexed: 10/22/2022] Open
Affiliation(s)
- Travis J Atchley
- Dept. of Neurological Surgery, FOT 1005, 1720 2nd Ave. South, University of Alabama at Birmingham; Birmingham, AL, 35294, USA.
| | - Nicholas M B Laskay
- Dept. of Neurological Surgery, FOT 1005, 1720 2nd Ave. South, University of Alabama at Birmingham; Birmingham, AL, 35294, USA
| | - Dagoberto Estevez-Ordonez
- Dept. of Neurological Surgery, FOT 1005, 1720 2nd Ave. South, University of Alabama at Birmingham; Birmingham, AL, 35294, USA
| | - Winfield S Fisher
- Dept. of Neurological Surgery, FOT 1005, 1720 2nd Ave. South, University of Alabama at Birmingham; Birmingham, AL, 35294, USA
| | - Mark R Harrigan
- Dept. of Neurological Surgery, FOT 1005, 1720 2nd Ave. South, University of Alabama at Birmingham; Birmingham, AL, 35294, USA
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14
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Rotim K, Kalousek V, Splavski B, Tomasović S, Rotim A. HYBRID MICROSURGICAL AND ENDOVASCULAR APPROACH IN THE TREATMENT OF MULTIPLE CEREBRAL ANEURYSMS: AN ILLUSTRATIVE CASE SERIES IN CORRELATION WITH LITERATURE DATA. Acta Clin Croat 2021; 60:33-40. [PMID: 34588719 PMCID: PMC8305362 DOI: 10.20471/acc.2021.60.01.05] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 02/26/2021] [Indexed: 11/24/2022] Open
Abstract
Contemporary cerebral aneurysm treatment has advanced due to the expansion of microsurgical and endovascular techniques having different advantages and restraints. However, some aneurysms cannot be effectively treated by a single method alone due to their specific anatomy, location, complexity, and/or multiplicity. Subsequently, multiple aneurysms sometimes necessitate a hybrid strategy integrating both methods. The study aims were to discuss indications, possibilities, and challenges of a hybrid strategy in the decision making and treatment of multiple intracranial aneurysms. A single-institution illustrative case series of multiple intracranial aneurysm patients treated by a hybrid approach was analyzed and management outcome discussed and correlated with literature data. Following the treatment, both patients from our case series recovered well, having complete and stable aneurysmal occlusion with no relapse and no postoperative procedure-related complications or long-lasting neurological symptoms. In conclusion, a hybrid approach is advised as a treatment option for multiple cerebral aneurysms when a single modality is insufficient to bring satisfactory results. It may be a suitable and safe addition to an assortment of treatments pledging clinical improvement and enabling positive management outcome in patients with ruptured and non-ruptured multiple cerebral aneurysms.
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Affiliation(s)
| | - Vladimir Kalousek
- 1Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia; 3University of Applied Health Sciences, Zagreb, Croatia; 4Department of Radiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 5Josip Juraj Strossmayer University of Osijek, Faculty of Dental Medicine and Health, Osijek, Croatia; 6Department of Neurology, Sveti Duh University Hospital, Zagreb, Croatia
| | - Bruno Splavski
- 1Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia; 3University of Applied Health Sciences, Zagreb, Croatia; 4Department of Radiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 5Josip Juraj Strossmayer University of Osijek, Faculty of Dental Medicine and Health, Osijek, Croatia; 6Department of Neurology, Sveti Duh University Hospital, Zagreb, Croatia
| | - Sanja Tomasović
- 1Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia; 3University of Applied Health Sciences, Zagreb, Croatia; 4Department of Radiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 5Josip Juraj Strossmayer University of Osijek, Faculty of Dental Medicine and Health, Osijek, Croatia; 6Department of Neurology, Sveti Duh University Hospital, Zagreb, Croatia
| | - Ante Rotim
- 1Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia; 3University of Applied Health Sciences, Zagreb, Croatia; 4Department of Radiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 5Josip Juraj Strossmayer University of Osijek, Faculty of Dental Medicine and Health, Osijek, Croatia; 6Department of Neurology, Sveti Duh University Hospital, Zagreb, Croatia
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Ricciardi L, Trungu S, Scerrati A, Mongardi L, Flacco ME, Raco A, Miscusi M, De Bonis P, Sturiale CL. Surgical treatment of intracranial blister aneurysms: A systematic review. Clin Neurol Neurosurg 2021; 202:106550. [PMID: 33588360 DOI: 10.1016/j.clineuro.2021.106550] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 02/02/2021] [Accepted: 02/03/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Intracranial blister aneurysms (BAs) are challenging vascular lesions related to high morbidity and mortality rates. Different surgical and endovascular techniques have been proposed to treat BAs; however, there is no consensus on a preferred treatment. OBJECTIVE To systematically review the pertinent literature on clinical and radiological outcomes of different surgical treatments for BAs management, to meta-analyze their clinical and radiological outcomes, and compare these results with those from recent meta-analyses on endovascular treatments for BAs. METHODS The present study was consistently conducted according to the PRISMA guidelines. Five different online medical databases (PubMed, Medline, EMBASE, Scopus, and Web-of-Science) were screened from 2010 through 2020. Papers reporting clinical and radiological outcomes of different surgical treatments for BAs were considered. Event rates were pooled across studies using random-effects meta-analysis. RESULTS A total of 35 studies reporting on 514 patients (534 aneurysms) were included. Aneurysm clipping in 223 patients (45.4%; 95% CI 21.9-53.8), bypass and trapping in 87 (17.7%; 95% CI 1.89-21.6), clipping and wrapping in 82 (16.7%; 95% CI 3.71-19.0), and wrapping in 33 (6.7%; 95% CI 0.0-4.87) were the mostly common performed treatments. Complete occlusion rate was reported in 90.7% of patients. The complication rate was as high as 61.1%, the mortality rate was 7.4%, and the mean mRS at follow-up was 2.5. CONCLUSIONS Our meta-analysis suggests that surgical treatments for BAs are related to higher occlusion, complications and mortality rate than endovascular strategies. However, there is a high-heterogeneity among the included studies and data are poorly reported; so comparing the two type of treatments is unreliable in order to establish which one is better.
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Affiliation(s)
- Luca Ricciardi
- UOC Di Neurochirurgia, Azienda Ospedaliera Sant'Andrea, Dipartimento NESMOS, Sapienza, Rome, Italy
| | - Sokol Trungu
- UOC Di Neurochirurgia, Azienda Ospedaliera Sant'Andrea, Dipartimento NESMOS, Sapienza, Rome, Italy; UO di Neurochirurgia, Pia Fondazione di Culto e Religione Cardinal G. Panico, Tricase, LE, Italy
| | - Alba Scerrati
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy; Department of Neurosurgery, S. Anna University Hospital, Ferrara, Italy.
| | - Lorenzo Mongardi
- Department of Neurosurgery, S. Anna University Hospital, Ferrara, Italy
| | | | - Antonino Raco
- UOC Di Neurochirurgia, Azienda Ospedaliera Sant'Andrea, Dipartimento NESMOS, Sapienza, Rome, Italy
| | - Massimo Miscusi
- UOC Di Neurochirurgia, Azienda Ospedaliera Sant'Andrea, Dipartimento NESMOS, Sapienza, Rome, Italy
| | - Pasquale De Bonis
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy; Department of Neurosurgery, S. Anna University Hospital, Ferrara, Italy
| | - Carmelo Lucio Sturiale
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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16
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Chen S, Chen X, Ning B, Cao Y, Wang S. Supraclinoid internal carotid artery blister-like aneurysms: hypothesized pathogenesis and microsurgical clipping outcomes. Chin Neurosurg J 2021; 7:10. [PMID: 33517915 PMCID: PMC7849078 DOI: 10.1186/s41016-020-00226-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 12/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Blister-like aneurysms (BLAs) on the supraclinoid segment of the internal carotid artery (ICA) are an enigma of cerebrovascular disease. Neither has a definite pathogenesis been so far identified, nor have uniform treatment guidelines been established for them. Our aim was to develop a hypothesis regarding the evolution of BLAs according to their macroscopic morphologies and to evaluate the efficacy of microsurgical clipping. METHODS The clinical data and morphological features of 15 consecutive patients with 16 BLAs on the supraclinoid ICA were retrospectively reviewed. The treatment strategies were analyzed, and functional outcomes were evaluated using the modified Rankin scale (mRS). Favorable outcomes were defined as a mRS score of 0-2. RESULTS Morphologically, aneurysm growth with expansion of the aneurysm neck before the surgical procedure occurred in two ruptured and one unruptured aneurysm. Daughter bleb formation was observed in two ruptured and five unruptured aneurysms. A varied degree of parent artery sclerosis was observed in nine patients. Thirteen patients were treated with direct surgical clipping, one patient was treated with clipping and wrapping, and the remaining patient was treated with an encircling clipping graft. Favorable and unfavorable outcomes were observed in 13 and two cases, respectively. Follow-up angiograms revealed 4 cases of stenosis with respective degree of mild, 30%, 50%, and 80% without any neurological dysfunction. CONCLUSIONS We suggest a hypothesis that BLAs on the supraclinoid ICA may share different evolving mechanisms between ruptured and unruptured lesions. A majority of them can be reliably and safely obliterated by direct clipping technique, except for the aneurysms accompanied with severely atherosclerotic parent walls.
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Affiliation(s)
- Shanwen Chen
- Department of Neurosurgery, the Hospital of Shunyi District, No.3 Guangming Nan Street, Shunyi District, Beijing, 101300, China
| | - Xin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, No. 119 South 4th Ring West Road, Fengtai District, Beijing, 100050, China
| | - Bo Ning
- Department of Neurosurgery, Guangzhou Red Cross Hospital, Jinan University, No. 396 Tongfu Zhong Road, Haizhu District, Guangzhou, 510220, Guangdong, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, No. 119 South 4th Ring West Road, Fengtai District, Beijing, 100050, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, No. 119 South 4th Ring West Road, Fengtai District, Beijing, 100050, China.
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17
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Catapano JS, Nguyen CL, Frisoli FA, Sagar S, Baranoski JF, Cole TS, Labib MA, Whiting AC, Ducruet AF, Albuquerque FC, Lawton MT. Small intracranial aneurysms in the Barrow Ruptured Aneurysm Trial (BRAT). Acta Neurochir (Wien) 2021; 163:123-129. [PMID: 33034770 DOI: 10.1007/s00701-020-04602-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 09/30/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Treatment of small ruptured aneurysms (SRAs) remains controversial, with literature reporting difficulty with endovascular versus microsurgical approaches. This paper analyzes outcomes after endovascular coiling and microsurgical clipping among patients with SRAs prospectively enrolled in the Barrow Ruptured Aneurysm Trial (BRAT). METHOD All BRAT patients were included in this study. Patient demographics, aneurysm size, aneurysm characteristics, procedure-related complications, and outcomes at discharge and at 1-year and 6-year follow-up were evaluated. A modified Rankin scale (mRS) score > 2 was considered a poor outcome. RESULTS Of 73 patients with SRAs, 40 were initially randomly assigned to endovascular coiling and 33 to microsurgical clipping. The rate of treatment crossover was significantly different between coiling and clipping; 25 patients who were assigned to coiling crossed over to clipping, and no clipping patients crossed over to coiling (P < 0.001). Among SRA patients, 15 underwent coiling and 58 underwent clipping; groups did not differ significantly in demographic characteristics or aneurysm type (P ≥ 0.11). Mean aneurysm diameter was significantly greater in the endovascular group (3.0 ± 0.3 vs 2.6 ± 0.6; P = 0.02). The incidence of procedure-related complications was similar for endovascular and microsurgical treatments (odds ratio [95% confidence interval], 1.0 [0.1-10.0], P = 0.98). Both groups had comparable overall outcome (mRS score > 2) at discharge and 1-year and 6-year follow-up (P = 0.48 and 0.73, respectively). CONCLUSIONS Most SRA patients in the BRAT underwent surgical clipping, with a high rate of crossover from endovascular approaches. Endovascular treatment was equivalent to surgical clipping with regard to procedure-related complications and neurologic outcomes.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Candice L Nguyen
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Fabio A Frisoli
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Soumya Sagar
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Jacob F Baranoski
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Tyler S Cole
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Mohamed A Labib
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Alexander C Whiting
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Michael T Lawton
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA.
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18
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Zhang N, Xin WQ. Application of hybrid operating rooms for clipping large or giant intracranial carotid-ophthalmic aneurysms. World J Clin Cases 2020; 8:5149-5158. [PMID: 33269251 PMCID: PMC7674719 DOI: 10.12998/wjcc.v8.i21.5149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/15/2020] [Accepted: 09/17/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND A hybrid operating room (Hybrid-OR) is a surgical theatre that combines a conventional operating room with advanced medical imaging devices. There are still plenty of limitations when endovascular treatment or microsurgical treatment is used individually to treat large or giant carotid-ophthalmic aneurysms.
AIM To explore and summarize the technical features and effectiveness of the application of a Hybrid-OR in managing major intracranial carotid-ophthalmic aneurysms.
METHODS The Department of Neurosurgery treated 12 cases of large or giant intracranial carotid-ophthalmic aneurysms between March 2013 and December 2019 in a Hybrid-OR. All cases were treated with clipping and parent vessel reconstruction.
RESULTS With the assistance of the Hybrid-OR, the rate of incomplete intraoperative aneurysm clipping decreased from 25% (3/12) to 0%, while the rate of vessel stenosis decreased from 16.7% (2/12) to 8.35% (1/12). In terms of thromboembolic events, ischemic infarction complication occurred in only one patient, and none of the patients experienced embolic infarction complications. All 12 patients were followed for an average of 3 years, and no aneurysms recurred. The postoperative recovery was evaluated with the modified Rankin Scale (mRS): 11 patients showed no symptoms (mRS = 0), 1 patient showed slight disability (mRS 1-2), and none of the patients had severe disability (mRS = 5) or died (mRS = 6).
CONCLUSION The Hybrid-OR provides new ideas for the surgical clipping of large or giant intracranial carotid-ophthalmic aneurysms and decreases the rate of intraoperative vessel stenosis and unsuccessful clipping.
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Affiliation(s)
- Nai Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Wen-Qiang Xin
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, China
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19
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Yoon BH, Byun J, Park YS, Kim M, Lee JS, Park W, Park JC, Ahn JS. Clinical Interrogation of Mandatory Insertion of Central Venous Catheter for Clipping Surgery of Unruptured Intracranial Aneurysm: A Propensity Score Matched Study. World Neurosurg 2020; 146:e405-e412. [PMID: 33250188 DOI: 10.1016/j.wneu.2020.10.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/20/2020] [Accepted: 10/20/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND OBJECTIVE Microsurgical clipping, along with endovascular treatment, has evolved in the treatment of unruptured intracranial aneurysms (UIA), and these developments have resulted in a reduction of the complication rate. We discuss the need for a central venous catheter (CVC) insertion as an anesthetic preparation for microsurgical clipping. METHODS Between January 2019 and September 2019, 722 patients with UIA were treated at our institution. We excluded patients with a history of endovascular treatment or bypass surgery, recurrent aneurysms after coil embolization, brain tumors, or subarachnoid hemorrhages. A total of 272 patients were enrolled. Eighty-four patients underwent CVC insertion, and 188 patients underwent clipping surgery without CVC insertion. Outcome-related factors were compared between the 2 groups. We performed propensity score matching of the 2 groups to increase comparability. RESULTS There were no significant differences in outcome, sex, aneurysm location, aneurysm multiplicity, aneurysm size, or comorbid disease between the 2 groups. The mean age at the time of surgery was higher in the non-CVC insertion group than in the CVC insertion group. There were no meaningful differences in primary outcomes, including premature rupture and intraoperative motor evoked potential/somatosensory evoked potential change, and secondary outcomes, including estimated blood loss, duration of intensive care unit stay, duration of hospitalization, and Glasgow Outcome Scale score at discharge. CONCLUSIONS CVC insertion for clipping surgery for UIA is not mandatory. Considering the possible complications associated with CVCs, we cautiously suggest aneurysm surgery with CVC insertion in patients with serious medical comorbidities, aneurysm sizes >10 mm, and difficult proximal parent artery control.
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Affiliation(s)
- Byul Hee Yoon
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joonho Byun
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Yong Seok Park
- Department of Anesthesiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Moinay Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Sung Lee
- Department of Biostatistics, 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
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20
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Ngo HM, Chu HT, Nguyen DD. Microsurgery for a ruptured intracranial aneurysm in a 3-year-old child: A case report. Int J Surg Case Rep 2020; 76:458-462. [PMID: 33072496 PMCID: PMC7553868 DOI: 10.1016/j.ijscr.2020.10.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/04/2020] [Accepted: 10/04/2020] [Indexed: 11/28/2022] Open
Abstract
Intracranial aneurysms are rare in children, only case reports and case series published. Subarachnoid hemorrhage is the most common feature of pediatric intracranial aneurysm with good clinical grade. Microsurgical clipping is safe and effective in treatment of pediatric intracranial aneurysms.
Introduction Pediatric intracranial aneurysms are rare, with some different characteristics from those in adults. Here, we present a case of distal anterior cerebral artery aneurysm which we believe the first case from Vietnam. Presentation of case A 3 years old boy presented with headache, lethargic and hemiparesis was diagnosed ruptured distal anterior cerebral artery aneurysm with CTA. 10 days before admission in our hospital, the toddler was admitted in local hospital with diagnosis of SAH without more accurate findings. Clipping microsurgery of aneurysms with left interhemispheric approach was done with good outcome. Discussion The epidermiology, presentation and diagnosis and strategy of treatments as well as their outcomes were discussed. We also discussed our thoughts about our case within the limited-resource condition such as in Vietnam. Conclusion Pediatric intracranial anerusyms are rare but should be recognised in neurosurgical practice. Surgery is an effective treatment method.
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Key Words
- A2, A2 segment of anterior cerebral artery
- ACA, anterior cerebral artery
- AN, aneurysm
- CT, computed tomography
- CTA, computer tomography angiography
- Case report
- DSA, digital subtraction angiography
- EVD, external ventricular drain
- GOS, Glassgow Outcome Score
- IA, intracranial aneurysm
- ICA, internal carotid artery
- ICU, Intensive care unit
- IVH, intraventricular hemorrhage
- LOC, Loss of conciousness
- Microsurgical clipping
- Pediatric intracranial aneurysm
- SAH, subarachnoidal hemorrhage
- Surgery
- mRS, modified Rankin Scale
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Affiliation(s)
- Hung Manh Ngo
- Department of Neurosurgery, Viet Duc Hospital, Hanoi, Viet Nam.
| | - Hung Thanh Chu
- Hanoi Medical University, No 1 Ton That Tung Street, Hanoi, Viet Nam.
| | - Dong Duc Nguyen
- Department of Neurosurgery, Viet Duc Hospital, Hanoi, Viet Nam.
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21
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Koo AB, Elsamadicy AA, Lin IH, David WB, Sujijantarat N, Santarosa C, Cord BJ, Zetchi A, Hebert R, Bahrassa F, Malhotra A, Matouk CC. Predictors of Extended Length of Stay Following Treatment of Unruptured Adult Cerebral Aneurysms: A Study of The National Inpatient Sample. J Stroke Cerebrovasc Dis 2020; 29:105230. [PMID: 33066916 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105230] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/26/2020] [Accepted: 07/30/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND In an unprecedented era of soaring healthcare costs, payers and providers alike have started to place increased importance on measuring the quality of surgical procedures as a surrogate for operative success. One metric used is the length of hospital stay (LOS) during index admission. For the treatment of unruptured cerebral aneurysms, the determinants of extended length of stay are relatively unknown. The aim of this study was to identify the patient- and hospital-level factors associated with extended LOS following treatment for unruptured cerebral aneurysms. METHODS The National Inpatient Sample years 2010 - 2014 was queried. Adults (≥18 years) with unruptured aneurysms undergoing either clipping or coiling were selected using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Extended LOS was defined as greater than 75th percentile for the entire cohort (>5 days). Weighted patient demographics, comorbidities, complications, LOS, disposition and total cost were recorded. Multivariate logistic regression was used to determine the odds ratio for risk-adjusted extended LOS. The primary outcome was the degree which patient comorbidities or postoperative complications correlated with extended LOS. RESULTS A total of 46,880 patients were identified for which 9,774 (20.8%) patients had extended LOS (Normal LOS: 37,106; Extended LOS: 9,774). Patients in the extended LOS cohort presented with a greater number of comorbidities compared to the normal LOS cohort. A greater proportion of the normal LOS cohort was coiled (Normal LOS: 63.0% vs. Extended LOS: 33.5%, P<0.001), while more patients in the extended LOS cohort were clipped (Normal LOS: 37.0% vs. Extended LOS: 66.5%, P<0.001). The overall complication rate was higher in the extended LOS cohort (Normal LOS: 7.3% vs. Extended LOS: 43.8%, P<0.001). On average, the extended LOS cohort incurred a total cost nearly twice as large (Normal LOS: $26,050 ± 13,430 vs. Extended LOS: $52,195 ± 37,252, P<0.001) and had more patients encounter non-routine discharges (Normal LOS: 8.5% vs. Extended LOS: 52.5%, P<0.001) compared to the normal LOS cohort. On weighted multivariate logistic regression, multiple patient-specific factors were associated with extended LOS. These included demographics, preadmission comorbidities, choice of procedure, and inpatient complications. The odds ratio for extended LOS was 5.14 (95% CI, 4.30 - 6.14) for patients with 1 complication and 19.58 (95% CI, 15.75 - 24.34) for patients with > 1 complication. CONCLUSIONS Our study demonstrates that extended LOS after treatment of unruptured aneurysms is influenced by a number of patient-level factors including demographics, preadmission comorbidities, type of aneurysm treatment (open surgical versus endovascular), and, importantly, inpatient complications. A better understanding of these independent predictors of prolonged length of hospital stay may help to improve patient outcomes and decrease overall healthcare costs.
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Affiliation(s)
- Andrew B Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | | | - I-Hsin Lin
- Yale Center for Analytical Sciences, New Haven, CT
| | - Wyatt B David
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | | | - Corrado Santarosa
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Branden J Cord
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Akli Zetchi
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Ryan Hebert
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Farhad Bahrassa
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Ajay Malhotra
- Department of Radiology & Biomedical Imaging, Yale University School of Medicine, New Haven, CT
| | - Charles C Matouk
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT; Department of Radiology & Biomedical Imaging, Yale University School of Medicine, New Haven, CT.
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22
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Raper DMS, Rutledge C, Winkler EA, Abla AA. Definitive Treatment With Microsurgical Clipping After Recurrence and Rerupture of Coiled Anterior Cerebral Artery Aneurysms. Oper Neurosurg (Hagerstown) 2020; 19:393-402. [PMID: 32409831 DOI: 10.1093/ons/opaa103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 02/14/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The extent of obliteration of ruptured intracranial aneurysms treated with coil embolization has been correlated with the risk of rerupture. However, many practitioners consider that a small neck remnant is unlikely to result in significant risk after coiling. OBJECTIVE To report our recent experience with ruptured anterior cerebral artery aneurysms treated with endovascular coiling, which recurred or reruptured, requiring microsurgical clipping for subsequent treatment. METHODS Retrospective review of patients with intracranial aneurysms treated at our institution since August 2018. Patient and aneurysm characteristics, initial and subsequent treatment approaches, and outcomes were reviewed. RESULTS Six patients were included. Out of those 6 patients, 5 patients had anterior communicating artery aneurysms, and 1 patient had a pericallosal aneurysm. All initially presented with subarachnoid hemorrhage (SAH) and were treated with coiling. Recurrence occurred at a median of 7.5 mo. In 2 cases, retreatment was initially performed with repeat endovascular coiling, but further recurrence was observed. Rerupture from the residual or recurrent aneurysm occurred in 3 cases. In 2 cases, the aneurysm dome recurred; in 1 case, rerupture occurred from the neck. All 6 patients underwent treatment with microsurgical clipping. Follow-up catheter angiography demonstrated a complete occlusion of the aneurysm in all cases with the preservation of the parent vessel. CONCLUSION Anterior cerebral artery aneurysms may recur after endovascular treatment, and even small neck remnants present a risk of rerupture after an initial SAH. Complete treatment requires a complete exclusion of the aneurysm from the circulation. Even in cases that have been previously coiled, microsurgical clipping can represent a safe and effective treatment option.
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Affiliation(s)
- Daniel M S Raper
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Caleb Rutledge
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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23
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Pirayesh A, Ota N, Noda K, Petrakakis I, Kamiyama H, Tokuda S, Tanikawa R. Microsurgery of residual or recurrent complex intracranial aneurysms after coil embolization - a quest for the ultimate therapy. Neurosurg Rev 2020; 44:1031-1051. [PMID: 32212048 DOI: 10.1007/s10143-020-01290-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 03/12/2020] [Accepted: 03/17/2020] [Indexed: 11/24/2022]
Abstract
The long-term stability of coil embolization (CE) of complex intracranial aneurysms (CIAs) is fraught with high rates of recanalization. Surgery of precoiled CIAs, however, deviates from a common straightforward procedure, demanding sophisticated strategies. To shed light on the scope and limitations of microsurgical re-treatment, we present our experiences with precoiled CIAs. We retrospectively analysed a consecutive series of 12 patients with precoiled CIAs treated microsurgically over a 5-year period, and provide a critical juxtaposition with the literature. Five aneurysms were located in the posterior circulation, 8 were large-giant sized, 5 were calcified/thrombosed. One presented as a dissecting-fusiform aneurysm, 9 ranked among wide neck aneurysms. Eight lesions were excluded by neck clipping (5 necessitating coil extraction); 1 requiring adjunct CE. The dissecting-fusiform aneurysm was resected with reconstruction of the parent artery using a radial artery graft. Three lesions were treated with flow alteration (parent artery occlusion under bypass protection). Mean interval coiling-surgery was 4.6 years (range 0.5-12 years). Overall, 10 aneurysms were successfully excluded; 2 lesions treated with flow alteration displayed partial thrombosis, progressing over time. Outcome was good in 8 and poor in 4 patients (2 experiencing delayed neurological morbidity), and mean follow-up was 24.3 months. No mortality was encountered. Microsurgery as a last resort for precoiled CIAs can provide-in a majority of cases-a definitive therapy with good outcome. Since repeat coiling increases the complexity of later surgical treatment, we recommend for this subgroup of aneurysms a critical evaluation of CE as an option for re-treatment.
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Affiliation(s)
- Ariyan Pirayesh
- Department of Neurosurgery - Stroke Center, Sapporo Teishinkai Hospital, 3-1 Higashi 1, Kita 33, Higashi-ku, Sapporo, Hokkaido, 065-0033, Japan.
| | - Nakao Ota
- Department of Neurosurgery - Stroke Center, Sapporo Teishinkai Hospital, 3-1 Higashi 1, Kita 33, Higashi-ku, Sapporo, Hokkaido, 065-0033, Japan
| | - Kosumo Noda
- Department of Neurosurgery - Stroke Center, Sapporo Teishinkai Hospital, 3-1 Higashi 1, Kita 33, Higashi-ku, Sapporo, Hokkaido, 065-0033, Japan
| | - Ioannis Petrakakis
- Department of Neurosurgery - Stroke Center, Sapporo Teishinkai Hospital, 3-1 Higashi 1, Kita 33, Higashi-ku, Sapporo, Hokkaido, 065-0033, Japan
| | - Hiroyasu Kamiyama
- Department of Neurosurgery - Stroke Center, Sapporo Teishinkai Hospital, 3-1 Higashi 1, Kita 33, Higashi-ku, Sapporo, Hokkaido, 065-0033, Japan
| | - Sadahisa Tokuda
- Department of Neurosurgery - Stroke Center, Sapporo Teishinkai Hospital, 3-1 Higashi 1, Kita 33, Higashi-ku, Sapporo, Hokkaido, 065-0033, Japan
| | - Rokuya Tanikawa
- Department of Neurosurgery - Stroke Center, Sapporo Teishinkai Hospital, 3-1 Higashi 1, Kita 33, Higashi-ku, Sapporo, Hokkaido, 065-0033, Japan
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24
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Goertz L, Pflaeging M, Hamisch C, Kabbasch C, von Spreckelsen N, Laukamp K, Pennig L, Wetzel C, Brinker G, Goldbrunner R, Krischek B. Identifying Predictors for Aneurysm Remnants After Clipping by Morphometric Analysis and Proposal of a Novel Risk Score. World Neurosurg 2019; 136:e300-e309. [PMID: 31901493 DOI: 10.1016/j.wneu.2019.12.158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 12/24/2019] [Accepted: 12/26/2019] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Although the risk of aneurysm remnants after microsurgical clipping is generally low, complete aneurysm occlusion is not always guaranteed. We performed a morphometric analysis of intracranial aneurysms to identify predictors for aneurysm remnants and to propose a novel risk score. METHODS This is a retrospective, single-center analysis of consecutive patients with ruptured and unruptured aneurysms who underwent microsurgical clipping and postoperative digital subtraction angiography between 2010 and 2018. Based on preoperative rotational angiography, distinct morphologic aneurysm characteristics were determined and correlated with postoperative angiographic results. Factors predictive in the univariate and multivariate analyses were determined to establish a risk score for postoperative remnants after aneurysm clipping. RESULTS Among 140 patients with 166 clipped aneurysms, aneurysm remnants were present in 19.9%. In the multivariate analysis, ruptured aneurysm status (odds ratio [OR], 7.8; 95% confidence interval [CI], 1.7-36; P < 0.01) and increased aspect ratio (OR, 1.9; 95% CI, 1.0-4.0; P = 0.07) were associated with postoperative aneurysm remnants. Anterior communicating artery location (P = 0.02), internal carotid artery location (P = 0.06), increased aneurysm inclination angle (P < 0.01), and irregular aneurysm shape (P = 0.07) were further predictors for aneurysm remnants in the univariate analysis. These factors were weighted and included into a risk sum score for postoperative aneurysm remnants (range, 0-8 points), which performed with good accuracy (area under the curve = 0.807). CONCLUSIONS After external validation of the proposed risk score, it could help identify cases requiring angiographic control after aneurysm surgery.
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Affiliation(s)
- Lukas Goertz
- University of Cologne, Medical Faculty and University Hospital, Center for Neurosurgery, Cologne, Germany.
| | - Muriel Pflaeging
- University of Cologne, Medical Faculty and University Hospital, Center for Neurosurgery, Cologne, Germany
| | - Christina Hamisch
- University of Cologne, Medical Faculty and University Hospital, Center for Neurosurgery, Cologne, Germany
| | - Christoph Kabbasch
- University of Cologne, Medical Faculty and University Hospital, Center for Neurosurgery, Cologne, Germany
| | - Niklas von Spreckelsen
- University of Cologne, Medical Faculty and University Hospital, Center for Neurosurgery, Cologne, Germany; Harvey Cushing Neuro-Oncology Laboratories, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kai Laukamp
- Department of Neuroradiology, University Hospital of Cologne, Cologne, Germany; Department of Radiology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA; Department of Radiology, Case Western Reserve University Cleveland, Ohio, USA
| | - Lenhard Pennig
- Department of Neuroradiology, University Hospital of Cologne, Cologne, Germany
| | - Christian Wetzel
- University of Cologne, Medical Faculty and University Hospital, Center for Neurosurgery, Cologne, Germany
| | - Gerrit Brinker
- University of Cologne, Medical Faculty and University Hospital, Center for Neurosurgery, Cologne, Germany
| | - Roland Goldbrunner
- University of Cologne, Medical Faculty and University Hospital, Center for Neurosurgery, Cologne, Germany
| | - Boris Krischek
- University of Cologne, Medical Faculty and University Hospital, Center for Neurosurgery, Cologne, Germany
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Darkwah Oppong M, Deuschl C, Pierscianek D, Rauschenbach L, Chihi M, Radbruch A, Dammann P, Wrede KH, Özkan N, Müller O, Forsting M, Sure U, Jabbarli R. Treatment allocation of ruptured anterior communicating artery aneurysms: The influence of aneurysm morphology. Clin Neurol Neurosurg 2019; 186:105506. [PMID: 31494460 DOI: 10.1016/j.clineuro.2019.105506] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 08/19/2019] [Accepted: 08/30/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Since publication of the ISAT study, the majority of neurovascular centers adhere to "coil first" policy for patients with subarachnoid hemorrhage (SAH). However, final allocation in favor of coiling or clipping is based on anatomic features of ruptured intracranial aneurysms with respect to clinical characteristics of SAH. In this study, we analyzed the parameters relevant for treatment allocation of ruptured anterior communicating artery aneurysms (AComAA). PATIENTS AND METHODS From our institutional SAH database, all cases with ruptured AComAA, which underwent diagnostic subtraction angiography (DSA) with subsequent treatment allocation, were included. The radiographic features of AComAA were collected from pre-treatment DSA. In addition, demographic, clinical and radiographic parameters of SAH were recorded. The variables selected through univariate analyses were subsequently evaluated using multivariate regression analysis. RESULTS Of 300 SAH patients in the final analysis, the majority of the cases underwent endovascular coiling (n = 221, 73.7%). The following aneurysm features were associated with treatment modality in the univariate analysis: maximal sack size (p = 0.034), perpendicular height (p = 0.007), aspect ratio (p < 0.001) and sack/neck-ratio (p = 0.001). Accordingly, the following cutoffs for these variables were defined upon the receiver operating characteristics curves: 5 mm for sack size, 6 mm for perpendicular height, 1.6 for aspect ratio and sack/neck-ratio. In the multivariate analysis, aspect ratio of 1.6 was the only independent predictor of treatment allocation (p = 0.005; aOR = 2.57; 95% CI 1.33-4.96), which remained significant (p = 0.003; aOR = 2.77; 95% CI 1.41-5.45) after adjusting for patients' age, WFNS & Fisher grades, as well as intracerebral hematoma volume. CONCLUSION Although not-routinely assessed during initial allocation treatment, our retrospective analysis proved that aspect ratio is a reliable predictor of treatment allocation of ruptured AComAA. Except for large space-occupying ICH commonly obligating the microsurgical treatment, other clinical and radiographic characteristics of SAH do not seem to be of clinical relevance for the selection of treatment modality.
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Affiliation(s)
- Marvin Darkwah Oppong
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany.
| | - Cornelius Deuschl
- Institute for Diagnostic and Interventional Radiology, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Daniela Pierscianek
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Laurèl Rauschenbach
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Mehdi Chihi
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Alexander Radbruch
- Institute for Diagnostic and Interventional Radiology, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Karsten H Wrede
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Neriman Özkan
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Oliver Müller
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
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26
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Byoun HS, Oh CW, Kwon OK, Lee SU, Ban SP, Kim SH, Kim T, Bang JS, Kim SU, Choi J, Park KS. Intraoperative neuromonitoring during microsurgical clipping for unruptured anterior choroidal artery aneurysm. Clin Neurol Neurosurg 2019; 186:105503. [PMID: 31494461 DOI: 10.1016/j.clineuro.2019.105503] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 08/18/2019] [Accepted: 08/26/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate the safety and unexpected finding of the intraoperative neuromonitoring (IONM) including somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) during microsurgical clipping of an unruptured anterior choroidal artery (AChA) aneurysm. PATIENTS AND METHODS From January 2011 to March 2018, the neurophysiological, clinical, and radiological data of 115 patients who underwent microsurgical clipping for an unruptured AChA aneurysm under IONM were retrospectively analyzed. The incidence of ischemic complications after microsurgical clipping of unruptured AChA aneurysms as well as the false-negative rate, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of IONM during surgery were calculated. RESULTS Ischemic complications after the microsurgical clipping of an AChA aneurysm under IONM occurred in 7 of 115 patients (6.08%). Among them, 3 were symptomatic (2.6%). The false-negative rate of IONM for ischemic complications was 6.08% (7 patients). High specificity; 100% (95% confidence interval [95% CI] = 0.972-1.000), PPVs; 100% (95% CI = 0.055-1.000), and NPVs; 93% (95% CI = 0.945-0.973) with low sensitivity; 11.1% (95% CI = 0.006-0.111) were calculated. CONCLUSIONS IONM including transcranial MEP during microsurgical clipping of unruptured AChA aneurysm might have limited usefulness. Therefore, other MEP monitoring using direct cortical stimulation or modified transcranial methodology should be considered to compensate for it.
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Affiliation(s)
- Hyoung Soo Byoun
- Department of Neurosurgery, Chungnam National University Hospital, Daejeon, South Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - O-Ki Kwon
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Si Un Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Seung Pil Ban
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Sung Hoon Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Tackeun Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Jae Seung Bang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea.
| | - Sung Un Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Jongsuk Choi
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Kyung Seok Park
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea.
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Ogilvy CS, Jordan NJ, Ascanio LC, Enriquez-Marulanda AA, Salem MM, Moore JM, Thomas AJ. Surgical and Endovascular Comprehensive Treatment Outcomes of Unruptured Intracranial Aneurysms: Reduction of Treatment Bias. World Neurosurg 2019; 126:e878-e887. [PMID: 30872200 DOI: 10.1016/j.wneu.2019.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 03/01/2019] [Accepted: 03/02/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Determining the risks of treatment of unruptured intracranial aneurysms is critical in the decision-making process of management. Most studies have reported the results for endovascular or surgical management. Our objective was to better delineate the risk estimates for unruptured intracranial aneurysms treated with surgical or endovascular techniques in a comprehensive fashion, according to the patients' risk profiles. METHODS Data were gathered from 553 patients with 658 unruptured intracranial aneurysms treated at a single institution from 2014 to 2017. The decision to treat was determined by a projected morbidity that was lower than the natural history rupture risk. Data on aneurysm size, location, patient age, and outcome at the last clinical visit (modified Rankin scale scores) were collected and analyzed retrospectively. RESULTS The mean patient age was 59 years, and the mean lesion size was 7.3 mm. Microsurgical clipping was used in 251 lesions (38.2%), endovascular coiling in 70 (10.6%), stent-assisted coiling in 89 (13.5%), and a pipeline embolization device in 248 (37.7%). Complications from the procedures or during hospital admission occurred 66 lesions (10% of the total). Of these 66 complications, 28 (4.32% of the total) were non-neurological, treated, and resolved without permanent morbidity. Neurologic complications occurred in 38 procedures (5.7% of the total). Of these, 7 (1%) resulted in a permanent poor outcome (modified Rankin scale score, 3-6). CONCLUSION Aneurysmal obliteration using endovascular and surgical approaches in a comprehensive fashion has low treatment risks for unruptured aneurysms. The nomograms generated are useful in the discussion with patients and families regarding the risks of total institutional treatment of unruptured aneurysms.
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Affiliation(s)
- Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States.
| | - Noah J Jordan
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Luis C Ascanio
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Alejandro A Enriquez-Marulanda
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Mohamed M Salem
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
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28
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Lopez-Gonzalez MA, Sharafeddin F, Eastin TM, Gospodarev V, Jaeger A. Microsurgical Technique for Basilar Apex Aneurysm Clipping: Two-Dimensional Video. World Neurosurg 2019; 126:467. [PMID: 30862602 DOI: 10.1016/j.wneu.2019.02.189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 02/22/2019] [Accepted: 02/23/2019] [Indexed: 10/27/2022]
Abstract
We present the case of a 57-year-old female with hypertension, current smoker status, and recent headaches. Imaging studies showed an unruptured 8-mm basilar apex wide neck aneurysm located 4 mm above posterior clinoid (Figure 1) with a 3-mm anterior communicant artery aneurysm. No contraindications were encountered for endovascular treatment, although after we evaluated endovascular and surgical options, surgical clipping was considered also a safe and favorable option based on anterior projection of aneurysm, height of the basilar artery bifurcation, small and elongated posterior communicant artery, and available space between posterior clinoid and basilar artery (4 mm). The presence of a second aneurysm increased the patient's interest in a more definitive treatment, as we mentioned the possibility of its treatment if considered safe intraoperatively. A cranio-orbito-zygomatic craniotomy, anterior clinoidectomy, and sylvian fissure dissection was performed with electrophysiology monitoring. The exposure was enhanced by sphenoparietal sinus ligation, and the anterior clinoidectomy allowed working spaces at optic-carotid and carotid-oculomotor spaces for Liliequist membrane dissection, without need for posterior clinoid removal (Figure 2). Brief temporary clipping at basilar trunk below superior cerebellar arteries at perforating free zone was performed. Two clips were applied, obliterating adequately the aneurysm respecting perforating vessels. After the basilar apex aneurysm clipping, we proceeded in a standard fashion to clip the additional anterior communicant artery aneurysm. Micro-Doppler and intraoperative angiogram confirmed aneurysm exclusion and patent parent vessels (Video 1). The patient developed minimal ptosis due to partial right oculomotor nerve palsy that recovered completely in 2 weeks; otherwise, her neurologic exam was normal. At 1-year follow up, computed tomography angiography showed complete aneurysm exclusion.
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Affiliation(s)
| | - Fransua Sharafeddin
- Center for Neuroscience Research, Loma Linda University, School of Medicine, Loma Linda, California, USA
| | - Timothy Marc Eastin
- Department of Neurosurgery, Loma Linda University, School of Medicine, Loma Linda, California, USA
| | - Vadim Gospodarev
- Loma Linda University, School of Medicine, Loma Linda, California, USA
| | - Andrew Jaeger
- Loma Linda University, School of Medicine, Loma Linda, California, USA
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Wu J, Tong X, Liu Q, Cao Y, Zhao Y, Wang S. Microsurgical ligation for incompletely coiled or recurrent intracranial aneurysms: a 17-year single-center experience. Chin Neurosurg J 2019; 5:7. [PMID: 32922907 PMCID: PMC7398258 DOI: 10.1186/s41016-019-0153-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 01/30/2019] [Indexed: 11/10/2022] Open
Abstract
Background In this retrospective single-center study, we presented our experience in the microsurgical management of incompletely coiled or recurrent aneurysms after initial endovascular coiling. Methods During a 17-year period, 48 patients underwent microsurgical clipping of incompletely coiled or recurrent aneurysms after coiling (Gurian group B). The clinical data, surgical technique, and postoperative outcome were recorded and analyzed. Results Before coiling, 42 patients (87.5%) experienced aneurysm rupture. Most of the aneurysms (46/48, 96%) were located in the anterior circulation. After coiling, 6 patients had incompletely coiled aneurysms and 42 patients had recurrent aneurysms, with a mean time of 20.2 months from coiling to recurrence. Coil extrusion occurred in none of the incompletely coiled aneurysms and 71% (30/42) of the recurrent aneurysms. Clipping techniques are direct microsurgical clipping without coil removal in 16 patients, partial coil removal in 14 patients, and total coil removal in 18 patients. Postoperative and follow-up angiography revealed complete occlusion of the aneurysms in all patients. No patient died during postoperative follow-up period (mean, 78.9 months; range, 10-190 months). Good outcomes (GOS of 4 or 5) were achieved in 87.5% (42/48) of the patients at the final follow-up. Conclusions Microsurgical clipping is effective for incompletely coiled or recurrent aneurysms after initial coiling. For recurrent aneurysms that have coils in the neck, have no adequate neck for clipping, or cause mass effects on surrounding structures, partial or total removal of coiled mass can facilitate surgical clipping and lead to successful obliteration of the aneurysms.
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Affiliation(s)
- Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050 China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
| | - Xianzeng Tong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qingyuan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050 China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050 China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050 China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050 China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
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Zhang L, Wang H, Pan Y, Mao L. Effect Analysis of Microsurgical Clipping and Endovascular Embolization for the Treatment of Middle Cerebral Artery Aneurysms. World Neurosurg 2019; 125:e1074-e1081. [PMID: 30790728 DOI: 10.1016/j.wneu.2019.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 02/06/2019] [Accepted: 02/07/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To evaluate the safety and effectiveness of microsurgical clipping and endovascular embolization for the treatment of middle cerebral artery aneurysm (MCAA). MATERIAL AND METHODS The clinical data of 482 patients with MCAA treated with microsurgical clipping or endovascular embolization were analyzed retrospectively. According to whether the aneurysms were ruptured, patients were divided into a ruptured group and an unruptured group. Demographics, clinical manifestation, and postoperative complications were recorded. RESULTS In the microsurgical clipping group (257 patients), there were 114 male and 143 female patients. The mean age was (55 ± 10) years and the mean course of disease was 3 (1, 36) days. The total numbers of MCAA were 274, including 179 ruptured aneurysms and 95 unruptured aneurysms. In the endovascular embolization group (225 patients), there were 98 male and 127 female patients. The mean age was (54 ± 11) years and the mean course of disease was 10 (1, 55) days. The total numbers of MCAA were 234, including 126 ruptured aneurysms and 108 unruptured aneurysms. There was no difference between the incidence of complications in the ruptured and unruptured groups. The outcome of the endovascular embolization group was better than the microsurgical clipping group in ruptured aneurysms (P = 0.000). The recurrence rate of the endovascular embolization group was greater than the microsurgical clipping group in ruptured aneurysms (P = 0.023). CONCLUSIONS Both microsurgical clipping and endovascular embolization were safe and effective methods for the treatment of MCAA, but patients with ruptured MCAAs treated with endovascular embolization were more likely to experience recurrence.
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Affiliation(s)
- Li Zhang
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu Province, P. R. China
| | - Handong Wang
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu Province, P. R. China.
| | - Yunxi Pan
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu Province, P. R. China
| | - Lei Mao
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu Province, P. R. China
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O'Neill AH, Chandra RV, Slater LA, Chong W, Xenos C, Danks AR, Lai LT. Influence of comorbidities on treatment of unruptured intracranial aneurysms in the elderly. J Clin Neurosci 2019; 62:38-45. [PMID: 30655235 DOI: 10.1016/j.jocn.2019.01.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 12/15/2018] [Accepted: 01/03/2019] [Indexed: 11/30/2022]
Abstract
Current evidence does not conclusively justify conservative management of unruptured intracranial aneurysms (UIA) in the elderly (age ≥ 65 years). To rationalise intervention, the authors investigated the role of age and comorbidity burden on treatment outcomes. A retrospective chart review for consecutive cases of UIAs treated in the elderly between 2007 and 2018 was performed. Preoperative Charlson Comorbidity Index (CCI) and Neurovascular Comorbidities Index (NCI) were calculated. Standard statistical methods with univariate and multiple logistic regression were used. A total of 123 patients (46 surgery, 77 endovascular) with 131 UIAs were treated. The mean age was 70.6 ± 4.1 years, and 90 patients were female (73.1%). The mean aneurysm size was 8.6 ± 5.0 mm, and the mean follow up period was 22.9 ± 21.3 months. The rates of poor outcome (mRS > 1) at discharge, 6 weeks and 6 months were 9.8%, 5.8% and 3.6%, respectively. There was no difference in outcomes between surgical and endovascular treatment. Correlation and regression analyses revealed that aneurysm size, higher preoperative comorbidity index (CCI > 4), and endovascular treatment with a stent or flow diverter (p = 0.009, 0.02, and 0.005, respectively) were associated with a poor outcome. When adjusted in a multivariate analysis, only high comorbidity burden (CCI > 4) predicted unfavourable outcome (p = 0.01). Elderly patients who undergo treatment for UIAs are at high risk of postoperative deterioration. Careful preoperative case selection based on comorbidity burden, rather than chronological age, would be useful for improved risk stratification.
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Affiliation(s)
| | - Ronil V Chandra
- Department of Surgery, Monash University, Melbourne, Australia; Neuro-Interventional Radiology Unit, Department of Imaging, Monash Health, Melbourne, Australia
| | - Lee-Anne Slater
- Neuro-Interventional Radiology Unit, Department of Imaging, Monash Health, Melbourne, Australia
| | - Winston Chong
- Neuro-Interventional Radiology Unit, Department of Imaging, Monash Health, Melbourne, Australia
| | | | - Andrew Robert Danks
- Department of Neurosurgery, Monash Health, Melbourne, Australia; Department of Surgery, Monash University, Melbourne, Australia
| | - Leon T Lai
- Department of Neurosurgery, Monash Health, Melbourne, Australia; Department of Surgery, Monash University, Melbourne, Australia.
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Vourla E, Filis A, Cornelius JF, Bostelmann R, Turowski B, Kalakoti P, Rubbert C, Suresh MP, Tortora A, Steiger HJ, Petridis AK. Natural History of De Novo Aneurysm Formation in Patients with Treated Aneurysmatic Subarachnoid Hemorrhage: A Ten-Year Follow-Up. World Neurosurg 2018; 122:e291-e295. [PMID: 30321678 DOI: 10.1016/j.wneu.2018.10.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 10/01/2018] [Accepted: 10/03/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND De novo aneurysm formation after completely occluded aneurysms via clipping or coiling has not been well studied. Although known to occur several years after initial aneurysm management, the natural history of de novo aneurysms is obscure. We investigated the formation of new aneurysms in patients who had previously undergone treatment of intracranial aneurysms. METHODS In a retrospective, single-institutional series, eligible patients who had undergone treatment of ruptured cerebral aneurysms from 2000 to 2011 were included. The primary outcome measure was the development of de novo aneurysms during long-term follow-up. RESULTS Overall, 130 patients (63% women) who had undergone microsurgical clipping (n = 63; 48.5%) or endovascular coiling (n = 67%; 51.5%) for ruptured aneurysms were included. The average follow-up time for our cohort was 10 ± 2.7 years. De novo aneurysms occurred in 10 of 130 patients (7.7%), with a mean time of 7.9 years for aneurysm detection. No association between the formation of de novo aneurysms and the location of the treated aneurysms, smoking status, hypertension, age, or gender was found. Follow-up imaging studies were performed every 2 years. De novo aneurysms had formed in 2 patients within 2-5 years, 7 patients after 5-10 years, and 1 patient after 10 years of follow-up. In 2 of 10 patients, the de novo aneurysm had ruptured and led to subarachnoid haemorrhage. CONCLUSION The rate of de novo aneurysm occurrence was 7.6%, with a mean time to development of 7.9 years. This underscores the significance of long-term monitoring of patients with intracranial aneurysms. In our series, most new aneurysms had occurred after 5 years of follow-up.
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Affiliation(s)
- Eleni Vourla
- Department of Neurosurgery, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Andreas Filis
- Department of Neurosurgery, imland Klinik Rendsburg, Rendsburg, Germany.
| | - Jan F Cornelius
- Department of Neurosurgery, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Richard Bostelmann
- Department of Neurosurgery, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Bernd Turowski
- Institute of Neuroradiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Piyush Kalakoti
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Christian Rubbert
- Institute of Neuroradiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | | | - Angelo Tortora
- Department of Neurosurgery, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Hans Jakob Steiger
- Department of Neurosurgery, University Hospital Duesseldorf, Duesseldorf, Germany
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Darkwah Oppong M, Pierscianek D, Ahmadipour Y, Dinger TF, Dammann P, Wrede KH, Özkan N, Müller O, Sure U, Jabbarli R. Intraoperative Aneurysm Rupture During Microsurgical Clipping: Risk Re-evaluation in the Post-International Subarachnoid Aneurysm Trial Era. World Neurosurg 2018; 119:e349-e356. [PMID: 30059784 DOI: 10.1016/j.wneu.2018.07.158] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 07/16/2018] [Accepted: 07/18/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Intraoperative aneurysm rupture (IOAR) is a common complication during intracranial aneurysm (IA) surgery. In light of the paradigm shift regarding IA selected for clipping in the post-International Subarachnoid Aneurysm Trial (ISAT) era, we aimed to evaluate the risk factors and effects of IOAR in an institutional series of clipped ruptured IA (RIA) and unruptured IA (UIA). MATERIAL AND METHODS All IAs treated with microsurgical clipping at our institution between 2003 and 2016 were eligible for this study. Demographic, clinical, and radiographic factors were correlated with occurrence of IOAR in univariate and multivariate analyses. The effect on outcome was analyzed for RIA and UIA separately. RESULTS Nine hundred and three clipped IAs were included in the final analysis (538 UIA and 365 RIA). IOAR occurred in 163 cases (18.1%), mostly during clipping of RIA (37.5% vs. 4.8%) In multivariate analysis, ruptured status (adjusted odds ratio [aOR], 10.46; P < 0.001), sack size (aOR, 1.05 per mm increase; P = 0.038) and IA location in the anterior communicating artery (aOR, 2.31; P < 0.001) independently predicted IOAR. For RIA cases, IOAR was also independently predicted by rebleeding before therapy (aOR, 3.11; P = 0.033) and clinical severity of subarachnoid hemorrhage (aOR, 1.18 per WFNS grade increase; P = 0.049). IOAR independently predicted poor outcome (aOR, 1.83; P = 0.042) after RIA surgery. In turn, IOAR affected only the risk for cerebral infarct (OR, 3.75; P = 0.003) and incomplete IA occlusion (OR, 3.45; P = 0.003) for UIA cases, but not the outcome (P = 0.263). CONCLUSIONS IOAR was independently predicted by the ruptured status, location, and size of IA and by initial severity of aneurysmal bleeding and pretreatment rebleeding. The influence of IOAR differed between RIA and UIA cases.
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Affiliation(s)
- Marvin Darkwah Oppong
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany.
| | - Daniela Pierscianek
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Yahya Ahmadipour
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Thiemo Florin Dinger
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Karsten Henning Wrede
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Neriman Özkan
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Oliver Müller
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
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Abstract
Advances in neuroimaging and its widespread use for screening have increased the diagnosis of unruptured intracranial aneurysms (UIAs), including small-sized UIAs. The clinical management of these small-sized UIAs requires a patient-specific judgment of the risk of aneurysm rupture, if not treated, versus the risk of complications from surgical or endovascular treatment. Experienced cerebrovascular teams recommend treating small UIAs in young patients or in patients with more than one aneurysm rupture risk factor who also have a reasonable life expectancy. However, individual overall assessment of risk is critical for patients with UIAs to decide the next steps of care.
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Affiliation(s)
- Jan-Karl Burkhardt
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Arnau Benet
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Michael T Lawton
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.
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Nanda A, Patra DP, Bir SC, Maiti TK, Kalakoti P, Bollam P. Microsurgical Clipping of Unruptured Intracranial Aneurysms: A Single Surgeon's Experience over 16 Years. World Neurosurg 2017; 100:85-99. [PMID: 28057589 DOI: 10.1016/j.wneu.2016.12.099] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 12/22/2016] [Accepted: 12/23/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Unruptured intracranial aneurysms (UIAs) have become an issue of greater significance as their detection rates have increased over the years. We present the overall experience of microsurgical clipping of unruptured aneurysms by a single surgeon over a period of more than 16 years. METHODS The clinical and radiologic data were reviewed retrospectively. Clinical outcome at follow-up was assessed with Glasgow Outcome Scale, and angiograms were reviewed for the degree of occlusion. RESULTS One hundred ninety-six patients with 221 UIAs were included in the analysis. The median age of patients was 54 years, with a female preponderance. Eighty-two percent of the patients had chronic headache on presentation. Middle cerebral artery aneurysms (32.2%) and posterior-inferior-cerebellar-artery aneurysms (46.1%) were most common in the anterior and posterior circulation, respectively. The perioperative complication rate was 17.3%. The overall surgical morbidity and mortality were 2.1% and 1.5%, respectively. With median follow-up of 11.3 months, 82% of patients were almost asymptomatic with a complete occlusion rate of 94%. The proportion of UIAs being coiled has significantly increased in the last decade, with a concomitant increase in the risk of poor clinical outcome after surgery. CONCLUSION Surgical clipping is effective and can provide a good long-term outcome. The most commendable consequence that it provides is a better long-term occlusion rate. The experience of the individual surgeon is important for a superior and enduring overall outcome. An increase in the rate of coiling in recent years has affected the outcome rate after surgery that calls for further evaluation.
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Affiliation(s)
- Anil Nanda
- Department of Neurosurgery, Louisiana State University Health Sciences Centre, Shreveport, Louisiana, USA.
| | - Devi Prasad Patra
- Department of Neurosurgery, Louisiana State University Health Sciences Centre, Shreveport, Louisiana, USA
| | - Shyamal C Bir
- Department of Neurosurgery, Louisiana State University Health Sciences Centre, Shreveport, Louisiana, USA
| | - Tanmoy K Maiti
- Department of Neurosurgery, Louisiana State University Health Sciences Centre, Shreveport, Louisiana, USA
| | - Piyush Kalakoti
- Department of Neurosurgery, Louisiana State University Health Sciences Centre, Shreveport, Louisiana, USA
| | - Papireddy Bollam
- Department of Neurosurgery, Louisiana State University Health Sciences Centre, Shreveport, Louisiana, USA
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Moore JM, Caplan L, Hwang P, Mandan A, Ogilvy CS, Thomas AJ. Dementia resulting from expansion of basilar artery aneurysm: two case reports and a review of the literature. Acta Neurochir (Wien) 2016; 158:1901-5. [PMID: 27531175 DOI: 10.1007/s00701-016-2923-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 08/01/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Dementia places a large burden on the economy, with financial and emotional costs incurred by patients, caregivers and the health sector. METHODS AND RESULTS We report the first published case series of giant basilar aneurysm leading to progressive cognitive and functional decline. We review the literature regarding giant aneurysms and their association with dementia and the possible underlying pathophysiological mechanism. CONCLUSIONS This report highlights a number of therapeutic considerations when determining the best management strategy for these difficult lesions.
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Affiliation(s)
- Justin M Moore
- Department of Neurosurgery, The Alfred Hospital, Melbourne, Victoria, Australia.
- Division of Neurosurgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA.
- Division of Neurosurgery, Department of Surgery, Beth Israel Deaconess Medical Center, 110 Francis Street, Suite 3B, Boston, MA, 02215-5501, USA.
| | - Louis Caplan
- Division of Neurology, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Peter Hwang
- Department of Neurosurgery, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Anoop Mandan
- Department of Radiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Christopher S Ogilvy
- Division of Neurosurgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Ajith J Thomas
- Division of Neurosurgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
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Andereggen L, Gralla J, Andres RH, Weber S, Schroth G, Beck J, Widmer HR, Reinert M, Raabe A, Peterhans M. Stereolithographic models in the interdisciplinary planning of treatment for complex intracranial aneurysms. Acta Neurochir (Wien) 2016; 158:1711-20. [PMID: 27416860 DOI: 10.1007/s00701-016-2892-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 07/04/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Treatment of complex intracranial aneurysms requires strategic pre-interventional or preoperative planning. In addition to modern three-dimensional (3D) rotational angiography, computed tomography angiography (CTA) or magnetic resonance angiogram (MRA), a solid, tangible 3D model may improve anatomical comprehension and treatment planning. A 3D rapid prototyping (RP) technique based on multimodal imaging data was evaluated for use in planning of treatment for complex aneurysmal configurations. METHODS Six patients with complex aneurysms were selected for 3D RP based on CTA and 3D rotational angiography data. Images were segmented using image-processing software to create virtual 3D models. Three-dimensional rapid prototyping techniques transformed the imaging data into physical 3D models, which were used and evaluated for interdisciplinary treatment planning. RESULTS In all cases, the model provided a comprehensive 3D representation of relevant anatomical structures and improved understanding of related vessels. Based on the 3D model, primary bypass surgery with subsequent reconstruction of the aneurysm was then considered advantageous in all but one patient after simulation of multiple approaches. CONCLUSIONS Preoperative prediction of intraoperative anatomy using the 3D model was considered helpful for treatment planning. The use of 3D rapid prototyping may enhance understanding of complex configurations in selected large or giant aneurysms, especially those pretreated with clips or coils.
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Affiliation(s)
- Lukas Andereggen
- Department of Neurosurgery, University of Bern, Inselspital, Bern, Switzerland
- Institute of Diagnostic and Interventional Neuroradiology, University of Bern, Bern, Switzerland
- Department of Neurosurgery and F.M. Kirby Neurobiology Centre, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, University of Bern, Bern, Switzerland
| | - Robert H Andres
- Department of Neurosurgery, University of Bern, Inselspital, Bern, Switzerland
| | - Stefan Weber
- ARTORG Centre for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Gerhard Schroth
- Institute of Diagnostic and Interventional Neuroradiology, University of Bern, Bern, Switzerland
| | - Jürgen Beck
- Department of Neurosurgery, University of Bern, Inselspital, Bern, Switzerland
| | - Hans Rudolf Widmer
- Department of Neurosurgery, University of Bern, Inselspital, Bern, Switzerland
| | - Michael Reinert
- Department of Neurosurgery, Neurocenter of Southern Switzerland, 6930, Lugano, Switzerland.
| | - Andreas Raabe
- Department of Neurosurgery, University of Bern, Inselspital, Bern, Switzerland
| | - Matthias Peterhans
- ARTORG Centre for Biomedical Engineering Research, University of Bern, Bern, Switzerland
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Safavi-Abbasi S, Moron F, Sun H, Wilson C, Frock B, Oppenlander ME, Xu DS, Ghafil C, Zabramski JM, Spetzler RF, Nakaji P. Techniques and Outcomes of Gore-Tex Clip-Wrapping of Ruptured and Unruptured Cerebral Aneurysms. World Neurosurg 2016; 90:281-290. [PMID: 26960285 DOI: 10.1016/j.wneu.2016.02.109] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 02/23/2016] [Accepted: 02/25/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Some aneurysms without a definable neck and associated parent vessel pathology are particularly difficult to treat and may require clipping with circumferential wrapping. We report the largest available contemporary series examining the techniques of Gore-Tex clip-wrapping of ruptured and unruptured intracranial aneurysms and patient outcomes. METHODS The presentation, location, and shape of the aneurysm; wrapping technique; outcome at discharge and last follow-up; and any change in the aneurysm at last angiographic follow-up were reviewed retrospectively in 30 patients with Gore-Tex clip-wrapped aneurysms. RESULTS Gore-Tex clip-wrapping was used in 8 patients with ruptured aneurysms and 22 patients with unruptured aneurysms. Aneurysms included 23 fusiform, 3 blister, and 4 otherwise complex, multilobed, or giant aneurysms. Of the 30 aneurysms, 63% were in the anterior circulation. The overall mean patient age was 52.5 years (range, 17-80 years). Postoperatively, there were no deaths or worsening of neurologic status and no parent vessel stenoses or strokes. The mean Glasgow Outcome Scale score at last follow-up was 4.7. The mean follow-up time was 42.3 months (median, 37.0 months; range, 3-96 months). There were 105.8 patient follow-up years. Aneurysms recurred in 2 patients with Gore-Tex clip-wrapping. No patients developed rehemorrhage. Overall risk of recurrence was 1.9% annually. CONCLUSIONS Gore-Tex has excellent material properties for circumferential wrapping of aneurysms and parent arteries. It is inert and does not cause a tissue reaction or granuloma formation. Gore-Tex clip-wrapping can be used safely for microsurgical management of ruptured and unruptured cerebral aneurysms with acceptable recurrence and rehemorrhage rates.
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Affiliation(s)
- Sam Safavi-Abbasi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Felix Moron
- Department of Neurological Surgery, HIGA Vicente Lopez y Planes Gral Rodriguez, Buenos Aires, Argentina
| | - Hai Sun
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Christopher Wilson
- Department of Neurological Surgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, USA
| | - Ben Frock
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Mark E Oppenlander
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - David S Xu
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Cameron Ghafil
- Department of Neurological Surgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, USA
| | - Joseph M Zabramski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Peter Nakaji
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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Sanmillan JL, Lawton MT, Rincon-Torroella J, El-Sayed IH, Zhang X, Meybodi AT, Gabarros A, Benet A. Assessment of the Endoscopic Endonasal Transclival Approach for Surgical Clipping of Anterior Pontine Anterior-Inferior Cerebellar Artery Aneurysms. World Neurosurg 2016; 89:368-75. [PMID: 26852706 DOI: 10.1016/j.wneu.2016.01.081] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 01/26/2016] [Accepted: 01/27/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Aneurysms of the anterior pontine segment of the anterior-inferior cerebellar artery (AICA) are uncommon. Their treatment is challenging because critical neurovascular structures are adjacent to it and the available surgical corridors are narrow and deep. Although endoscopic endonasal approaches are accepted for treating midline skull base lesions, their role in the treatment vascular lesions remains undefined. The present study is aimed to assess the anatomic feasibility of the endoscopic endonasal transclival (EET) approach for treating anterior pontine AICA aneurysms and compare it with the subtemporal anterior transpetrosal (SAT) approach. METHODS Twelve cadaveric specimens were prepared for surgical simulation. The AICAs were exposed using both EET and SAT approaches. Surgical window area and the length of the exposed artery were measured. The distance from the origin of the artery to the clip applied for proximal control was measured. The number of AICA perforators exposed and the anatomic features of each AICA were recorded. RESULTS The EET approach provided a wider surgical window area compared with the SAT (P < 0.001). More AICA perforators were visualized using the EET approach (P < 0.05). To obtain proximal control of the AICA, an aneurysm clip could be applied closer to the origin of AICA using EET (0.2 ± 0.42 mm) compared with SAT (6.26 ± 3.4 mm) (P < 0.001). CONCLUSION Clipping anterior pontine AICA aneurysms using the EET approach is feasible. Compared with SAT, the EET approach provides advantages in surgical window area, ensuring proximal control before aneurysm dissection, visualization of perforating branches, and better proximal control.
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Affiliation(s)
| | | | | | | | - Xin Zhang
- University of California, San Francisco, California, USA
| | | | | | - Arnau Benet
- University of California, San Francisco, California, USA.
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Cheng XQ, Chen Q, Zhou CS, Li JR, Zhang ZJ, Zhang LJ, Huang W, Lu GM. Whole-brain CT perfusion combined with CT angiography for ischemic complications following microsurgical clipping and endovascular coiling of ruptured intracranial aneurysms. J Clin Neurosci 2016; 26:50-6. [PMID: 26775148 DOI: 10.1016/j.jocn.2015.05.067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 05/13/2015] [Accepted: 05/22/2015] [Indexed: 10/22/2022]
Abstract
Ischemic complications associated with microsurgical clipping and endovascular coiling affects the outcome of patients with intracranial aneurysms. We prospectively evaluated 58 intracranial aneurysm patients who had neurological deterioration or presented with poor grade (Hunt-Hess grades III and IV), aneurysm size >13 mm and multiple aneurysms after clipping or coiling. Thirty patients had ischemic complications (52%) as demonstrated by whole-brain CT perfusion (WB-CTP) combined with CT angiography (CTA). Half of these 30 patients had treatment-associated reduction in the diameter of the parent vessels (n=6), ligation of the parent vessels or perforating arteries (n=2), and unexplained or indistinguishable vascular injury (n=7); seven of these 15 (73%) patients suffered infarction. The remaining 15 patients had disease-associated cerebral ischemia caused by generalized vasospasm (n=6) and focal vessel vasospasm (n=9); six of these 15 (40%) patients developed infarction. Three hemodynamic patterns of ischemic complications were found on WB-CTP, of which increased time to peak, time to delay and mean transit time associated with decreased cerebral blood flow and cerebral blood volume were the main predictors of irreversible ischemic lesions. In conclusion, WB-CTP combined with CTA can accurately determine the cause of neurological deterioration and classify ischemic complications. This combined approach may be helpful in assessing hemodynamic patterns and monitoring operative outcomes.
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Affiliation(s)
- Xiao Qing Cheng
- Department of Medical Imaging, Jinling Hospital, Clinical School of Medical College, Nanjing University, 305 Zhongshan East Road, Xuanwu District, Nanjing, Jiangsu Province 210002, China
| | - Qian Chen
- Department of Medical Imaging, Jinling Hospital, Clinical School of Medical College, Nanjing University, 305 Zhongshan East Road, Xuanwu District, Nanjing, Jiangsu Province 210002, China
| | - Chang Sheng Zhou
- Department of Medical Imaging, Jinling Hospital, Clinical School of Medical College, Nanjing University, 305 Zhongshan East Road, Xuanwu District, Nanjing, Jiangsu Province 210002, China
| | - Jian Rui Li
- Department of Medical Imaging, Jinling Hospital, Clinical School of Medical College, Nanjing University, 305 Zhongshan East Road, Xuanwu District, Nanjing, Jiangsu Province 210002, China
| | - Zong Jun Zhang
- Department of Medical Imaging, Jinling Hospital, Clinical School of Medical College, Nanjing University, 305 Zhongshan East Road, Xuanwu District, Nanjing, Jiangsu Province 210002, China
| | - Long Jiang Zhang
- Department of Medical Imaging, Jinling Hospital, Clinical School of Medical College, Nanjing University, 305 Zhongshan East Road, Xuanwu District, Nanjing, Jiangsu Province 210002, China
| | - Wei Huang
- Department of Medical Imaging, Jinling Hospital, Clinical School of Medical College, Nanjing University, 305 Zhongshan East Road, Xuanwu District, Nanjing, Jiangsu Province 210002, China
| | - Guang Ming Lu
- Department of Medical Imaging, Jinling Hospital, Clinical School of Medical College, Nanjing University, 305 Zhongshan East Road, Xuanwu District, Nanjing, Jiangsu Province 210002, China.
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Chung J, Seok JH, Kwon MA, Kim YB, Joo JY, Hong CK. Effects of preventive surgery for unruptured intracranial aneurysms on attention, executive function, learning and memory: a prospective cohort study. Acta Neurochir (Wien) 2016; 158:197-205. [PMID: 26602237 DOI: 10.1007/s00701-015-2641-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 11/12/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND We prospectively evaluated the effects of preventive surgery for unruptured intracranial aneurysms on attention, executive function, learning and memory. METHODS Between March 2012 and June 2013, 56 patients were recruited for this study. Fifty-one patients met the inclusion criteria and were enrolled. Inclusion criteria were as follows: (1) age ≤65 years and (2) planned microsurgery or endovascular surgery for unruptured intracranial aneurysm. Exclusion criteria were as follows: (1) preoperative intelligence quotient <80 (n = 3); (2) initial modified Rankin scale ≥1 (n = 1); (3) loss to follow-up (n = 1). An auditory controlled continuous performance test (ACCPT), word-color test (WCT) and verbal learning test (VLT) were performed before and after (6 months) preventive surgery. RESULTS ACCPT (attention), WCT (executive function) and VLT (learning and memory) scores did not change significantly between the pre- and postoperative evaluations. The ACCPT, WCT, total VLT scores (verbal learning) and delayed VLT scores (memory) did not differ significantly between patients undergoing microsurgery and those undergoing endovascular surgery. However, ACCPT, WCT and delayed VLT scores decreased postoperatively in patients with leukoaraiosis on preoperative FLAIR images (OR 9.899, p = 0.041; OR 11.421, p = 0.006; OR 2.952, p = 0.024, respectively). CONCLUSIONS Preventive surgery for unruptured intracranial aneurysms did not affect attention, executive function, learning or memory. However, patients with leukoaraiosis on FLAIR images might be prone to deficits in attention, executive function and memory postoperatively, whereas learning might not be affected.
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Affiliation(s)
- Joonho Chung
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211, Eonjuro, Gangnam-gu, Seoul, 135-720, Republic of Korea
- Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jeong-Ho Seok
- Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Min A Kwon
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211, Eonjuro, Gangnam-gu, Seoul, 135-720, Republic of Korea
| | - Yong Bae Kim
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211, Eonjuro, Gangnam-gu, Seoul, 135-720, Republic of Korea
| | - Jin-Yang Joo
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211, Eonjuro, Gangnam-gu, Seoul, 135-720, Republic of Korea
| | - Chang-Ki Hong
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211, Eonjuro, Gangnam-gu, Seoul, 135-720, Republic of Korea.
- Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Talamonti G, Nichelatti M, Al Mashni AA, D'Aliberti G. Life-Threatening Cerebral Hematoma Owing to Aneurysm Rupture. World Neurosurg 2016; 85:215-27. [PMID: 26361325 DOI: 10.1016/j.wneu.2015.08.082] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 08/28/2015] [Accepted: 08/29/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To refine the surgical indications of surgery for life-threatening cerebral hematomas caused by aneurysm rupture, through the analysis of possible outcome predictors. METHODS Forty-nine consecutive patients requiring prompt clot evacuation were retrospectively reviewed. In all cases, the hematoma was equal to or greater than 60 mL. The bleeding aneurysm was located on the middle cerebral artery in 26 cases, on the internal carotid artery in 10 cases, and on the anterior cerebral artery in 13 cases; four aneurysms were giant. Six patients underwent aneurysm coiling followed by clot removal, whereas 43 patients were managed by concomitant clot evacuation and aneurysm clipping. The main clinical and radiologic features, the management paths and the treatment modalities were correlated with the outcomes. A statistical analysis was conducted. RESULTS Overall mortality was 32.6%, severe morbidity was 22.4% and 22 patients (44.8%) achieved favorable results. The short-term results were more significantly influenced by the radiological parameters than by the initial clinical conditions. The prognostic weight of the radiologic findings was partially lost for six-month results, whereby management factors gained in importance. CONCLUSIONS The bleeding severity was strongly determinant for early mortality. However, if patients can survive the initial crucial phase, their chances of a favorable outcome are not negligible. Further improvement may be possible through better patient selection and the identification of nonsalvageable subjects.
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Doss VT, Goyal N, Humphries W, Hoit D, Arthur A, Elijovich L. Comparison of Intraoperative Indocyanine Green Angiography and Digital Subtraction Angiography for Clipping of Intracranial Aneurysms. Interv Neurol 2015; 3:129-34. [PMID: 26279659 DOI: 10.1159/000381148] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Residual aneurysm after microsurgical clipping carries a risk of aneurysm growth and rupture. Digital subtraction angiography (DSA) remains the standard to determine the adequacy of clipping. Intraoperative indocyanine green (ICG) angiography is increasingly utilized to confirm optimal clip positioning across the neck and to evaluate the adjacent vasculature. OBJECTIVE We evaluated the correlation between ICG and DSA in clipped intracranial aneurysms. METHODS A retrospective study of patients who underwent craniotomy and microsurgical clipping of intracranial aneurysms with ICG for 2 years. Patient characteristics, presentation details, operative reports, and pre- and postclipping angiographic images were reviewed to determine the adequacy of the clipping. RESULTS Forty-seven patients underwent clipping with ICG and postoperative DSA: 57 aneurysms were clipped; 23 patients (48.9%) presented with subarachnoid hemorrhage. Nine aneurysms demonstrated a residual on DSA not identified on ICG (residual sizes ranged from 0.5 to 4.3 mm; average size: 1.8 mm). Postoperative DSA demonstrated no branch occlusions. CONCLUSION Intraoperative ICG is useful in the clipping of intracranial aneurysms to ensure a gross patency of branch vessels; however, the presence of residual aneurysms and subtle changes in flow in branch vessels is best seen by DSA. This has important clinical implications with regard to follow-up imaging and surgical/endovascular management.
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Affiliation(s)
- Vinodh T Doss
- Department of Neurology, University of Tennessee Health Sciences Center., USA ; Department of Neurosurgery, University of Tennessee Health Sciences Center., USA ; Department of Neurosurgery, University of Tennessee Health Sciences Center., USA
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Sciences Center., USA
| | - William Humphries
- Department of Neurosurgery, University of Tennessee Health Sciences Center., USA ; Department of Semmes-Murphey Neurologic and Spine Institute, Memphis, Tenn., USA
| | - Dan Hoit
- Department of Neurosurgery, University of Tennessee Health Sciences Center., USA ; Department of Semmes-Murphey Neurologic and Spine Institute, Memphis, Tenn., USA
| | - Adam Arthur
- Department of Neurosurgery, University of Tennessee Health Sciences Center., USA ; Department of Semmes-Murphey Neurologic and Spine Institute, Memphis, Tenn., USA
| | - Lucas Elijovich
- Department of Neurology, University of Tennessee Health Sciences Center., USA ; Department of Neurosurgery, University of Tennessee Health Sciences Center., USA ; Department of Semmes-Murphey Neurologic and Spine Institute, Memphis, Tenn., USA
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Gardner PA, Vaz-Guimaraes F, Jankowitz B, Koutourousiou M, Fernandez-Miranda JC, Wang EW, Snyderman CH. Endoscopic Endonasal Clipping of Intracranial Aneurysms: Surgical Technique and Results. World Neurosurg 2015; 84:1380-93. [PMID: 26117084 DOI: 10.1016/j.wneu.2015.06.032] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 06/15/2015] [Accepted: 06/16/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Microsurgical clipping of intracranial aneurysms requires meticulous technique and is usually performed through open approaches. Endoscopic endonasal clipping of intracranial aneurysms may use the same techniques through an alternative corridor. The aim of this article is to report a series of patients who underwent an endoscopic endonasal approach (EEA) for microsurgical clipping of intracranial aneurysms. METHODS We conducted a retrospective chart review. Surgical outcome and complications were noted. The conceptual application and the technical nuances of these procedures are discussed. RESULTS Ten patients underwent EEA for clipping of 11 intracranial aneurysms arising from the paraclinoidal internal carotid artery (n = 9) and vertebrobasilar system (n = 2). The internal carotid artery aneurysms projected medially, whereas the vertebrobasilar artery aneurysms were directly ventral to the brainstem with low-lying basilar apices. One patient required craniotomy for distal control given the size and thrombosed nature of the aneurysm. Proximal and distal vascular control with direct visualization of the aneurysm was obtained in all patients. In all cases, aneurysms were completely occluded. Among complications, 3 patients had postoperative cerebrospinal fluid leakage and 2 other patients had meningitis. Two patients suffered lacunar strokes. One recovered completely and the other remains with mild disabling symptoms. CONCLUSIONS EEAs can provide direct access for microsurgical clipping of rare and carefully selected intracranial aneurysms. The basic principles of cerebrovascular surgery have to be followed throughout the procedure. These surgeries require a skull base team with a neurosurgeon well versed in both endoscopic endonasal and cerebrovascular surgery, working in concert with an otolaryngologist experienced in skull base endoscopy and reconstruction.
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Affiliation(s)
- Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
| | - Francisco Vaz-Guimaraes
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Brian Jankowitz
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Maria Koutourousiou
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Juan C Fernandez-Miranda
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Eric W Wang
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Affiliation(s)
- Menno R Germans
- Department of Neurosurgery, St. Elisabeth Hospital, Tilburg, The Netherlands
| | - R Loch Macdonald
- Division of Neurosurgery, St. Michael's Hospital, Ontario, Canada; Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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Park JH, Kim YI, Lim YC. Clinical outcomes of treatment for intracranial aneurysm in elderly patients. J Cerebrovasc Endovasc Neurosurg 2014; 16:193-9. [PMID: 25340020 PMCID: PMC4205244 DOI: 10.7461/jcen.2014.16.3.193] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 07/28/2014] [Accepted: 08/11/2014] [Indexed: 11/24/2022] Open
Abstract
Objective The aim of this study is to evaluate the clinical course of intracranial aneurysm in patients aged 65 years and older and the immediate outcome after its aggressive management. Materials and Methods We performed a retrospective analysis using the medical records of 159 elderly patients managed at our institute from September 2008 to December 2013. Obtained clinical information included age, sex, Hunt and Hess grade (HHG), aneurysm location, Fisher grade (FG) and the treatment modality. Concomitant clinical data aside from cerebrovascular condition (hypertension, diabetes, previous medication) were evaluated to determine risk factors that might affect the functional outcomes. Results A total of 108 patients (67.9%) presented with subarachnoid hemorrhage (SAH), and 51 (32.1%) with unruptured intracranial aneurysms (UIAs). Coiling was performed in 101 patients and 58 patients underwent clipping. In the SAH population, 62 patients (57.4%) showed favorable outcomes, with a mortality rate of 11.3% (n = 18). In the UIAs population, 50 (98%) patients achieved 'excellent' and one (2%) achieved 'good' outcome. Factors including high-grade HHG (p < 0.001), advanced age (p = 0.014), and the presence of intraventricular hematoma (IVH) (p = 0.017) were significant predictors of poor outcome. Conclusion SAH patients with high grade HHG and IVH are associated with poor outcome with statistical significance, all the more prominent the older the patient is. Therefore, the indication for aggressive therapy should be considered more carefully in these patients. However, as the outcomes for elderly patients with UIAs were excellent regardless of the treatment modality, aggressive treatment could always be considered in UIAs cases.
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Affiliation(s)
- Jun Hee Park
- Department of Neurosurgery, Ajou University School of Medicine, Suwon, Korea
| | - Young Im Kim
- Department of Neurosurgery, Ajou University School of Medicine, Suwon, Korea
| | - Yong Cheol Lim
- Department of Neurosurgery, Ajou University School of Medicine, Suwon, Korea
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Bae DH, Kim JM, Won YD, Choi KS, Cheong JH, Yi HJ, Kim CH. Clinical outcome of paraclinoid internal carotid artery aneurysms after microsurgical neck clipping in comparison with endovascular embolization. J Cerebrovasc Endovasc Neurosurg 2014; 16:225-34. [PMID: 25340024 PMCID: PMC4205248 DOI: 10.7461/jcen.2014.16.3.225] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 07/15/2014] [Accepted: 09/04/2014] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Because of the complex anatomical association among vascular, dural, and bony structures, paraclinoid internal carotid artery (ICA) aneurysms remain a major challenge for vascular neurosurgeons. We studied the clinical outcomes of 61 paraclinoid ICA aneurysms after microsurgical clipping in comparison with endovascular coiling. MATERIALS AND METHODS Between January 2008 and December 2012, we treated 61 paraclinoid ICA aneurysms created by surgical clipping or endovascular coiling. Preoperative neurologic status and postoperative outcome were evaluated using the Glasgow coma scale (GCS) and the modified Rankin scale (mRS). Postoperative hydrocephalus and vasospasm were reviewed using the patients' medical charts. RESULTS Most patients were in good clinical condition before the operations and had good treatment outcomes. Clinical vasospasm was observed after the operation in five patients, and hydrocephalus occurred in six patients. No statistically significant difference regarding aneurysm size, sex, GCS score, H-H grade, and mRS was observed between the surgical clipping group and the endovascular coiling group. In addition, the treatment results and complications did not show statistically significant difference in either group. CONCLUSION Surgical occlusion of paraclinoid ICA aneurysms is difficult; however, no significant differences were observed in the treatment results or complications when compared with coil embolization. In particular, use of an adequate surgical technique may lead to better outcomes than those for coil embolization in the treatment of large and/or wide-neck paraclinoid ICA aneurysms.
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Affiliation(s)
- Dong-Hyun Bae
- Department of Neurosurgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Jae-Min Kim
- Department of Neurosurgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Yu-Deok Won
- Department of Neurosurgery, Hanyang University Medical Center, Hanyang University college of Medicine, Seoul, Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Jin-Hwan Cheong
- Department of Neurosurgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Hyeong-Joong Yi
- Department of Neurosurgery, Hanyang University Medical Center, Hanyang University college of Medicine, Seoul, Korea
| | - Choong-Hyun Kim
- Department of Neurosurgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
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Clark JC, Spetzler RF. Dealing with the aneurysmal remnants after endovascular treatment. World Neurosurg 2014; 83:149-51. [PMID: 25238679 DOI: 10.1016/j.wneu.2014.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 09/13/2014] [Indexed: 11/26/2022]
Affiliation(s)
- Justin C Clark
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Robert F Spetzler
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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Chalouhi N, Thakkar V, Tjoumakaris S, Fernando Gonzalez L, Hasan D, Rosenwasser R, Singhal S, Jabbour PM. Microsurgical clipping of large and giant cerebral aneurysms: a single-center contemporary experience. J Clin Neurosci 2014; 21:1424-7. [PMID: 24792725 DOI: 10.1016/j.jocn.2013.11.052] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 11/22/2013] [Accepted: 11/29/2013] [Indexed: 10/25/2022]
Abstract
Several treatment strategies are available to manage large and giant cerebral aneurysms, including surgical, endovascular and combined approaches. We present our experience with microsurgical clipping of large and giant aneurysms. A total of 138 patients with 139 aneurysms of which 128 were large (≥10mm) and 11 were giant (≥25mm) were treated at our institution between 2004 and 2011. Data were collected from a prospectively maintained neurovascular database. Of 138 patients, 53 (38.4%) patients presented with subarachnoid hemorrhage (SAH). Peri-operative complications occurred in 16.7% of patients causing permanent morbidity in 4.4% and death in 0.7%. Complete occlusion, as evident on intra-operative angiography, was achieved in all clipped aneurysms (100%). Long-term follow-up angiography showed no recurrence (mean follow-up time, 43.9 months; range: 1-72 months). Favorable outcomes at discharge (Glasgow Outcome Scale score 4 or 5) were noted in 64.1% of SAH patients and 93% of non-SAH patients. Favorable outcomes at follow-up (mean follow up time, 42.5 months) were seen in 96% of patients. In our experience, microsurgical clipping of large and giant aneurysms carries low rates of morbidity and mortality with high rates of favorable outcomes. The excellent durability of surgical treatment stands in stark contrast with the high recurrence rates observed with coiling for this subset of aneurysms. These data suggest that microsurgical clipping continues to be a viable option that can be offered for patients with large and giant aneurysms.
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Affiliation(s)
- Nohra Chalouhi
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 901 Walnut Street 3rd Floor, Philadelphia, PA 19107, USA
| | - Vismay Thakkar
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 901 Walnut Street 3rd Floor, Philadelphia, PA 19107, USA
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 901 Walnut Street 3rd Floor, Philadelphia, PA 19107, USA
| | - L Fernando Gonzalez
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 901 Walnut Street 3rd Floor, Philadelphia, PA 19107, USA
| | - David Hasan
- Department of Neurosurgery, University of Iowa, Iowa City, IA, USA
| | - Robert Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 901 Walnut Street 3rd Floor, Philadelphia, PA 19107, USA
| | - Saurabh Singhal
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 901 Walnut Street 3rd Floor, Philadelphia, PA 19107, USA
| | - Pascal M Jabbour
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 901 Walnut Street 3rd Floor, Philadelphia, PA 19107, USA.
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Derrey S, Penchet G, Thines L, Lonjon M, David P, Bataille B, Emery E, Lubrano V, Laguarrigue J, Bresson D, Pelissou I, Irthum B, Lejeune JP, Proust F. French collaborative group series on giant intracranial aneurysms: Current management. Neurochirurgie 2014; 61:371-7. [PMID: 24647149 DOI: 10.1016/j.neuchi.2013.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2013] [Revised: 08/31/2013] [Accepted: 11/13/2013] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Giant intracranial aneurysms represent a major therapeutic challenge for each surgical team. The aim of our study was to extensively review the French contemporary experience in treating giant intracranial aneurysms in order to assess the current management. PATIENTS AND METHODS This retrospective multicenter study concerned consecutive patients treated for giant intracranial aneurysms (2004-2008) in different French university hospitals (Bordeaux, Caen, Clermont-Ferrand, Lille, Lyon, Nice, Paris-Lariboisière, Rouen et Toulouse). Different variables were analyzed: the diagnostic circumstances, the initial clinical status based on the WFNS scale, aneurysmal features and exclusion procedure. At 6 months, the outcome was evaluated according to the modified Rankin Scale (mRS): favorable (mRS 0-2) and unfavorable (mRS 3-6). A multivariate logistic regression model included all the independent variables with P<0.25 in the univariate analysis (P<0.05). RESULTS A total of 79 patients with a mean age of 51.5 ± 1.6 years (median: 52 years; range: 16-79) were divided into two groups, with the ruptured group (n=26, 32.9%) significantly younger (P<0.05, Student's-t-test) than the unruptured group (n=53, 67.1%). After SAH, the initial clinical status was good in 12 patients (46.2%), and in the unruptured group, the predominant diagnosis circumstance was a pseudo-tumor syndrome occurring in 22 (41.5%). The first procedure of aneurysm treatment in the global population was endovascular in 42 patients (53.1%), microsurgical in 29 (36.7%) and conservative in 8 (10.2). An immediate neurological deterioration was reported in 38 patients (48.1%) after endovascular treatment in 19 (45.2% of endovascular procedures), after miscrosurgical in 15 (51.7% of microsurgical procedures) and after conservative in 4 (the half). At 6 months, the outcome was favorable in 45 patients (57%) and after multivariate analysis, the predictive factors of favorable outcome after management of giant cerebral aneurysm were the initial good clinical status in cases of SAH (P<0.002), the endovascular treatment (P<0.005), and the absence of neurological deterioration (P<0.006). The endovascular procedure was obtained as a predictive factor because of the low risk efficacy of indirect procedures, in particular a parent vessel occlusion. CONCLUSION The overall favorable outcome rate concerned 57% of patients at 6 months despite 53.8% of poor initial clinical status in cases of rupture. The predictive factors for favorable outcome were good clinical status, endovascular treatment and the absence of postoperative neurological deterioration. Endovascular treatment should be integrated into the therapeutic armenmatarium against giant cerebral aneurysms but the durability of exclusion should be taken into account during the multidisciplinary discussion by the neurovascular team.
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Affiliation(s)
- S Derrey
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - G Penchet
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - L Thines
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - M Lonjon
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - P David
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - B Bataille
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - E Emery
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - V Lubrano
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - J Laguarrigue
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - D Bresson
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - I Pelissou
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - B Irthum
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - J-P Lejeune
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - F Proust
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France.
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