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Calvanese F, Auricchio AM, Pohjola A, Hafez A, Nurminen V, Korja M, Numminen J, Lehecka M, Raj R, Niemelä M. Changes in treatment of intracranial aneurysms during the last decade in a large European neurovascular center. Acta Neurochir (Wien) 2024; 166:173. [PMID: 38594469 PMCID: PMC11004042 DOI: 10.1007/s00701-024-06064-4] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 03/26/2024] [Indexed: 04/11/2024]
Abstract
OBJECTIVE Treatment modality for ruptured and unruptured intracranial aneurysms has shifted during the last two decades from microsurgical treatment towards endovascular treatment. We present how this transition happened in a large European neurovascular center. METHODS We conducted a retrospective observational study consecutive patients treated for an unruptured or ruptured intracranial aneurysm at Helsinki University Hospital during 2012-2022. We used Poisson regression analysis to report age-adjusted treatment trends by aneurysm location and rupture status. RESULTS A total of 2491 patients with intracranial aneurysms were treated (44% ruptured, 56% unruptured): 1421 (57%) surgically and 1070 (43%) endovascularly. A general trend towards fewer treated aneurysms was noted. The proportion of patients treated surgically decreased from 90% in 2012 to 20% in 2022. The age-adjusted decrease of surgical versus endovascular treatment was 6.9%/year for all aneurysms, 6.8% for ruptured aneurysms, and 6.8% for unruptured aneurysms. The decrease of surgical treatment was most evident in unruptured vertebrobasilar aneurysms (10.8%/year), unruptured communicating artery aneurysms (10.1%/year), ruptured communicating artery aneurysms (10.0%/year), and ruptured internal carotid aneurysms (9.0%/year). There was no change in treatment modality for middle cerebral artery aneurysms, of which 85% were still surgically treated in 2022. A trend towards an increasing size for treated ruptured aneurysms was found (p = 0.033). CONCLUSION A significant shift of the treatment modality from surgical to endovascular treatment occurred for all aneurysm locations except for middle cerebral artery aneurysms. Whether this shift has affected long-term safety and patient outcomes should be assessed in the future.
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Affiliation(s)
- Francesco Calvanese
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
| | - Anna Maria Auricchio
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Anni Pohjola
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
| | - Ahmad Hafez
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
| | - Ville Nurminen
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
| | - Miikka Korja
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
| | - Jussi Numminen
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
| | - Martin Lehecka
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
| | - Rahul Raj
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland.
| | - Mika Niemelä
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
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Tatsuta Y, Endo H, Ogino T, Yamaguchi Y, Kamiyama K, Osato T, Nakamura H. Internal carotid artery-persistent primitive anterior choroidal artery aneurysms: report of two cases and literature review. Acta Neurochir (Wien) 2024; 166:94. [PMID: 38376611 DOI: 10.1007/s00701-024-05988-1] [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: 12/18/2023] [Accepted: 12/28/2023] [Indexed: 02/21/2024]
Abstract
PURPOSE Persistent primitive anterior choroidal artery (PPAChA) is a rare vascular anomaly. The clinical course of internal carotid artery (ICA)-PPAChA aneurysms has not been well described. CASE REPORTS We report two patients with an ICA-PPChA aneurysm and summarize previously reported cases. RESULTS Including our two, a total of 10 patients with an ICA-PPAChA aneurysm have been reported. Data were not described for one. Among the remaining nine, five patients (56%) experienced aneurysmal rupture. Five patients underwent surgical clipping and four underwent endovascular coiling. The procedure was completed in all but one patient who had a tiny branch artery adherent to the aneurysm; this patient was converted from clipping to aneurysm coating with a cotton sheet. Among the other eight patients, one who underwent coiling experienced an internal capsule infarction. The remaining seven had a satisfactory postoperative course; however, an asymptomatic occlusion of the PPAChA at its origin was noted on postoperative angiography in one. CONCLUSION PPChA is associated with a high incidence of aneurysm formation and rupture. During treatment of ICA-PPAChA aneurysms, obstruction of the PPAChA and any surrounding perforating arteries should be avoided to prevent ischemic stroke.
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Affiliation(s)
- Yasuyuki Tatsuta
- Department of Neurosurgery, Nakamura Memorial Hospital, South 1, West 14, Chuo-Ku, Sapporo, Hokkaido, 060-8570, Japan.
| | - Hideki Endo
- Department of Neurosurgery, Nakamura Memorial Hospital, South 1, West 14, Chuo-Ku, Sapporo, Hokkaido, 060-8570, Japan
| | - Tatsuya Ogino
- Department of Neurosurgery, Nakamura Memorial Hospital, South 1, West 14, Chuo-Ku, Sapporo, Hokkaido, 060-8570, Japan
| | - Yohei Yamaguchi
- Department of Neurosurgery, Nakamura Memorial Hospital, South 1, West 14, Chuo-Ku, Sapporo, Hokkaido, 060-8570, Japan
| | - Kenji Kamiyama
- Department of Neurosurgery, Nakamura Memorial Hospital, South 1, West 14, Chuo-Ku, Sapporo, Hokkaido, 060-8570, Japan
| | - Toshiaki Osato
- Department of Neurosurgery, Nakamura Memorial Hospital, South 1, West 14, Chuo-Ku, Sapporo, Hokkaido, 060-8570, Japan
| | - Hirohiko Nakamura
- Department of Neurosurgery, Nakamura Memorial Hospital, South 1, West 14, Chuo-Ku, Sapporo, Hokkaido, 060-8570, Japan
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3
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Muhammad S, Zhang R, Filler T, Hänggi D, Meling TR. Trans-lateral ventricular approach for surgical treatment of high-located P2-P3 junction posterior cerebral artery aneurysms: from anatomical research to clinical application. Acta Neurochir (Wien) 2024; 166:50. [PMID: 38289511 PMCID: PMC10828004 DOI: 10.1007/s00701-024-05942-1] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/24/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND Posterior cerebral artery (PCA) aneurysms, though rare, pose treatment challenges. Endovascular therapy is the preferred option, but microsurgery becomes necessary in certain cases. Various microsurgical approaches have been suggested for PCA aneurysms, particularly those at the P2-P3 junction. This study highlights the trans-lateral ventricular approach (TVA) for addressing these complex aneurysms. This study aims to assess the feasibility and safety of the trans-lateral ventricular approach (TVA) for treating high-located complex PCA aneurysms at the P2-P3 junction. The study evaluates both clinical outcomes and anatomical considerations. METHODS Two cases of PCA aneurysms at the P2-P3 junction were treated using TVA in 2019. Navigation-guided entry via the interparietal sulcus was planned. Ventriculostomy was performed from the cortex to the lateral ventricle's atrium. Medial atrial floor dissection exposed PCA's P2-P3 segments. Neuronavigation and ultrasound-aided guidance was used. Anatomical studies on fixed and contrast-perfused specimens refined the approach. RESULTS Both cases saw successful aneurysm clipping. The unruptured aneurysm patient was discharged in 6 days. The poor-grade SAH patient required extended ICU care, moving to rehabilitation with mRS = 4. The unruptured complex aneurysm case exhibited no deficits, returning to work in 3 months. Anatomical dissections validated TVA for high-located P2-P3 junction PCA aneurysms. CONCLUSION While endovascular therapy remains primary, this study demonstrates the viability of navigation-guided TVA for select high-located P2-P3 junction PCA aneurysms. Successes and challenges underscore the importance of patient selection and anatomical awareness.
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Affiliation(s)
- Sajjad Muhammad
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Mooren Str. 5, 40225, Düsseldorf, Germany.
- Department of Neurosurgery, King Edward Medical University, Lahore, Pakistan.
| | - Rui Zhang
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Mooren Str. 5, 40225, Düsseldorf, Germany
- Department of Neurosurgery, Xingtai People's Hospital Hebei Medical University, Xingtai, China
| | - Timm Filler
- Institute for Anatomy I, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Mooren Str. 5, 40225, Düsseldorf, Germany
| | - Daniel Hänggi
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Mooren Str. 5, 40225, Düsseldorf, Germany
- Department of Neurosurgery, King Edward Medical University, Lahore, Pakistan
- International Neuroscience Institute (INI), Rudolf-Pichlmayr-Straße 4, 30625, Hannover, Germany
| | - Torstein R Meling
- Department of Neurosurgery, The National Hospital of Denmark, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Besta NeuroSim Center, Department of Neurological Surgery, Instituto Nazionale Neurologico "C. Besta,", Milan, Italy
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Choi S, Choi YH, Lee HS, Shin KW, Kim YJ, Park HP, Cho WS, Oh H. Effects of Scalp Nerve Block on the Quality of Recovery after Minicraniotomy for Clipping of Unruptured Intracranial Aneurysms : A Randomized Controlled Trial. J Korean Neurosurg Soc 2023; 66:652-663. [PMID: 37042173 PMCID: PMC10641417 DOI: 10.3340/jkns.2023.0010] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/13/2023] [Accepted: 04/10/2023] [Indexed: 04/13/2023] Open
Abstract
OBJECTIVE This study compared the quality of recovery (QoR) after minicraniotomy for clipping of unruptured intracranial aneurysms (UIAs) between patients with and without scalp nerve block (SNB). METHODS Patients were randomly assigned to the SNB (SNB using ropivacaine with epinephrine, n=27) and control (SNB using normal saline, n=25) groups. SNB was performed at the end of surgery. To assess postoperative QoR, the QoR-40, a patient-reported questionnaire, was used. The QoR-40 scores were measured preoperatively, 1-3 days postoperatively, at hospital discharge, and 1 month postoperatively. Pain and intravenous patient-controlled analgesia (IV-PCA) consumption were evaluated 3, 6, 9, and 12 hours and 1-3 days postoperatively. RESULTS All QoR-40 scores, including those measured 1 day postoperatively (primary outcome measure; 155.0 [141.0-176.0] vs. 161.0 [140.5-179.5], p=0.464), did not significantly differ between the SNB and control groups. The SNB group had significantly less severe pain 3 (numeric rating scale [NRS]; 3.0 [2.0-4.0] vs. 5.0 [3.5-5.5], p=0.029), 9 (NRS; 3.0 [2.0-4.0] vs. 4.0 [3.0-5.0], p=0.048), and 12 (NRS; 3.0 [2.0-4.0] vs. 4.0 [3.0-5.0], p=0.035) hours postoperatively. The total amount of IV-PCA consumed was significantly less 3 hours postoperatively in the SNB group (2.0 [1.0-4.0] vs. 4.0 [2.0-5.0] mL, p=0.044). CONCLUSION After minicraniotomy for clipping of UIAs, SNB reduced pain and IV-PCA consumption in the early postoperative period but did not improve the QoR-40 scores.
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Affiliation(s)
- Seungeun Choi
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Young Hoon Choi
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hoo Seung Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Kyong Won Shin
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Yoon Jung Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hee-Pyoung Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Won-Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyongmin Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Pettersson SD, Khorasanizadeh M, Maglinger B, Garcia A, Wang SJ, Taussky P, Ogilvy CS. Trends in the Age of Patients Treated for Unruptured Intracranial Aneurysms from 1990 to 2020. World Neurosurg 2023; 178:233-240.e13. [PMID: 37562685 DOI: 10.1016/j.wneu.2023.08.007] [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: 07/11/2023] [Revised: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND The decision for treatment for unruptured intracranial aneurysms (UIAs) is often difficult. Innovation in endovascular devices have improved the benefit-to-risk profile especially for elderly patients; however, the treatment guidelines from the past decade often recommend conservative management. It is unknown how these changes have affected the overall age of the patients selected for treatment. Herein, we aimed to study potential changes in the average age of the patients that are being treated over time. METHODS A systematic search of the literature was performed to identify all studies describing the age of the UIAs that were treated by any modality. Scatter diagrams with trend lines were used to plot the age of the patients treated over time and assess the presence of a potential significant trend via statistical correlation tests. RESULTS A total of 280 studies including 83,437 UIAs treated between 1987 and 2021 met all eligibility criteria and were entered in the analysis. Mean age of the patients was 55.5 years, and 70.7% were female. There was a significant increasing trend in the age of the treated patients over time (Spearman r: 0.250; P < 0.001), with a 1-year increase in the average age of the treated patients every 5 years since 1987. CONCLUSIONS The present study indicates that based on the treated UIA patient data published in the literature, older UIAs are being treated over time. This trend is likely driven by safer treatments while suggesting that re-evaluation of certain UIA treatment decision scores may be of great interest.
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Affiliation(s)
- Samuel D Pettersson
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - MirHojjat Khorasanizadeh
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Benton Maglinger
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Alfonso Garcia
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - S Jennifer Wang
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Philipp Taussky
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
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6
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Liu J, You H, Guo D, Li Z, Jin Y, Fan X, Qiao H. Application of intraoperative evoked potential monitoring in patients with anterior cerebral artery aneurysms. J Stroke Cerebrovasc Dis 2023; 32:107214. [PMID: 37352826 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107214] [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: 03/11/2023] [Revised: 05/30/2023] [Accepted: 06/07/2023] [Indexed: 06/25/2023] Open
Abstract
OBJECTIVES The location of the aneurysm can affect the relationship between changes in intraoperative neurophysiological monitoring indicators and postoperative outcomes. The current study aimed to evaluate the application value of motor evoked potential and somatosensory evoked potential monitoring in anterior cerebral artery aneurysm surgery. METHODS The data of 219 patients with anterior cerebral artery aneurysms treated via surgical clipping were retrospectively reviewed. The correlation of motor/somatosensory evoked potential monitoring with postoperative motor dysfunction was assessed using false positive rate, false negative rate, sensitivity, and specificity. Binary multivariate logistic regression analysis was applied to identify potential predictors for postoperative motor dysfunction. RESULTS Motor evoked potential monitoring showed satisfactory effectiveness in predicting postoperative motor dysfunction (Sensitivity, 60.00%; Specificity, 85.43%; False positive rate, 14.57%; False negative rate, 40%). While somatosensory evoked potential did not (Sensitivity, 15.00%; Specificity, 96.98%; False positive rate, 3.02%; False negative rate, 85%). Abnormal motor evoked potential was identified as the only independent predictor for both short-term (odds ratio, 8.893; 95% confidence interval, 2.749-28.773; p<0.001) and long-term postoperative motor dysfunction (odds ratio, 7.877; 95% confidence interval, 2.144-28.945; p=0.002). CONCLUSIONS During intraoperative neurophysiological monitoring for patients with anterior cerebral artery aneurysms, paying more attention to motor evoked potential changes was a reasonable choice. And somatosensory evoked potential monitoring can serve as an auxiliary reference.
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Affiliation(s)
- Jiajia Liu
- Department of Neurophysiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Hao You
- Department of Neurophysiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Dongze Guo
- Department of Neurophysiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Zhibao Li
- Department of Neurophysiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Yanwen Jin
- Department of Neurophysiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Xing Fan
- Department of Neurophysiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.
| | - Hui Qiao
- Department of Neurophysiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.
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7
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Hu P, Yan T, Li Y, Guo G, Gao X, Su Z, Du S, Jin R, Tao J, Yuan Y, Yang X, Xiao B, Wu M, Ye M, Lv S, Liao J, Chen Q, Zhu X. Effect of Surgical Clipping versus Endovascular Coiling on the Incidence of Delayed Cerebral Ischemia in Patients with Aneurysmal Subarachnoid Hemorrhage: A Multicenter Observational Cohort Study with Propensity Score Matching. World Neurosurg 2023:S1878-8750(23)00046-3. [PMID: 36657714 DOI: 10.1016/j.wneu.2023.01.032] [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: 01/07/2023] [Accepted: 01/10/2023] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The effect of surgical clipping (SC) and endovascular coiling (EC) on the incidence of delayed cerebral ischemia (DCI) in patients with aneurysmal subarachnoid hemorrhage (aSAH) has always been a controversial topic. Hence, it is necessary to reanalyze the effects of the 2 surgical methods on DCI, which determines the choice of the most favorable method for patients who are suitable for both surgical modalities. METHODS A multicenter retrospective observational cohort study was performed to evaluate all consecutive patients with aSAH admitted to 5 medical centers in China between April 2019 and June 2021. Univariable and multivariable analyses were used to confirm risk factors of DCI after aSAH. A 1:1 propensity score matching model was generated in the EC and SC groups to reduce the influence of all confounding factors on DCI. RESULTS A total of 412 patients were included, and 115 patients (27.9%) developed DCI. After propensity score matching for controlling demographic information, past medical history, admission clinical status, aneurysm characteristics, and inflammatory factors associated with DCI, 133 patients with SC and 133 patients with EC treatment were matched. The results of the matched cohorts indicate a significantly lower incidence of DCI when patients received EC than SC (31.9% vs. 20%; adjusted odds ratio, 1.87; 95% confidence interval, 1.08-3.29; P = 0.027). CONCLUSIONS The study found that the patients who received SC treatment had a higher incidence of DCI than did those who received EC and suggested that ruptured intracerebral aneurysm is preferentially coiled rather than clipped if the aneurysm is suitable for both surgical modalities.
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Maeda T, Ooigawa H, Suzuki K, Sato H, Iihoshi S, Kohyama S, Kurita H. Predictors of Ischemic Complication in Anterior Choroidal Artery Aneurysm Repair. World Neurosurg 2022; 167:e157-e164. [PMID: 35934295 DOI: 10.1016/j.wneu.2022.07.111] [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: 06/09/2022] [Accepted: 07/25/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Treatment of anterior choroidal artery (AchoA) aneurysms is challenging because of the risk of artery injury. The objective of the study was to evaluate the incidence and predictors of AchoA infarction in patients who underwent surgical or endovascular procedure. METHODS We included 123 patients with AchoA aneurysms treated by surgical clipping (n = 62; 50.4%) or endovascular coiling, including flow diverter placement (n = 61; 49.6%). The clinical and radiological data were retrospectively analyzed. AchoA infarction was defined as the presence of a hyperintense signal on diffusion-weighted imaging in the area of AchoA, including the posterior limb of the internal capsule. RESULTS AchoA infarction was detected in 8 cases (6.5%), with similar incidence in both groups (6.5% [4/62] vs. 6.6% [4/61]). It occurred in ruptured aneurysms more frequently than in unruptured aneurysms (14.3% [6/42] vs. 2.5% [2/81], P = 0.019). In the surgical group, all 4 affected patients had a non-proximal type AchoA, whereas in the non-infarction group, 9 patients (15.5%) had a non-proximal type AchoA (P = 0.001). In the endovascular group, the incidence was higher in patients with ruptured aneurysms (17.3% [4/23] vs. 0% [0/38], P = 0.017) and lower in patients with pre-admission antiplatelet therapy (0% [0/39] vs. 18.8% [4/22], P = 0.014). CONCLUSIONS Repair of an AchoA aneurysm is associated with the risk of incurring post-procedural AchoA infarction. Surgical clipping and endovascular coiling have similar complication rates, but risk factors specific to each intervention exist. Careful surgical planning to avoid these risk factors in each therapeutic modality may improve patient outcomes.
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Affiliation(s)
- Takuma Maeda
- Department of Cerebrovascular Surgery, International Medical Center, Saitama Medical University, Hidaka, Japan.
| | - Hidetoshi Ooigawa
- Department of Cerebrovascular Surgery, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Kaima Suzuki
- Department of Cerebrovascular Surgery, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Hiroki Sato
- Department of Endovascular Neurosurgery, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Satoshi Iihoshi
- Department of Endovascular Neurosurgery, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Shinya Kohyama
- Department of Endovascular Neurosurgery, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Hiroki Kurita
- Department of Cerebrovascular Surgery, International Medical Center, Saitama Medical University, Hidaka, Japan
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Nagaraj A, Raju B, Jumah F, Nanda A. Surgical Resection and Clipping of an Atherosclerotic Partially Calcified Middle Cerebral Artery Trifurcation Aneurysm with Clipping of an Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video. World Neurosurg 2022; 166:28. [PMID: 35643407 DOI: 10.1016/j.wneu.2022.05.077] [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: 12/01/2021] [Revised: 05/17/2022] [Accepted: 05/18/2022] [Indexed: 12/15/2022]
Abstract
It is estimated within the western population that 10%-13% of patients possess multiple intracranial aneurysms1 and are linked to certain risk factors. Thrombotic aneurysms are a rare subgroup of complex aneurysms characterized by an organized intraluminal thrombus.2,3 They differ from typical saccular aneurysms in terms of morphology, natural history, symptomatology, and difficulty in treatment with conventional strategies.2,4 The risk of rupture is poorly characterized and assumed to be comparable with that of nonthrombotic aneurysms.2 A subset of thrombotic aneurysms can be treated surgically with conventional clipping, and direct clipping has been associated with the best surgical outcome.2 Despite its safety, endovascular treatment is associated with a high risk of recurrence and retreatment compared with surgical treatment,5 with recanalization rates up to 5× higher compared with nonthrombosed aneurysms.6,7 A 64-year-old male presented with headaches and dizziness for 6 months. He was neurologically intact. Imaging revealed a calcified thrombosed right middle cerebral artery aneurysm and an anterior communicating artery aneurysm, both of which underwent clipping. The patient consented to the procedure. Preservation of blood flow in branch arteries in thrombosed aneurysms is challenging. Thrombectomy and clip reconstruction in such cases can occlude the branch vessels, compromising blood flow. Achieving adequate proximal control and meticulous dissection of the branches is necessary before reconstruction. We present a 2-dimensional video demonstrating the surgical steps of clipping and reconstruction of the giant thrombosed middle cerebral artery aneurysm. Complete occlusion was achieved, and the patient tolerated the operation well with an uneventful postoperative course.
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Affiliation(s)
- Anmol Nagaraj
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School & University Hospital, New Brunswick, New Jersey, USA
| | - Bharath Raju
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School & University Hospital, New Brunswick, New Jersey, USA
| | - Fareed Jumah
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School & University Hospital, New Brunswick, New Jersey, USA
| | - Anil Nanda
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School & University Hospital, New Brunswick, New Jersey, USA.
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Kwon MY, Lee SU, Kim WB, Lee Y, Pang CH, Kim T, Oh CW, Bang JS. Implantation of Acellular Dermal Matrix to Prevent Frontotemporal Depression Following Minipterional Craniotomy for the Surgical Clipping of Unruptured Intracranial Aneurysms. World Neurosurg 2022; 166:e11-e22. [PMID: 35569746 DOI: 10.1016/j.wneu.2022.05.021] [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: 03/25/2022] [Revised: 05/05/2022] [Accepted: 05/05/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The objective of the study was to assess the esthetic efficacy of acellular dermal matrix (ADM) implantation to prevent frontotemporal depression (FTD) following minipterional craniotomy (MPT) to clip unruptured intracranial aneurysms. METHODS We retrospectively compared the incidence of FTD in 100 patients treated without ADM from March to July 2019 and 100 patients treated with ADM from August to December 2019. ADM was implanted in the interfascial layer to cover the temporalis muscle. The specific location and degree of FTD were analyzed by measuring the thickness and area of multiple points (P1-P12) and regions (S1-S3) through brain computed tomography preoperatively and 1 year postoperatively. RESULTS In the non-ADM group, the thickness at P1, P2, P5, P6, and P9 was reduced and the area of S1 and S2 was smaller after surgery than before surgery (P < 0.05), similar to the incision and suture site of the temporalis muscle. However, in the ADM group, the preoperative and postoperative measurements were not different. FTD recognition was significantly lower in the ADM group (6.0%) than that in the non-ADM group (17.0%) (P = 0.015) and occurred in the retroorbital region through P1, P2, P5, and P6, with the area under the receiver operating characteristic curves of 0.840, 0.766, 0.811, and 0.751, respectively. ADM implantation was the only significant predictive factor for FTD recognition in multivariate logistic regression analysis (odds ratio = 0.30; 95% confidence interval: 0.11-0.79; P = 0.015). CONCLUSIONS Even MPT cannot completely prevent FTD in the retroorbital region. ADM implantation in MPT can help to improve esthetic satisfaction.
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Affiliation(s)
- Min-Yong Kwon
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Si Un Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Woong-Beom Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Yongjae Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Chang Hwan Pang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Tackeun Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jae Seung Bang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.
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11
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Beneš V, Štekláčová A, Bradáč O. Repeated Aneurysm Intervention. Adv Tech Stand Neurosurg 2022; 44:277-96. [PMID: 35107686 DOI: 10.1007/978-3-030-87649-4_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Over the past 25 years the endovascular treatment of cerebral aneurysms has gained preference in some countries over the traditional surgical procedures. The review part of the article clearly demonstrates that the clinical results of both modalities are similar and the difference is seen only in technical effectivity. Surgical techniques fail far less frequently than the endovascular ones. Incompletely occluded or growing aneurysms after the endovascular approach expose the patient to the risk of rebleeding with all possible consequences. Markedly repeated procedures are much more common for endovascularly treated aneurysms, again with all the risks.In the authors institution over the past 20 years, a total of 2032 aneurysms were treated. In 1263 endovascularly managed aneurysms the regrowth or inclomplete initial occlusion necessitated 159 repeated propcedures (12.6%). In surgical group the total of 27 aneurysms needed retreatment (3.5%). The difference is statistically significant. In nine patients in endovascular group the rebleeding was the reason for repeated procedures. No rebleeding was seen in the surgical group.This fact, also shown in the review part of the article, is important in patients counseling. Given the similar clinical results of both modalities the patient should be advised on the necessity of repeated follow-ups and of possible technical failure and eventual repeated procedure which is more likely if endovascular procedure is chosen.
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12
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Stauning AT, Eriksson F, Benndorf G, Holst AV, Hauerberg J, Stavngaard T, Poulsgaard L, Rochat P, Eskesen V, Birkeland P, Mathiesen T, Munch TN. Mortality among patients treated for aneurysmal subarachnoid hemorrhage in Eastern Denmark 2017-2019. Acta Neurochir (Wien) 2022; 164:2419-2430. [PMID: 35864221 PMCID: PMC9303843 DOI: 10.1007/s00701-022-05303-w] [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: 01/26/2022] [Accepted: 06/29/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The aim of the study was to investigate (1) the 30-day, 3-month, and 12-month cumulative mortalities for patients who underwent aneurysm occlusion, and (2) the causes of death, and (3) the potential risk factors for death. METHODS All patients who underwent surgical clipping or endovascular treatment of a ruptured aneurysm at Copenhagen University Hospital, during the period of January 1, 2017-December 31, 2019, were included and followed up for 12 months. Data regarding vital status, causes of death, comorbidities, treatment, and clinical presentations on admission was collected. The absolute mortality risk was estimated as a function of time with a 95% confidence interval. The associations between potential risk factors and death were estimated as odds ratios with 95% confidence intervals using logistic regression models. RESULTS A total of 317 patients were included. The overall cumulative mortalities after 30 days, 3 months, and 12 months were 10.7%, 12.9%, and 16.1%, respectively. The most common cause of death was severe primary hemorrhage (52.9%), followed by infections (15.7%) and rebleeding (11.8%). WFNS score > 3 and Fisher score > 3 on admission, preprocedural hydrocephalus, and preprocedural rebleeding were found significantly associated with higher risk of death. CONCLUSIONS Considerable mortality was seen. Possible preventable causes accounted for approximately 22% of the deaths. The occurrence of both pre- and postprocedural rebleeding's indicates an opportunity of further improvement of the mortality by (1) further reduction of time from aSAH to aneurysm occlusion and (2) continuous efforts in improving methods of aneurysm occlusion.
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Affiliation(s)
- Agnes T. Stauning
- Department of Neurosurgery, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100 Copenhagen, Denmark
| | - Frank Eriksson
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Goetz Benndorf
- Department of Neuroradiology, Copenhagen University Hospital, Copenhagen, Denmark ,Department of Radiology, Baylor College of Medicine, Houston, TX USA
| | - Anders V. Holst
- Department of Neurosurgery, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100 Copenhagen, Denmark
| | - John Hauerberg
- Department of Neurosurgery, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100 Copenhagen, Denmark
| | - Trine Stavngaard
- Department of Neuroradiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Poulsgaard
- Department of Neurosurgery, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100 Copenhagen, Denmark
| | - Per Rochat
- Department of Neurosurgery, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100 Copenhagen, Denmark
| | - Vagn Eskesen
- Department of Neurosurgery, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100 Copenhagen, Denmark
| | - Peter Birkeland
- Department of Neurosurgery, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100 Copenhagen, Denmark
| | - Tiit Mathiesen
- Department of Neurosurgery, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100 Copenhagen, Denmark ,Department of Radiology, Baylor College of Medicine, Houston, TX USA ,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Tina N. Munch
- Department of Neurosurgery, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100 Copenhagen, Denmark ,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark ,Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
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13
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Darsaut TE, Keough MB, Boisseau W, Findlay JM, Bojanowski MW, Chaalala C, Iancu D, Weill A, Roy D, Estrade L, Lejeune JP, Januel AC, Carlson AP, Sauvageau E, Al-Jehani H, Orlov K, Aldea S, Piotin M, Gaberel T, Gevry G, Raymond J. Middle Cerebral Artery Aneurysm Trial (MCAAT): A randomized care trial comparing surgical and endovascular management of MCA aneurysm patients. World Neurosurg 2021; 160:e49-e54. [PMID: 34971833 DOI: 10.1016/j.wneu.2021.12.083] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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: 11/05/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Whether the best management of middle cerebral artery (MCA) aneurysm patients is surgical or endovascular remains uncertain, with little evidence to guide decision-making. A randomized care trial offering MCA aneurysm patients a 50% chance of surgical and a 50% chance of endovascular management may optimize outcomes in the presence of uncertainty. METHODS The Middle Cerebral Artery Aneurysm Trial (MCAAT) is an investigator-initiated, multi-center, parallel group, prospective, 1:1 randomized controlled clinical trial. All adult patients with MCA aneurysms, ruptured or unruptured, amenable to surgical and endovascular treatment can be included. The composite primary outcome is 'Treatment Success': i) occlusion or exclusion of the aneurysm using the allocated treatment modality; ii) no intracranial hemorrhage during follow-up; iii) no retreatment of the target aneurysm during follow-up, iv) no residual aneurysm on angiographic follow-up and v) independence (mRS <3) at 1 year. The trial tests two versions of the same hypothesis (one for ruptured and one for unruptured MCA aneurysm patients): Surgical management will lead to a 15% absolute increase in the proportion of patients reaching Treatment Success from 55% to 70% (ruptured) or from 75% to 90% (unruptured aneurysm patients) compared to endovascular treatment (any method). In this pragmatic trial, outcome evaluations are by treating physicians, except for 1 year angiographic results which will be core lab assessed. The trial will be monitored by an independent data safety monitoring committee to assure safety of participants. MCAAT is registered at clinicaltrials.gov: NCT05161377. CONCLUSION Patients with MCA aneurysms can be optimally managed within a care trial protocol.
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Affiliation(s)
- Tim E Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Canada
| | - Michael B Keough
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Canada
| | - William Boisseau
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - J Max Findlay
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Canada
| | - Michel W Bojanowski
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Chiraz Chaalala
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Daniela Iancu
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Alain Weill
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Daniel Roy
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Laurent Estrade
- Department of Interventional Neuroradiology, CHU de Lille, Hôpital Salengro, Lille, France
| | - Jean-Paul Lejeune
- Department of Neurosurgery, CHU de Lille, Hôpital Salengro, Lille, France
| | - Anne-Christine Januel
- Department of Interventional Neuroradiology, CHU de Toulouse, Hôpital Purpan, Toulouse, France
| | - Andrew P Carlson
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Health, Jacksonville, Florida, USA
| | - Hosam Al-Jehani
- Department of Neurosurgery and Radiology, King Fahad University Hospital, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia
| | - Kirill Orlov
- Endovascular Neurosurgery Research Center, Federal Center of Brain Research and Neurotechnologies of the Federal Medical Biological Agency of Russia, Moscow, Russia
| | - Sorin Aldea
- Department of Neurosurgery, Rothschild Foundation Hospital, Paris, France
| | - Michel Piotin
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | | | - Guylaine Gevry
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Jean Raymond
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
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14
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Fukuda H, Hamada F, Nonaka M, Ueba Y, Fukui N, Kurosaki Y, Morioka J, Koyanagi M, Nakajima N, Uezato M, Yasuda T, Chin M, Yamagata S, Murao K, Yamada K, Ohta T, Lo B, Ueba T. Impact of subcallosal artery origin and A1 asymmetry on surgical outcomes of anterior communicating artery aneurysms. Acta Neurochir (Wien) 2021; 163:2955-65. [PMID: 34453215 DOI: 10.1007/s00701-021-04979-w] [Citation(s) in RCA: 2] [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: 06/11/2021] [Accepted: 08/19/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Surgical clipping of anterior communicating artery (ACoA) aneurysms remains challenging due to their complex anatomy. Anatomical risk factors for ACoA aneurysm surgery require further elucidation. The aim of this study is to investigate whether proximity of the midline perforating artery, subcallosal artery (SubCA), and associated anomaly of the ACoA complex affect functional outcomes of ACoA aneurysm surgery. METHODS A total of 92 patients with both unruptured and ruptured ACoA aneurysms, who underwent surgical clipping, were retrospectively analyzed from a multicenter, observational cohort database. Association of ACoA anatomy with SubCA origin at the aneurysmal neck under microsurgical observation was analyzed in the interhemispheric approach subgroup (n = 56). Then, we evaluated whether anatomical factors associated with SubCA neck origin affected surgical outcomes in the entire cohort (both interhemispheric and pterional approaches, n = 92). RESULTS In the interhemispheric approach cohort, combination of A1 asymmetry and aneurysmal size ≥ 5.0 mm was stratified to have the highest probability of the SubCA neck origin by a decision tree analysis. Then, among the entire cohort using either interhemispheric or pterional approach, combination of A1 asymmetry and aneurysmal size ≥ 5.0 mm was significantly associated with poor functional outcomes by multivariable logistic regression analysis (OR 6.76; 95% CI 1.19-38.5; p = 0.03) as compared with A1 symmetry group in the acute subarachnoid hemorrhage settings. CONCLUSION Combination of A1 asymmetry and larger aneurysmal size was significantly associated with SubCA aneurysmal neck origin and poor functional outcomes in ACoA aneurysm surgery. Interhemispheric approach may be proposed to provide a wider and unobstructed view of SubCA for ACoA aneurysms with this high-risk anatomical variant.
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15
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Barrenechea IJ, Baldoncini M, González-López P, Campero Á. Optic Nerve Mobilization as an Alternative to Anterior Clinoidectomy for Superior Carotid-Ophthalmic Aneurysms: Operative Technique. World Neurosurg 2021; 152:137-43. [PMID: 34129989 DOI: 10.1016/j.wneu.2021.06.008] [Citation(s) in RCA: 2] [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: 05/04/2021] [Revised: 06/07/2021] [Accepted: 06/08/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Carotid-ophthalmic aneurysms arise from the internal carotid artery between the distal dural ring and the origin of the posterior communicating artery. The surgical treatment of these aneurysms usually requires anterior clinoidectomy. However, this procedure is not without complications. In the present report, we have described optic nerve mobilization after optic foraminotomy as an alternative to anterior clinoidectomy to clip superior carotid-ophthalmic aneurysms. METHODS We have reported the cases of 3 patients with superior carotid-ophthalmic aneurysms who had undergone surgical clipping. Instead of an anterior clinoidectomy, the optic nerve was mobilized after performing optic foraminotomy. The optic canal was carefully unroofed with a 3-mm, high-speed, diamond drill under constant cold saline irrigation to avoid thermal damage to the optic nerve. After incision of the falciform ligament and optic sheath, the optic nerve was gently mobilized with a No. 6 Penfield dissector, facilitating aneurysmal neck exposure and clipping through a widened opticocarotid triangle. RESULTS The postoperative course was uneventful for all 3 patients, without any added visual defect. Optic nerve mobilization allowed us to safely widen the opticocarotid triangle and dissect the aneurysm off the optic nerve, without the need for clinoidectomy. This alternative technique permitted, not only early decompression of the optic nerve, but also dissection of the arachnoid between the inferior surface of the optic nerve and the superior surface of the ophthalmic-carotid artery and aneurysm dome. CONCLUSIONS Optic nerve mobilization after optic foraminotomy proved to be a safe and relatively easy technique for exposing and treating superior carotid-ophthalmic aneurysms.
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16
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O'Neal CM, Ernst GL, Hughes KL, Stephens TM, Hendrix MC, Gross NL, Bohnstedt BN, Cheema AA. Reported incidence and treatment modalities of giant cerebral aneurysms in the pediatric population: A systematic review and illustrative case report. J Clin Neurosci 2021; 90:14-20. [PMID: 34275538 DOI: 10.1016/j.jocn.2021.03.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 03/04/2021] [Accepted: 03/30/2021] [Indexed: 02/04/2023]
Abstract
Giant intracranial aneurysms represent a complex pathology that pose challenges for management, especially in the pediatric population. With emerging endovascular techniques, combined endovascular and open surgical approaches may be a favorable alternative for complex cases. In this systematic review, we characterize the treatment modalities of giant aneurysms in the pediatric population and provide an update on the number of giant aneurysms reported in the literature by anatomic location. We conducted a literature search of PubMed, Embase, and Medline databases with the following terms: 'pediatric' AND 'giant' AND 'intracranial aneurysm.' Studies were included if data on treatment modality and aneurysm location were available for pediatric patients with giant intracranial aneurysms. The literature search yielded a total of 188 papers, with 82 pediatric patients from 33 articles ultimately meeting inclusion criteria. There were significantly more male than female patients (p = 0.011), with 52 and 29 respectively. Patients presenting with a ruptured aneurysm were significantly younger than patients presenting without rupture (p = 0.018), with a median age of 8.0 and 12.0 years, respectively. There were 45 giant aneurysms reported in the anterior circulation and 37 in the posterior circulation. Anterior aneurysms were most often treated with surgical approaches, while posterior aneurysms were typically treated with endovascular interventions (p = 0.002). Although combined surgical and endovascular approaches were the least frequently utilized, we suggest a combined approach may be particularly useful for patients with complex cases that require a management plan tailored to their needs.
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17
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Yang X, Zhou C, Liang L. Surgical clipping and endovascular embolization for senile patients with posterior communicating artery aneurysms complicated with oculomotor nerve palsy. Am J Transl Res 2021; 13:5679-5684. [PMID: 34150176 PMCID: PMC8205669] [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: 01/11/2021] [Accepted: 02/09/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To explore the clinical effect of the surgical clipping and endovascular embolization for senile patients with posterior communicating artery aneurysms (PComA) complicated with oculomotor nerve palsy (ONP) and their neurological recovery. METHODS A total of 96 senile patients with PComA complicated with ONP admitted to our hospital from May 2018 to May 2019 were selected and assigned into the experimental group and the control group according to the randomization method, with 48 cases in each group. The patients in the control group underwent surgical clipping, whereas the patients in the experimental group received the endovascular embolization. Subsequently, their surgical therapeutic effect, postoperative blood chemistry parameters, the incidence of complications, the recovery of neurological function and prognosis were analyzed and compared. RESULTS The operation duration, bleeding volume, respiratory recovery time and the time to extubation were significantly in favor of the experimental group when compared with the control group (P < 0.001); Senile patients in the experimental group had markedly lower levels of blood chemistry parameters than the control group (P < 0.001); The neurological recovery in the experimental group was found to be remarkably better than that in the control group (P < 0.05); The experimental group showed a distinct decrease in the incidence of complications compared to the control group (P < 0.05); A significant difference in good prognosis was observed between the control group and the experimental group (P < 0.05). CONCLUSION Endovascular embolization is more effective in the treatment of senile PComA with ONP. It is superior to the traditional surgical clipping, and has a lower incidence of complications, thereby contributing to the better recovery of neurological function and prognosis.
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Affiliation(s)
- Xue Yang
- Department of Neurosurgery, Wuhan Puren Hospital, Wuhan University of Science and Technology Wuhan, China
| | - Chizhong Zhou
- Department of Neurosurgery, Wuhan Puren Hospital, Wuhan University of Science and Technology Wuhan, China
| | - Ling Liang
- Department of Neurosurgery, Wuhan Puren Hospital, Wuhan University of Science and Technology Wuhan, China
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18
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Take Y, Kamide T, Kikkawa Y, Ikegami M, Teranishi A, Ehara T, Shibata A, Suzuki K, Ikeda T, Iihoshi S, Kohyama S, Kurita H. Current treatment options and prognostic factors for ruptured distal anterior cerebral artery aneurysms. Surg Neurol Int 2021; 12:171. [PMID: 34084599 PMCID: PMC8168794 DOI: 10.25259/sni_223_2021] [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: 03/05/2021] [Accepted: 03/31/2021] [Indexed: 11/22/2022] Open
Abstract
Background: Distal anterior cerebral artery (ACA) aneurysms are rare, representing 1–9% of all intracranial aneurysms. The best treatment strategy for these aneurysms continues to be debated. We clarified the clinical features and treatment outcomes of patients with ruptured distal ACA aneurysms according to the treatment options at our institute. Methods: Thirty-seven consecutive patients (26 women; mean age, 65.2 years) with ruptured distal ACA aneurysms who underwent surgical clipping or coil embolization between 2012 and 2018 were included in the study. Clinical presentations, radiographic findings, and outcomes were retrospectively reviewed and compared between patients who underwent either surgical clipping or coil embolization. Risk factors associated with poor outcomes (modified Rankin Scale 4–6) were analyzed using multiple regression analysis. Results: Nineteen patients (51.4%) had World Federation Neurological Surgeons (WFNS) Grade IV-V, 18 (48.7%) had frontal lobe hematomas, and 13 (35.1%) had multiple aneurysms. Surgical clipping and endovascular coiling were performed in 28 (75.7%) and nine (24.3%) patients, respectively. Aneurysms located at the A4-5 portions were mainly treated by surgical clipping (P = 0.04). There were no significant between-group differences in procedure-related morbidity and mortality; however, the complete occlusion rate was higher in the surgical group (P < 0.01). Overall, a favorable neurological outcome at discharge (mRS 0–3) was obtained in 23 patients (62.5%). Multiple regression analysis revealed that WFNS Grade IV-V and frontal lobe hematomas were risk factors for poor outcomes (mRS 4–6). Conclusion: Acceptable outcomes were obtained in 62.5% of cases, and there were no significant between-group differences in treatment results between clipping and coiling. A poor WFNS grade and intracerebral hematomas were risk factors for a poor prognosis.
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Affiliation(s)
- Yushiro Take
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Tomoya Kamide
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Yuichiro Kikkawa
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Masaki Ikegami
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Akio Teranishi
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Takuro Ehara
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Aoto Shibata
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Kaima Suzuki
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Toshiki Ikeda
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Satoshi Iihoshi
- Department of Neuroendovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Shinya Kohyama
- Department of Neuroendovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Hiroki Kurita
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
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Darsaut TE, Keough MB, Sagga A, Chan VKY, Diouf A, Boisseau W, Magro E, Kotowski M, Roy D, Weill A, Iancu D, Bojanowski MW, Chaalala C, Bilocq A, Estrade L, Lejeune JP, Bricout N, Scholtes F, Martin D, Otto B, Findlay JM, Chow MM, O'Kelly CJ, Ashforth RA, Rempel JL, Lesiuk H, Sinclair J, Altschul DJ, Arikan F, Guilbert F, Chagnon M, Farzin B, Gevry G, Raymond J. Surgical or Endovascular Management of Middle Cerebral Artery Aneurysms: A Randomized Comparison. World Neurosurg 2021; 149:e521-e534. [PMID: 33556601 DOI: 10.1016/j.wneu.2021.01.142] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 11/24/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 01/07/2023]
Abstract
OBJECTIVE There are few randomized data comparing clipping and coiling for middle cerebral artery (MCA) aneurysms. We analyzed results from patients with MCA aneurysms enrolled in the CURES (Collaborative UnRuptured Endovascular vs. Surgery) and ISAT-2 (International Subarachnoid Aneurysm Trial II) randomized trials. METHODS Both trials are investigator-led parallel-group 1:1 randomized studies. CURES includes patients with 3-mm to 25-mm unruptured intracranial aneurysms (UIAs), and ISAT-2 includes patients with ruptured aneurysms (RA) for whom uncertainty remains after ISAT. The primary outcome measure of CURES is treatment failure: 1) failure to treat the aneurysm, 2) intracranial hemorrhage during follow-up, or 3) residual aneurysm at 1 year. The primary outcome of ISAT-2 is death or dependency (modified Rankin Scale score >2) at 1 year. One-year angiographic outcomes are systematically recorded. RESULTS There were 100 unruptured and 71 ruptured MCA aneurysms. In CURES, 90 patients with UIA have been treated and 10 await treatment. Surgical and endovascular management of unruptured MCA aneurysms led to treatment failure in 3/42 (7%; 95% confidence interval [CI], 0.02-0.19) for clipping and 13/48 (27%; 95% CI, 0.17-0.41) for coiling (P = 0.025). All 71 patients with RA have been treated. In ISAT-2, patients with ruptured MCA aneurysms managed surgically had died or were dependent (modified Rankin Scale score >2) in 7/38 (18%; 95% CI, 0.09-0.33) cases, and 8/33 (24%; 95% CI, 0.13-0.41) for endovascular. One-year imaging results were available in 80 patients with UIA and 62 with RA. Complete aneurysm occlusion was found in 30/40 (75%; 95% CI, 0.60-0.86) patients with UIA allocated clipping, and 14/40 (35%; 95% CI, 0.22-0.50) patients with UIA allocated coiling. Complete aneurysm occlusion was found in 24/34 (71%; 95% CI, 0.54-0.83) patients with RA allocated clipping, and 15/28 (54%; 95% CI, 0.36-0.70) patients with RA allocated coiling. CONCLUSIONS Randomized data from 2 trials show that better efficacy may be obtained with surgical management of patients with MCA aneurysms.
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Affiliation(s)
- Tim E Darsaut
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Michael B Keough
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Abdelaziz Sagga
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Vivien K Y Chan
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Ange Diouf
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - William Boisseau
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Elsa Magro
- Service of Neurosurgery, CHU Cavale Blanche, InsermUMR 1101 LaTIM, Brest, France
| | - Marc Kotowski
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Daniel Roy
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Alain Weill
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Daniela Iancu
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Michel W Bojanowski
- Service of Neurosurgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Chiraz Chaalala
- Service of Neurosurgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Alain Bilocq
- Centre Hospitalier Régional de Trois-Rivières Service of Neurosurgery, Trois-Rivières, Quebec, Canada
| | - Laurent Estrade
- Department of Interventional Neuroradiology, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Jean-Paul Lejeune
- Department of Neurosurgery, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Nicolas Bricout
- Department of Interventional Neuroradiology, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Felix Scholtes
- Department of Neurosurgery, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - Didier Martin
- Department of Neurosurgery, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - Bernard Otto
- Division of Medical Imaging, Department of Medical Physics, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - J Max Findlay
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Michael M Chow
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Cian J O'Kelly
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Robert A Ashforth
- Department of Radiology and Diagnostic Imaging, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Jeremy L Rempel
- Department of Radiology and Diagnostic Imaging, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Howard Lesiuk
- Section of Neurosurgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - John Sinclair
- Section of Neurosurgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - David J Altschul
- Department of Neurological Surgery and Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Fuat Arikan
- Department of Neurosurgery and Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Francois Guilbert
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Miguel Chagnon
- Department of Mathematics and Statistics, Université de Montréal, Montréal, Quebec, Canada
| | - Behzad Farzin
- Interventional Neuroradiology Laboratory, Research Centre, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Guylaine Gevry
- Interventional Neuroradiology Laboratory, Research Centre, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Jean Raymond
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada; Interventional Neuroradiology Laboratory, Research Centre, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
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Preece A, Young S. Caring for Patients with Aneurysmal Subarachnoid Hemorrhage: Nursing Perspectives from the United Kingdom. Crit Care Nurs Clin North Am 2020; 33:47-59. [PMID: 33526198 DOI: 10.1016/j.cnc.2020.10.003] [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] [Indexed: 10/22/2022]
Abstract
The risk of rebleeding is greatest between 2 and 12 hours and is associated with increased risk of mortality and long-term dependent survival. Aneurysms should be secured within 48 hours of diagnosis. However, delays occur because of diagnosis and transfer of patients. Ninety-six hours is the current time it can take until treatment. The challenges for this service continue to be access to and sharing of diagnostic imaging, repatriation back to district general hospitals to continue treatment (eg, for rehabilitation), access to neurorehabilitation, and access to psychological and neurocognitive support.
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Affiliation(s)
- Anne Preece
- Neurosciences Department, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, UK.
| | - Sally Young
- Neurosciences Department, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, UK
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21
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Liang ES, Mahady K, Coulthard A, Winter C. Treatment of a middle cerebral artery aneurysm in the setting of Loeys-Dietz syndrome: Case report and review of literature. Radiol Case Rep 2020; 16:48-50. [PMID: 33163133 PMCID: PMC7607204 DOI: 10.1016/j.radcr.2020.10.012] [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: 09/26/2020] [Accepted: 10/06/2020] [Indexed: 11/30/2022] Open
Abstract
Loeys-Dietz syndrome (LDS) is a connective tissue disorder with associated systemic vasculopathies including intracranial arterial aneurysm formation and dissections. LDS is a relatively less well-known entity compared with other connective tissue disorders, such as Ehlers-Danlos or Marfan syndrome, and consequently experience in the management of the associated intracranial aneurysms is suboptimal. We present a case of surgical clipping of a middle cerebral artery aneurysm in a patient with LDS. A 46-year-old female with LDS (type III) was found to have a right middle cerebral artery (MCA) bifurcation aneurysm following vascular screening. The decision was made to surgically clip the aneurysm after consultation in our neurovascular multidisciplinary team meeting. A standard right pterional craniotomy was performed and the aneurysm was secured with 2 straight Sugita clips. The temporal M2 branch was noted to be thin walled and this prompted application of the second tandem clip, rather than risk re-positioning the initial clip. In our case, the MCA aneurysm neck was robust enough to take a clip without any complications, and therefore we suggest that the presence of LDS is not an absolute contra-indication to perform open craniotomy and clipping.
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Affiliation(s)
- Ee Shern Liang
- Department of Neurosurgery, Royal Brisbane and Women's Hospital, Corner of Butterfield Street and Bowen Bridge Road, Herston, 4029, Queensland, Australia
- Corresponding author.
| | - Kate Mahady
- Department of Interventional Neuroradiology, Royal Brisbane and Women's Hospital, Herston, 4029, Queensland, Australia
- University of Queensland, Herston, 4029, Queensland, Australia
| | - Alan Coulthard
- Department of Interventional Neuroradiology, Royal Brisbane and Women's Hospital, Herston, 4029, Queensland, Australia
- University of Queensland, Herston, 4029, Queensland, Australia
| | - Craig Winter
- Department of Neurosurgery, Royal Brisbane and Women's Hospital, Corner of Butterfield Street and Bowen Bridge Road, Herston, 4029, Queensland, Australia
- University of Queensland, Herston, 4029, Queensland, Australia
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Tian LQ, Fu QX. Recovery of posterior communicating artery aneurysm induced oculomotor nerve palsy: a comparison between surgical clipping and endovascular embolization. BMC Neurol 2020; 20:351. [PMID: 32948136 PMCID: PMC7501645 DOI: 10.1186/s12883-020-01847-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 04/02/2020] [Accepted: 06/28/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Oculomotor nerve palsy (ONP) is a common symptom of posterior communicating artery aneurysm (PcomAA) that can lead to impaired eye movement and pupil dilation. Currently, surgical clipping and endovascular embolization are the two most popular treatment methods for PcomAA-induced ONP; however, the recovery outcome between the two methods remains to be elucidated. METHODS In the present study, we thoroughly compared the pretreatment factors and recovery outcome of the two treatments on 70 patients with PcomAA-induced ONP. The patients were separated into two groups based on the treatment that was received. Pretreatment factors, including age, sex, time period between ONP onset and treatment, ONP type, aneurysm diameter, status of subarachnoid hemorrhage and aneurysm rupture were recorded for each individual patient. Recovery outcome of the patients was assessed over a 12-month period. RESULTS No significant differences were observed in any of the analyzed factors. Importantly, we revealed a significantly higher full recovery rate for the patients receiving the surgical clipping treatment than the ones that received the endovascular embolization treatment. In addition, we showed that patients' age was negatively correlated with the recovery extent in both treatment groups. CONCLUSIONS The outcome of our study suggests that surgical clipping might be a better option to treat PcomAA-induced ONP.
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Affiliation(s)
- Li-Qiang Tian
- Department of Neurosurgery, Linyi People's Hospital, Linyi, 276003, Shandong Province, China
| | - Qing-Xi Fu
- Department of Neurology, Linyi People's Hospital, Linyi, 276003, Shandong Province, China.
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Park JS, Kwon MY, Lee CY. Minipterional craniotomy for surgical clipping of anterior circulation aneurysms: compatibility between the feasibility, safety and efficiency. J Cerebrovasc Endovasc Neurosurg 2020; 22:65-77. [PMID: 32665913 PMCID: PMC7329563 DOI: 10.7461/jcen.2020.22.2.65] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/24/2020] [Accepted: 03/31/2020] [Indexed: 11/23/2022] Open
Abstract
Objective The aim of this study was to assess the feasibility, safety and efficiency of minipterional craniotomy (MPT) for surgical clipping of anterior circulation aneurysms. Methods A retrospective study was conducted to compare the MPT from Jan 2015 to Dec 2018 and conventional pterional craniotomy (CPT) from Jan 2012 to Dec 2013 in unruptured intracranial aneurysms (UIA) and ruptured intracranial aneurysms (RIA). The feasibility and safety of MPT and CPT were assessed by analyzing medical records, radiologic imaging, and clinical outcomes. The efficiency of MPT and CPT were based on a survey research of temporomandibular dysfunction, facial nerve paralysis, and facial asymmetry. Results Total 628 patients who underwent 458 MPT (UIA:313, RIA:145) and 170 CPT (UIA: 106, RIA: 64) with anterior circulation aneurysms were included in this study. The baseline characteristics between MPT and CPT had no difference (p>0.05). There was no difference in the incidence of postoperative hemorrhage or ischemic lesions between MPT and CPT (p>0.05). The incidence of surgical wound infection was lower in MPT (0.4%) than CPT (3.5%) (p=0.002). More than 90% of postoperative pain disappeared faster in MPT (14.25±4.83 days) than CPT (27.59±10.35 days), and the feeling of facial asymmetry in surgical side was also lower for MPT (1.7%) than CPT (7.6%) (p<0.001). In the MPT, no patients presented with progress to chronic pain, masticatory disability, discomfort of maximal mouth opening or permanent facial palsy. Conclusions We suggest that MPT and CPT had similar clinical outcomes, and MPT showed better functional and cosmetic outcomes than CPT in terms of temporomandibular dysfunction, facial nerve paralysis, and facial asymmetry. Therefore, MPT for surgical clipping of anterior circulation aneurysms can be a compatible technique that satisfies the feasibility, safety and efficiency.
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Affiliation(s)
- Jung-Sik Park
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Min-Yong Kwon
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Chang-Young Lee
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
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Kim M, Evins AI, Fukuda H, Kim N, Stieg PE, Bernardo A. Surgical Management of Posterior Communicating Artery Aneurysms in the Presence of a Low-Coursing Internal Carotid Artery and Narrowed Retrocarotid Window. World Neurosurg 2020; 139:558-566. [PMID: 32376373 DOI: 10.1016/j.wneu.2020.04.200] [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: 02/20/2020] [Revised: 04/24/2020] [Accepted: 04/26/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Anatomical variations of the course of the internal carotid artery (ICA) may complicate surgical clipping of posterior communicating artery (PCoA) aneurysms by narrowing the retrocarotid window. We evaluated the efficacy of the periclinoid surgical maneuvers for expanding the retrocarotid window and analyzed computed tomography angiography (CTA) data from patients with PCoA aneurysms to define parameters for low-coursing ICAs. METHODS Using cadaveric specimens, standard pterional craniotomies were fashioned and extradural or intradural periclinoid surgical maneuvers-cutting of the meningo-orbital band, anterior clinoidectomy, and cutting of the distal dural ring (DDR)-were performed, and their relative advantages for expanding the retrocarotid window were assessed. Additionally, preoperative CTA data from 24 patients with PCoA aneurysms used to calculate the angles of the ICA relative to the skull base. RESULTS Periclinoid maneuvers, especially the anterior clinoidectomy, provided additional exposure of the retrocarotid space. Cutting of the DDR allowed for partial mobilization of the ICA and widened the retrocarotid surgical window, enhancing maneuverability. The anterior clinoidectomy with cutting of the DDR allowed for enhanced exposure of the medial, middle, and posterolateral aspects of the retrocarotid space. Cutting the anterior petroclinoid fold and mobilizing cranial nerve III provided wide exposure of the lateral aspect of retrocarotid space. CONCLUSION When clipping PCoA aneurysms in the presence of normal-coursing ICAs (approximately ≥30° ICA angle), a standard pterional craniotomy with anterior clinoidectomy and cutting of the DDR allows for substantial expansion of the retrocarotid window.
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Affiliation(s)
- Michael Kim
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA; Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, NewYork, New York, USA
| | - Alexander I Evins
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, NewYork, New York, USA
| | - Hitoshi Fukuda
- Department of Neurosurgery, Kochi University Hospital, Nankoku, Kochi, Japan
| | - Namhee Kim
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, NewYork, New York, USA
| | - Philip E Stieg
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, NewYork, New York, USA
| | - Antonio Bernardo
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, NewYork, New York, USA.
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Eser Ocak P, Kocaeli H. Micro surgical Clipping of Giant P3 Segment Posterior Cerebral Artery Aneurysm: 2-Dimensional Operative Video. World Neurosurg 2020; 139:148. [PMID: 32311557 DOI: 10.1016/j.wneu.2020.04.035] [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: 01/09/2020] [Revised: 04/05/2020] [Accepted: 04/06/2020] [Indexed: 11/26/2022]
Abstract
Posterior cerebral artery (PCA) aneurysms comprise <2% of all intracranial aneurysms and are usually located on the P1 and P2 segments. Aneurysms of the P3 segment of the PCA are even rarer, and despite their proximity to the cerebral aqueduct, presentation with hydrocephalus is exceptional. This video demonstrates the case of a 28-year-old female patient who presented acute hydrocephalus due to a partially thrombosed, giant P3 segment PCA aneurysm. The patient was operated on in the semisitting position, and a right frontal ventricular drain was placed for brain relaxation. A U-shaped skin incision was made, and a left-sided, 6 cm × 6 cm parietooccipital craniotomy crossing the midline was performed. An interhemispheric approach was used to reach the aneurysm. The aneurysm was trapped via temporary clipping of the inflow and outflow arteries, thrombectomized, and then clipped using a right-angled fenestrated aneurysm clip. Postoperative computed tomography and magnetic resonance imaging revealed resolution of the hydrocephalus, and cerebral angiography confirmed total exclusion of the aneurysm from the circulation and occlusion of the P4 segment of the PCA, which was considered embolic. The patient made an excellent recovery, and she was discharged on postoperative day 3 (Video 1). This case demonstrates the efficacy of microsurgical clipping for a giant thrombotic P3 segment PCA aneurysm that caused a mass effect. Surgery excluded the aneurysm from the circulation and decompressed the cerebral aqueduct, obviating the need for a permanent ventriculoperitoneal shunt.
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Affiliation(s)
- Pinar Eser Ocak
- Department of Neurosurgery, Uludag University School of Medicine, Bursa, Turkey.
| | - Hasan Kocaeli
- Department of Neurosurgery, Uludag University School of Medicine, Bursa, Turkey
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Grasso G, Torregrossa F. Is Aspirin a Worthy Candidate in Preventing Intracranial Aneurysm Rupture? World Neurosurg 2020; 136:169-171. [PMID: 31954195 DOI: 10.1016/j.wneu.2020.01.075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 01/09/2020] [Accepted: 01/10/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Giovanni Grasso
- Neurosurgical Unit, Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy.
| | - Fabio Torregrossa
- Neurosurgical Unit, Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy
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Booth TC, Parra-Farinas C, deSouza RM, Kandasamy N, Bhattacharya J, Rangi P, Downer J. Woven Endobridge (WEB) Device as a Retreatment Strategy After Unsuccessful Surgical Clipping. World Neurosurg 2020; 139:111-120. [PMID: 32179191 DOI: 10.1016/j.wneu.2020.02.101] [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: 01/07/2020] [Revised: 02/16/2020] [Accepted: 02/17/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Surgical clipping of intracranial aneurysms is typically robust and durable. However, residual aneurysmal components may be seen after clipping. Furthermore, there may be occasional aneurysmal recurrence. These factors are both clinically relevant because subarachnoid hemorrhage after clipping is a rare but important event. The rationale for any treatment is to substantially decrease the future risk of hemorrhage. Small series have shown coiling as a retreatment strategy after unsuccessful clipping, but none has explored the feasibility of Woven Endobridge (WEB) implantation. CASE DESCRIPTION We examined the feasibility of WEB implantation as second-line treatment for wide-necked residual aneurysms after unsuccessful clipping. We also recorded the safety and efficacy in this small series of 6 patients. To determine safety, we measured the modified Rankin Scale score before and after the procedure, and at 2 later time points (mean follow-up, 5 months and 15 months). To determine efficacy, we obtained radiographic aneurysm occlusion outcomes (including WEB Occlusion Scale) at these 2 time points. Four middle cerebral artery and 2 anterior communicating artery complex aneurysms were treated with WEB implantation, showing feasibility in 6/6 cases (100%). Follow-up at 15 months showed no change from preprocedural modified Rankin Scale score and there were no other complications. There was adequate occlusion in 5/6 cases (83%). CONCLUSIONS WEB implantation provided a feasible option in this challenging retreatment scenario. This is a small series and prospective data are required to make outcome inferences for this population. Nonetheless, we observed no complications and high adequate occlusion rates.
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Affiliation(s)
- Thomas C Booth
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, United Kingdom; Department of Neuroradiology, King's College Hospital NHS Foundation Trust, London, United Kingdom.
| | | | - Ruth-Mary deSouza
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Naga Kandasamy
- Department of Neuroradiology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Jo Bhattacharya
- Department of Neuroradiology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Prem Rangi
- Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Jonathan Downer
- Department of Neuroradiology, Western General Hospital, Edinburgh, United Kingdom
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Szmuda T, Słoniewski P, Ali S, Dzierżanowski J, Kamieniecki A, Siedlecki K. Can sectioning the posterior communicating artery be predicted with computed tomography angiography in the micro surgical clipping of basilar apex aneurysms? Acta Neurochir (Wien) 2020; 162:567-579. [PMID: 31748903 DOI: 10.1007/s00701-019-04138-2] [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: 08/08/2019] [Accepted: 11/04/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Microsurgical clipping is a viable option for managing high-riding basilar apex aneurysms (BAXs) using a transsylvian approach. Cutting the posterior communicating artery (PCoA) at the perforator-free zone provides sufficient exposure of BAX, although it is not always safe. The aim was to qualitatively predict sectioning of the interfering PCoA by using preoperative computed tomographic angiography (CTA). METHODS A virtual trajectory from the lesser sphenoid wing to the neck of the aneurysm was simulated on CTA in 19 consecutive patients operated on BAX aneurysms from 2013 to 2018. The angles on CTA resembled the typical view through the extended pterional craniotomy. Next, the ipsilateral PCoA was tracked from the internal carotid to its end at the posterior cerebral artery in the trajectory. RESULTS The opticocarotid and carotid-oculomotor window served as the corridors for entering the interpeduncular fossa in 16 patients (84.2%) and in 3 patients (15.8%), respectively. The PCoA was intentionally cut during nine surgeries and preserved in 10 of them. The PCoA was cut more often when positioned toward the cranial base and more medially in the corridor; both the Kernel density analysis and the data points representing the position of the PCoA supported this finding (p < 0.01). The CTA-based position of either ends of the PCoA in the trajectory did not differ between cut and not-cut groups (p = 0.19-0.96). Aneurysm projection, rupture, size, PCoA diameter, length, and other distances on CTA were not related to the sectioning of PCoA (p > 0.05). CONCLUSIONS The probability of PCoA sectioning is higher when the PCoA is positioned medially and closer to the cranial base. If the anatomical course of the PCoA is recognized beforehand, it can contraindicate surgery. Preoperative CTA-based planning facilitates the surgery of BAX aneurysms. Therefore, CTA can make microsurgical clipping planning more predictable for the neurosurgeon and safer for the patient.
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Beeckmans K, Crunelle CL, Van den Bossche J, Dierckx E, Michiels K, Vancoillie P, Hauman H, Sabbe B. Cognitive outcome after surgical clipping versus endovascular coiling in patients with subarachnoid hemorrhage due to ruptured anterior communicating artery aneurysm. Acta Neurol Belg 2020; 120:123-132. [PMID: 31745846 DOI: 10.1007/s13760-019-01245-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 11/07/2019] [Indexed: 10/25/2022]
Abstract
Ruptured anterior communicating artery aneurysms are commonly associated with deficits in memory and executive functions. However, little studies are available on the effect of surgical clipping (SC) and endovascular coiling (EC) on cognitive functioning. This study evaluates cognitive functioning in 35 patients with subarachnoid hemorrhage after ruptured anterior communicating artery aneurysm (ACoA) compared to 20 healthy controls (HC) and assesses the effect of SC (n = 19) compared to EC (n = 16) on cognitive performances. All participants were investigated with an extensive neuropsychological test battery assessing attention, memory and visuospatial and executive functions. The strength of this study is an in-depth investigation of several cognitive domains together and several memory functions together within the auditory-verbal and visuospatial memory domain for unrelated and related information. The ACoA group was significantly more deficient in attention, auditory-verbal and visuospatial memory and executive functions compared to HCs. No significant differences were found between both groups concerning visuospatial functions. Within the patient group, the SC group, as compared to the EC group, showed a significantly worse performance for auditory-verbal and visuospatial memory. No significant differences could be detected between both groups with regard to attention and visuospatial and executive functions. In conclusion, this study provides evidence for the advantage of EC in ACoA patients over SC in terms of cognitive outcome.
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Ikawa F, Michihata N, Akiyama Y, Iihara K, Morita A, Kato Y, Yamaguchi S, Kurisu K, Fushimi K, Yasunaga H. Propensity Score Matching Analysis for the Patients of Unruptured Cerebral Aneurysm from a Post Hoc Analysis of a Nationwide Database in Japan. World Neurosurg 2020; 136:e371-e379. [PMID: 31931237 DOI: 10.1016/j.wneu.2020.01.005] [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: 10/30/2019] [Revised: 12/31/2019] [Accepted: 01/02/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND This study aimed to compare the functional outcome at discharge for unruptured cerebral aneurysms (UCAs) between surgical clipping and endovascular coiling in total, nonelderly (<65 years), and elderly (≥65 years) patients by nonbiased analysis based on a national database in Japan. METHODS A total of 15,671 patients with UCA were registered in the Diagnosis Procedure Combination, the nationwide database, from 2010 to 2015 in Japan. The outcome of the Barthel Index (BI) at discharge was investigated, and propensity score-matched analysis was conducted in total, nonelderly, and elderly patient groups. RESULTS Propensity score-matched analysis found no significant difference for in-hospital mortality between the 2 treatment methods in the total and both age-groups. The rate of morbidity of BI <90 at discharge was higher after surgical clipping than after endovascular coiling in the total (4.9% vs. 3.9%; P = 0.040; risk difference, -1.0%; 95% confidence interval, -3.6 to 2.3%) and the elderly age-group (8.1% vs. 5.0%; P < 0.001; risk difference, -3.1%; -4.8% to 1.5%), however, no significant association between the 2 treatment methods (2.4% vs. 2.6%; P = 0.67; risk difference, 0.22%; -0.79 to 1.22%) was found in the nonelderly group. CONCLUSIONS In elderly patients with UCA, a better outcome at discharge after endovascular coiling was found. However, no significantly different functional outcome at discharge between surgical clipping and endovascular coiling for UCA in nonelderly patients was confirmed by propensity score-matched analysis from a nationwide database in Japan.
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Affiliation(s)
- Fusao Ikawa
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Nobuaki Michihata
- Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Tokyo, Japan
| | - Yasuhiko Akiyama
- Department of Neurosurgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akio Morita
- Department of Neurological Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Yoko Kato
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Japan
| | | | - Kaoru Kurisu
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Tokyo, Japan
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Nisson PL, Meybodi T, Secomb TW, Berger GK, Roe DJ, Lawton MT. Patients Taking Antithrombotic Medications Present Less Frequently with Ruptured Aneurysms. World Neurosurg 2019; 136:e132-e140. [PMID: 31857268 DOI: 10.1016/j.wneu.2019.12.045] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 12/08/2019] [Accepted: 12/09/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Conflicting findings exist on the protective role of aspirin against aneurysmal subarachnoid hemorrhage (SAH). In this retrospective analysis, we compare the risk of SAH at presentation between patients treated microsurgically who were regularly taking an antithrombotic medication versus those who were not. METHODS Consecutive patients with solitary aneurysms treated by the senior author using a microsurgical approach were included from a database of patients treated between January 2010 and April 2013 at a tertiary academic medical center. χ2 and logistic regression analysis were performed, comparing the risk of SAH with antithrombotic use. RESULTS A total of 347 patients were included in the study, 156 (45%) of whom presented with SAH. A total of 63 patients (18%) were taking an antithrombotic medication (aspirin, 53; clopidogrel, 6; both, 4) and 12 (4%) were on anticoagulation medication. Multivariate analysis was conducted using SAH as the primary outcome and included patient age (odds ratio [OR], 0.99), gender (male, OR, 0.65), tobacco use (OR, 1.43), alcohol use (OR, 1.02), coronary artery disease (OR, 1.84), diabetes (OR, 1.03), hypertension (OR 0.91), and posterior circulation location (OR, 1.47). This analysis found that only antithrombotic use (OR, 0.20) was associated with a significantly lower rate of rupture at the time of presentation (P < 0.001). CONCLUSIONS Patients taking an antithrombotic were less likely to present with ruptured aneurysms. No difference was found for those taking anticoagulants. Patient outcomes did not differ between those on an antithrombotic versus those without. A randomized controlled trial is needed to further investigate the application of antithrombotics for preventing SAH.
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Affiliation(s)
- Peyton L Nisson
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA; Department of Neurosurgery, Cedars-Sinai, Los Angeles, California, USA
| | - Tayebi Meybodi
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Timothy W Secomb
- Department of Physiology, College of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Garrett K Berger
- College of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Denise J Roe
- Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA.
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Nussbaum ES, Goddard JK, Lowary J, Robinson JM, Hilton C, Nussbaum LA. Delayed sudden hearing recovery after treatment of a large vertebral artery aneurysm causing hearing loss and imbalance: a case report. Br J Neurosurg 2019; 36:515-519. [PMID: 31793349 DOI: 10.1080/02688697.2019.1698013] [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] [Indexed: 10/25/2022]
Abstract
Purpose: Cerebral aneurysms that compress cranial nerve VIII can cause hearing loss and imbalance. Hearing function that does not recover after aneurysm occlusion can signal neurological damage with the potential for permanent deafness.Case Description: A 72-year-old woman presented with gradually worsening left-sided hearing loss and imbalance over a period of 10 years. She was found to have a lesion of the cerebellopontine angle, which proved to be a large fusiform vertebral artery aneurysm with mass effect on cranial nerve VIII. The patient underwent surgical clip occlusion of the vertebral artery distal to the posterior inferior cerebellar artery and proximal to the aneurysm, which no longer filled on catheter angiography. Postoperatively, the patient experienced delayed complete loss of ipsilateral hearing on the third post-operative day. Otherwise, she made a good recovery with improvement in her balance issues. At that time, we suspected that delayed occlusion of a perforating vessel had probably caused irreversible hearing loss. Ten months later, the patient awoke with significant subjective recovery of her hearing. Audiometry confirmed substantial improvement in her hearing likely due to the aneurysm shrinking away from and decompressing the cranial nerve.Conclusion: This case highlights the continued usefulness of vascular occlusion in the management of selected cases of intracranial aneurysms and also that neurological function may recover suddenly, even in very delayed fashion, following treatment.
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Affiliation(s)
- Eric S Nussbaum
- Department of Neurosurgery, National Brain Aneurysm and Tumor Center, United Hospital, Twin Cities, MN, USA
| | | | - Jodi Lowary
- Department of Neurosurgery, National Brain Aneurysm and Tumor Center, United Hospital, Twin Cities, MN, USA
| | - Jenna M Robinson
- Department of Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - Chris Hilton
- Department of Otolaryngology, Regions Hospital, Saint Paul, MN, USA
| | - Leslie A Nussbaum
- Department of Neurosurgery, National Brain Aneurysm and Tumor Center, United Hospital, Twin Cities, MN, USA
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Klinger DR, Reinard KA, Ajayi OO, Delashaw JB. Micro surgical Clipping of an Anterior Communicating Artery Aneurysm Using a Novel Robotic Visualization Tool in Lieu of the Binocular Operating Microscope: Operative Video. Oper Neurosurg (Hagerstown) 2019; 14:26-28. [PMID: 29253287 DOI: 10.1093/ons/opx081] [Citation(s) in RCA: 13] [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: 08/29/2016] [Accepted: 03/16/2017] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION The binocular operating microscope has been the visualization instrument of choice for microsurgical clipping of intracranial aneurysms for many decades. OBJECTIVE To discuss recent technological advances that have provided novel visualization tools, which may prove to be superior to the binocular operating microscope in many regards. METHODS We present an operative video and our operative experience with the BrightMatterTM Servo System (Synaptive Medical, Toronto, Ontario, Canada) during the microsurgical clipping of an anterior communicating artery aneurysm. To the best of our knowledge, the use of this device for the microsurgical clipping of an intracranial aneurysm has never been described in the literature. RESULTS The BrightMatterTM Servo System (Synaptive Medical) is a surgical exoscope which avoids many of the ergonomic constraints of the binocular operating microscope, but is associated with a steep learning curve. The BrightMatterTM Servo System (Synaptive Medical) is a maneuverable surgical exoscope that is positioned with a directional aiming device and a surgeon-controlled foot pedal. While utilizing this device comes with a steep learning curve typical of any new technology, the BrightMatterTM Servo System (Synaptive Medical) has several advantages over the conventional surgical microscope, which include a relatively unobstructed surgical field, provision of high-definition images, and visualization of difficult angles/trajectories. CONCLUSION This device can easily be utilized as a visualization tool for a variety of cranial and spinal procedures in lieu of the binocular operating microscope. We anticipate that this technology will soon become an integral part of the neurosurgeon's armamentarium.
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Affiliation(s)
- Daniel R Klinger
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, Washington
| | - Kevin A Reinard
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, Washington
| | - Olaide O Ajayi
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, Washington.,Department of Neurosurgery, Loma Linda University Medical Center, Loma Linda, California
| | - Johnny B Delashaw
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, Washington
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Slator N, Talibi SS, Mundil N, Thomas A, Lamin S, Walsh R, Rodrigues D, Solanki GA. Paediatric intracranial aneurysms: a British institutional review. Childs Nerv Syst 2019; 35:1197-205. [PMID: 31089852 DOI: 10.1007/s00381-019-04159-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 04/14/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Paediatric intracranial aneurysms are rare, with a differing natural history and thought to account for only up to 7% of all intracranial aneurysms. There is much uncertainty that surrounds the prevalence of unruptured intracranial aneurysms and it is estimated to be anywhere between 2 and 90 per 1000. This is the largest British single-centre analysis of paediatric intracranial aneurysms. We present the patient course from their initial presentations to the outcome of treatment and evaluate a serial assessment of adequacy of aneurysmal obliteration radiologically. RESULTS Twenty-two paediatric cases were identified that required treatment. The median age of presentation was 11.3 years (mean 9.9, range 0 to 15.9), 68% (15/22) were male and 77% (17/22) were ruptured on presentation. The majority of aneurysms were located at the anterior circulation (77% (17/22)). The overall median aneurysm size (n = 21) was 7.4 mm (mean 5 mm, range 2.5-19 mm). Twenty patients survived the acute phase and 80% (16/20) underwent coil embolisation and the other patients' surgical clipping. The overall outcomes were available for the 20 patients; on discharge, 90% (18/20) had a favourable clinical outcome (GOS score of 3-5). Treatment-specific clinical favourable outcomes were 88% (14/16) for coil embolisation against 100% (4/4) after surgical clipping. Of the two patients that died in the acute phase, one had sickle cell anaemia. Aneurysm aetiology was unknown in all other cases. None of the patients had a family history of aneurysms. CONCLUSION Paediatric intracranial aneurysms while rare should be considered a differential diagnosis of children presenting with unexplained loss of consciousness with or without focal neurological deficit and/or headache. There is a two to one preponderance for males with a larger proportion of aneurysms within the posterior circulation (25%). Coil embolisation is the preferred method of securing a paediatric intracranial aneurysm.
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Ikawa F, Michihata N, Matsushige T, Abiko M, Ishii D, Oshita J, Okazaki T, Sakamoto S, Kurogi R, Iihara K, Nishimura K, Morita A, Fushimi K, Yasunaga H, Kurisu K. In-hospital mortality and poor outcome after surgical clipping and endovascular coiling for aneurysmal subarachnoid hemorrhage using nationwide databases: a systematic review and meta-analysis. Neurosurg Rev 2019; 43:655-667. [PMID: 30941595 DOI: 10.1007/s10143-019-01096-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [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: 01/07/2019] [Revised: 03/12/2019] [Accepted: 03/19/2019] [Indexed: 11/24/2022]
Abstract
There has never been evidence for aneurysmal subarachnoid hemorrhage (aSAH) by endovascular coiling compared to surgical clipping with all grade. The present study and meta-analysis aimed to clarify the in-hospital mortality and poor outcome in the nationwide databases of patients with all grade aSAH between them. The outcome of modified Rankin scale (mRS) at discharge was investigated according to the comprehensive nationwide database in Japan. The propensity score-matched analysis was conducted among patients with aSAH in this database registered between 2010 and 2015. Meta-analysis of studies was conducted based on the nationwide databases published from 2007 to 2018. According to this propensity score-matched analysis, no significant association for poor outcome of mRS > 2 was shown between surgical clipping and endovascular coiling (47.7% vs 48.3%, p = 0.48). However, significantly lower in-hospital mortality was revealed after surgical clipping than endovascular coiling (7.1% vs 12.2%, p < 0.001). Meta-analysis of propensity score-matched analysis in the nationwide database showed no significant association for poor outcome at discharge between them (odds ratio [OR], 1.08; 95% confidence interval [CI], 0.93 to 1.26; p = 0.31). Meta-analysis of propensity score-matched analysis for in-hospital mortality was lower after surgical clipping than after endovascular coiling, however, without significant difference (OR, 0.74; 95% CI, 0.52 to 1.04; p = 0.08). Further prospective randomized controlled study with all grade aSAH should be necessary to validate the in-hospital mortality and poor outcome.
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Affiliation(s)
- Fusao Ikawa
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Nobuaki Michihata
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Toshinori Matsushige
- Department of Neurosurgery and Interventional Neuroradiology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Masaru Abiko
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Daizo Ishii
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Jumpei Oshita
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Takahito Okazaki
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Shigeyuki Sakamoto
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Ryota Kurogi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Centre, Suita, Osaka, Japan
| | - Akio Morita
- Department of Neurological Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kaoru Kurisu
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
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Kotowski M, Farzin B, Fahed R, Guilbert F, Chagnon M, Darsaut TE, Daniel RT, Raymond J. Residual Cerebral Aneurysms After Micro surgical Clipping: A New Scale, an Agreement Study, and a Systematic Review of the Literature. World Neurosurg 2018; 121:e302-e321. [PMID: 30261387 DOI: 10.1016/j.wneu.2018.09.100] [Citation(s) in RCA: 7] [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: 08/01/2018] [Revised: 09/10/2018] [Accepted: 09/12/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The surgical repair of a cerebral aneurysm does not always lead to complete occlusion. A standardized repeatable method of reporting results of surgical clipping is desirable. Our purpose was to systematically review methods of classifying aneurysm remnants, provide a new scale with precise definitions of categories, and perform an agreement study to assess the variability in adjudicating remnants after aneurysm clipping. METHODS A systematic review was performed to identify ways to report angiographic results of surgical clipping between 1963 and 2017. Postclipping angiographic results of 43 patients were also independently evaluated by 10 raters of various experience and backgrounds using a new 4-category scale. Agreement between responses were analyzed using κ statistics. RESULTS The systematic review yielded 63 articles with 37 different nomenclatures using 2-6 categories. The reliability of judging the presence of an aneurysm remnant on catheter angiography was studied only twice, with only 2 raters each time, with contradictory results. Interobserver agreement using the new 4-category scale was moderate (κ = 0.52; 95% confidence interval, 0.43-0.62) for all observers, but improved to substantial (κ = 0.62; 95% confidence interval, 0.47-0.76) when results were dichotomized (grade 0/1 vs. 2/3). CONCLUSIONS Various classification schemes to evaluate angiographic results after surgical clipping exist in the literature, but they lack standardization. Adjudication using fewer, better defined categories may yield more reliable agreement.
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Affiliation(s)
- Marc Kotowski
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada; Faculty of Biology and Medicine, Université de Lausanne, Lausanne, Switzerland
| | - Behzad Farzin
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Robert Fahed
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada; Interventional Neuroradiology Unit, Fondati Rothschild Hospital, Paris, France
| | - François Guilbert
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Miguel Chagnon
- Department of Mathematics and Statistics, Université de Montréal, Montreal, Quebec, Canada
| | - Tim E Darsaut
- University of Alberta Hospital, Mackenzie Health Sciences Centre, Division of Neurosurgery, Department of Surgery, Edmonton, Canada
| | - Roy T Daniel
- Faculty of Biology and Medicine, Université de Lausanne, Lausanne, Switzerland; Department of Clinical Neurosciences, Neurosurgery Unit, Centre hospitalier universitaire vaudois (CHUV), Lausanne, Switzerland
| | - Jean Raymond
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
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Song Z, Qiu HC, Wang K, Liu AF, Zhou J, Chen XL, Zhao YL, Jiang WJ. [Analysis of the therapeutic effect of stent-assisted embolization and surgical clipping for the treatment of middle cerebral artery bifurcation aneurysms]. Zhonghua Yi Xue Za Zhi 2018; 98:2505-8. [PMID: 30139004 DOI: 10.3760/cma.j.issn.0376-2491.2018.31.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: To compare the clinical effects of stent-assisted embolization and surgical clipping in the treatment of middle cerebral artery bifurcation wide-necked aneurysms. Methods: From July 2014 to March 2017, the clinical and imaging data of 45 patients with Hunt-Hess 0-Ⅲ grade middle cerebral artery bifurcation wide-necked aneurysms were divided into stent-assisted embolization group (20 patients from PLA Rocktet Army Hospital) and surgical clipping group (25 patients from Peking University International Hospital). The total occlusion rates of aneurysm, operation-related adverse events, clinical outcomes, and results of follow-up imaging from the two groups were compared. Results: The total occlusion rates in the stent-assisted embolization group and surgical clipping group were 90.0% (18/20) and 92.0% (23/25), respectively, and the difference was not statistically significant (P=0.815). The favorable six-month postoperative outcomes defined as the modified Rankin Scale ≤2 were 94.7% (18/19) in the stent-assisted embolization group and 91.3% (21/23) in the surgical clipping group (P=0.667). Fewer patients experienced the operation-related adverse events in the stent-assisted embolization group (15.0%, 3/20), as compared to that of the surgical clipping group (24.0%, 6/25), but the difference were not significant (P=0.453). After 2-24 months (median 7 months) of the operation, the follow-up imaging indicated that in the stent-assisted embolization group, 2 out of the 19 patients had residual or recurrent aneurysms.While in the surgical clipping group, residual or recurrent aneurysms were identified in 2 out of the 23 patients 2-14 months (median 3 months) after the surgery; the frequency was not statistically different between the two groups (P=0.841). Conclusion: Stent assisted embolization is a safe and effective treatment for the low grade middle cerebral artery bifurcation wide-necked aneurysms.
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Xin C, Li Z, Zhang J, Xiong Z, Wu X, Zhao S, Cai M, Zhao W, Chen J. Combined Surgical and Endovascular Treatment of a Complex Posterior Communicating Artery Aneurysm at One-Stage in a Hybrid Operating Room. World Neurosurg 2018; 116:383-386. [PMID: 29763749 DOI: 10.1016/j.wneu.2018.05.033] [Citation(s) in RCA: 4] [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: 03/11/2018] [Revised: 05/03/2018] [Accepted: 05/04/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Although clipping and coiling of intracranial aneurysms are effective treatment options, they each have limitations. With the advent of the hybrid operating room, combined clipping and coiling for complex aneurysms in one stage becomes feasible. We report a successful case of a left posterior communicating artery aneurysm where combined clipping and endovascular treatment were applied. CASE DESCRIPTION A 57-year-old man had been complaining of severe headache for 10 days. The computed tomography scan from a previous hospital revealed a parasellar lesion, and the computed tomography angiography in our hospital showed a 16-mm posterior communicating artery aneurysm. Clipping of the aneurysm was scheduled in our hybrid operating room, which enabled intervention of intraoperative digital subtraction angiography (DSA). However, once the aneurysm was clipped, intraoperative DSA revealed that the aneurysm was remnant. We readjusted the clip and reran DSA, but the residual neck was still present. In an effort to preserve the parent artery and perforators, we decided to perform endovascular treatment. Coiling was achieved, followed by angiography, indicating that the aneurysm was almost eliminated. Overall, the patient underwent 4 angiographic explorations during surgery. CONCLUSIONS Combined open surgical and endovascular approaches to treat complex cerebral aneurysms in an hybrid operating room could offer an alternative when the aneurysms appear unclipped or remnant intraoperatively. In our experience, simultaneous clipping and coiling is a safe and effective procedure for efficient treatment of aneurysms.
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Affiliation(s)
- Can Xin
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, People's Republic of China
| | - Zhengwei Li
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, People's Republic of China
| | - Jianjian Zhang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, People's Republic of China
| | - Zhongwei Xiong
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, People's Republic of China
| | - Xiaolin Wu
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, People's Republic of China
| | - Shiyu Zhao
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, People's Republic of China
| | - Mingjun Cai
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, People's Republic of China
| | - Wenyuan Zhao
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, People's Republic of China
| | - Jincao Chen
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, People's Republic of China.
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Rahmanian A, Ghaffarpasand F, Alibai E, Choque-Velasquez J, Jahromi BR, Hernesniemi J. Surgical Outcome of Very Small Intracranial Aneurysms Utilizing the Double Clip Technique. World Neurosurg 2017; 110:e605-e611. [PMID: 29162525 DOI: 10.1016/j.wneu.2017.11.060] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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: 08/18/2017] [Revised: 11/10/2017] [Accepted: 11/11/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To report the outcome of patients with very small intracranial aneurysm (VSIA) undergoing surgical clipping using a double-clip technique. METHODS This cross-sectional study was conducted in Namazi Hospital, the main referral neurovascular center in Southern Iran during a 6-year period from September 2010 to March 2016. All patients with VSIAs (≤3 mm) undergoing surgery with double-clip technique were included. This technique reduces the clip slippage. The short- and long-term outcomes determined by Glasgow outcome score (GOS), modified Rankin Scale (MRS), and complications. RESULTS Operations were performed on 32 VSIAs in 26 patients with a mean ± SD age of 55.7 ± 10.1 years. Middle cerebral artery was the most common location for VSIA (50.0%). There was no neck remnant, and the complete occlusion rate was 100%. The rate of intraoperative aneurysm rupture was 30.8%, and none of the patients experienced rebleeding. The 6-month mortality rate was 0% in ruptured VSIAs and 6.25% in unruptured VSIAs. Most of the patients had favorable outcomes (88.5%), and the overall mortality rate was 11.5%. The rate of permanent neurologic deficit was 10.0% in ruptured and 12.5% in unruptured VSIAs. Multivariate logistic regression analysis revealed no association between baseline and clinical characteristics and outcome in this series. CONCLUSION VSIAs are difficult to treat because of their small sizes; therefore, with a double-clip technique, one can reduce complications related to the treatment of small aneurysms.
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Affiliation(s)
| | | | - Ehsanali Alibai
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Joham Choque-Velasquez
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Behnam Rezai Jahromi
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Juha Hernesniemi
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Ito Y, Yamamoto T, Ikeda G, Tsuruta W, Uemura K, Komatsu Y, Matsumura A. Early retreatment after surgical clipping of ruptured intracranial aneurysms. Acta Neurochir (Wien) 2017. [PMID: 28646464 DOI: 10.1007/s00701-017-3245-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Although a rerupture after surgical clipping of ruptured intracranial aneurysms is rare, it is associated with high morbidity and mortality. The causes for retreatment and rupture after surgical clipping are not clearly defined. METHODS From a prospectively maintained database of 244 patients who had undergone surgical clipping of ruptured intracranial aneurysms, we selected patients who experienced retreatment or rerupture within 30 days after surgical clipping. Aneurysm occlusions were examined by microvascular Doppler ultrasonography and indocyanine green video-angiography. Indications for retreatment included rerupture and partial occlusion. We analyzed the characteristics and causes of early retreatment. RESULTS Six patients (2.5%, 95% CI 0.9 to 5.3%) were retreated within 30 days after surgical clipping, including two patients (0.8%, 95% CI 0.1 to 2.9%) who experienced a rerupture. The retreated aneurysms were found in the anterior communicating artery (AcomA) (n = 5) and basilar artery (n = 1). Retreatment of the AcomA (7.5%) was performed significantly more frequently than that of other arteries (0.56%) (p < 0.01). A laterally projected AcomA aneurysm (17.4%) was more frequently retreated than were other aneurysm types (2.3%). Cases of laterally projecting AcomA aneurysms tended to result from an incomplete clip placed using a pterional approach from the opposite side of the aneurysm projection. CONCLUSIONS Despite developments, the rates of retreatment and rerupture after surgical clipping remain similar to those reported previously. Retreatment of the AcomA was significantly more frequent than was retreatment of other arteries. Patients underwent retreatment more frequently when they were originally treated for lateral type aneurysms using a pterional approach from the opposite side of the aneurysm projection. The treatment method and evaluation modalities should be considered carefully for AcomA aneurysms in particular.
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Kim JH, Kim CH, Lee CY. Efficacy of Arachnoid-Plasty on Chronic Subdural Hematoma Following Surgical Clipping of Unruptured Intracranial Aneurysms. World Neurosurg 2017; 104:303-310. [PMID: 28479524 DOI: 10.1016/j.wneu.2017.04.162] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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: 01/30/2017] [Revised: 04/25/2017] [Accepted: 04/26/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND We aimed to elucidate the effects of arachnoid plasty (ARP) on chronic subdural hematoma (CSDH) occurrence following clipping surgery. METHODS In total 217 patients (ARP, n = 97; non-ARP, n = 120) who had undergone unruptured intracranial aneurysm (UIA) surgical clipping via the pterional approach were retrospectively assessed. Predisposing factors for CSDH development following the surgery were investigated. Thickness and volume of the subdural fluid collection (SDFC) were measured to determine whether ARP affects postoperative SDFC. RESULTS The occurrence of postoperative CSDH was higher in patients without ARP compared to those with ARP (12.5 vs. 3.1%; P = 0.01). In multivariate analyses, having an SDFC volume ≥15 mL on postoperative day (POD) 8, (odds ratio [OR] = 15.113; range = 3.159-72.290), and male sex (OR = 4.274; range = 1.291-14.148) were identified as independent predictive factors. Having had ARP (OR = 0.228; range = 0.056-0.927) was, as an independent variable, negatively correlated with the occurrence of CSDH (P < 0.05). Moreover, SDFC volume ≥15 ml on POD 8 was significantly less common in the ARP group compared with the non-ARP group (P = 0.03). CONCLUSION Patients who underwent ARPs developed fewer CSDHs following UIA clipping surgery. The factors that predicted the development of CSDH included male sex, SDFC volume on POD 8, and ARP. In addition, the ARP patients had lower SDFC volumes (<15 mL). These findings suggested that ARP reduced the incidence of CSDHs after surgical clippings in patients with unruptured aneurysms.
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Affiliation(s)
- Jae-Hyun Kim
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Chang-Hyun Kim
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Chang-Young Lee
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea.
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La Pira B, Brinjikji W, Burrows AM, Cloft HJ, Vine RL, Lanzino G. Unruptured internal carotid artery bifurcation aneurysms: general features and overall results after modern treatment. Acta Neurochir (Wien) 2016; 158:2053-2059. [PMID: 27644699 DOI: 10.1007/s00701-016-2958-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [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: 06/22/2016] [Accepted: 09/05/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Internal carotid artery bifurcation aneurysms (ICAbifAs) present unique challenges to endovascular and surgical operators, and little is known about their natural history. We reviewed our institution's experience with ICAbifAs studying outcomes of surgical and endovascular management and natural history. METHODS Consecutive patients with unruptured ICAbifAs evaluated and/or treated over an 8-year interval were studied. Baseline demographics, neurovascular risk factors, aneurysm location and size, clinical presentation, treatment recommendations, and outcomes were prospectively collected and retrospectively analyzed. Continuous variables were compared with Student's t test and categorical variables with Chi-square tests. RESULTS Fifty-nine patients with 61 unruptured ICAbifAs were included. Seven aneurysms were treated surgically (11.5 %), 22 underwent endovascular treatment (36 %), and 32 were managed conservatively (52.5 %). In the surgical group, short- and long-term complete aneurysm occlusion rates were 100 % with no cases of perioperative or long-term permanent morbidity or treatment-related mortality. In the endovascular group, two patients (11.7 %) with giant aneurysms had perioperative thromboembolic events with transient morbidity. There was one case of aneurysm rupture at follow-up in a giant aneurysm treated with partial coil embolization. Complete/near-complete occlusion rates were 63 %. There was one case of aneurysm rupture after 114 aneurysm-years of follow-up in the conservative management group (0.89 %/year), but no ruptures were observed in small aneurysms selected for conservative management. CONCLUSIONS Unruptured small ICAbifAs have a benign natural history. In patients selected for treatment, excellent results can be achieved in the vast majority of patients with judicious use of endovascular and surgical therapy.
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Affiliation(s)
- Biagia La Pira
- Department of Neurologic Surgery, Mayo Medical School, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Medical School, Mayo Clinic, Rochester, MN, USA
| | - Anthony M Burrows
- Department of Neurologic Surgery, Mayo Medical School, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Harry J Cloft
- Department of Neurologic Surgery, Mayo Medical School, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
- Department of Radiology, Mayo Medical School, Mayo Clinic, Rochester, MN, USA
| | - Roanna L Vine
- Department of Radiology, Mayo Medical School, Mayo Clinic, Rochester, MN, USA
| | - Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Medical School, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
- Department of Radiology, Mayo Medical School, Mayo Clinic, Rochester, MN, USA.
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Kwon MY, Kim CH, Lee CY. Predicting Factors of Chronic Subdural Hematoma Following Surgical Clipping in Unruptured and Ruptured Intracranial Aneurysm. J Korean Neurosurg Soc 2016; 59:458-65. [PMID: 27651863 PMCID: PMC5028605 DOI: 10.3340/jkns.2016.59.5.458] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 03/09/2016] [Accepted: 06/08/2016] [Indexed: 11/27/2022] Open
Abstract
Objective The aim of this study is to analyze the differences in the incidence, predicting factors, and clinical course of chronic subdural hematoma (CSDH) following surgical clipping between unruptured (UIA) and ruptured intracranial aneurysm (RIA). Methods We conducted a retrospective analysis of 752 patients (UIA : 368 and RIA : 384) who underwent surgical clipping during 8 years. The incidence and predicting factors of CSDH development in the UIA and RIA were compared according to medical records and radiological data. Results The incidence of postoperative CSDH was higher in the UIA (10.9%) than in the RIA (3.1%) (p=0.000). In multivariate analysis, a high Hounsfield (HF) unit (blood clots) for subdural fluid collection (SFC), persistence of SFC ≥5 mm and male sex in the UIA and A high HF unit for SFC and SFC ≥5 mm without progression to hydrocephalus in the RIA were identified as the independent predicting factors for CSDH development (p<0.05). Conclusion There were differences in the incidence and predicting factors for CSDH following surgical clipping between UIA and RIA. Blood clots in the subdural space and persistence of SFC ≥5 mm were predicting factors in both UIA and RIA. However, progression to hydrocephalus may have in part contributed to low CSDH development in the RIA. We suggest that cleaning of blood clots in the subdural space and efforts to minimize SFC ≥5 mm at the end of surgery is helpful to prevent CSDH following aneurysmal clipping.
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Affiliation(s)
- Min-Yong Kwon
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Chang-Hyun Kim
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Chang-Young Lee
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
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Goto Y, Oshino S, Nishino A, Fujinaka T, Nakamura H, Yuguchi T, Mori S, Yoshimine T, Saitoh Y. Pituitary dysfunction after aneurysmal subarachnoid hemorrhage in Japanese patients. J Clin Neurosci 2016; 34:198-201. [PMID: 27492047 DOI: 10.1016/j.jocn.2016.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 07/06/2016] [Accepted: 07/10/2016] [Indexed: 11/20/2022]
Abstract
To elucidate the pituitary function of Japanese patients after aneurysmal subarachnoid hemorrhage (aSAH) and implicative factors related to growth hormone deficiency (GHD) after aSAH. We evaluated basal pituitary hormone levels among 59 consecutive aSAH patients with a modified Rankin Scale (mRS) ⩽4 at 3months after aSAH onset. Patients with low insulin-like growth factor 1 (IGF-1) SD score (SDS) or who seemed to develop pituitary dysfunction underwent provocative endocrine testing during a period of 3-36months after SAH onset. The relationship between IGF-1 SDS and clinical factors of the patients such as severity of SAH, aneurysm location, and treatment modalities, were assessed. Six patients (10.2%) demonstrated their IGF-1 SDS less than -2. Multiple logistic regression analyses revealed that patients who underwent surgical clipping had a significantly lower IGF-1 SDS (<-1SD) than patients who underwent endovascular embolization with an odds ratio of 5.83 (p=0.032). Thirty-three patients took provocative tests and five (15.6%) patients were identified as having GHD. The mean IGF-1 SDS of these five GHD patients was 0.08 SD. The aneurysms in all GHD patients were located in internal carotid artery (ICA) or anterior cerebral artery (ACA). To the best of our knowledge, this is the first report describing the prevalence of GHD in Japanese patients after aSAH, and it was not as high as that of previous European studies. We recommend that screening pituitary dysfunction for aSAH survivors with their aneurysms located in ICA or ACA.
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Hosainey SA, Meling TR. A 54-year-old man with 12 intracranial aneurysms and familial subarachnoid hemorrhage: case report. Neurosurg Rev 2016; 39:711-6. [PMID: 27452953 DOI: 10.1007/s10143-016-0769-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 07/01/2016] [Accepted: 07/13/2016] [Indexed: 10/21/2022]
Abstract
Unruptured intracranial aneurysms occur in 1-3 % of the general population, and the risk of rupture is generally considered to be low. However, patients with multiple aneurysms and familial predisposition carry a particular risk of subarachnoid hemorrhage (SAH). A 54-year-old hypertensive man underwent screening with a head CT angiography (CTA) because of his comorbidities. CTA revealed multiple bilateral aneurysms around the circle of Willis. At first surgery, seven aneurysms were clipped (BA, ACOM, ICA ×2, and MCA ×3), two of which were detected intraoperatively only. During the second surgery, another three aneurysms were surgically clipped (PCOM and MCA ×2), one of which was detected intraoperatively. Follow-up angiography revealed another two aneurysms. A PCOM aneurysm was treated by coil embolization and a VA aneurysm clipped surgically during a third admission. The patient made an uneventful recovery. However, 4 months after his second surgery, his daughter underwent surgical clipping of a right-sided ICA aneurysm. This case report highlights both the importance of screening of high risk patients with family history of SAH, as well as its limitations, as our patient developed two de novo aneurysms during 6-month follow-up and CTA preoperatively missed three small aneurysms.
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Jang JH, Song KS, Bang JS, Oh CW, Kwon OK, Chung YS. What Should Be Considered to Cause the Early Post-Craniotomy Seizure: Antibiotics (Cefazolin) Irrigation. J Korean Neurosurg Soc 2015; 58:462-6. [PMID: 26713147 PMCID: PMC4688316 DOI: 10.3340/jkns.2015.58.5.462] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 08/19/2015] [Accepted: 08/20/2015] [Indexed: 11/27/2022] Open
Abstract
Objective Post-craniotomy seizure (PCS) is reported only rarely. However, our department noted a 433% increase in PCS for a year beginning September 2010, especially after cerebrovascular surgery. Our goal was to identify the cause of our unusual outbreak of PCS. Methods For almost one year after September 2010, cases of PCS increased significantly in our department. We analyzed 973 patients who had received a major craniotomy between January 2009 and November 2011. We included seizures that occurred only in the first 24 postoperative hours, which we defined as early PCS. After verifying the presence of PCS, we analyzed multiple seizure-provoking factors and their relation to the duration and character of seizure activity. Results Overall PCS incidence was 7.2% (70/973). Cefazolin (2 g/L saline) was the antibiotic drug used for intraoperative irrigation in 88.4% of the operations, and no PCS occurred without intraoperative cefazolin irrigation. When analyzed by operation type, clipping surgery for unruptured aneurysms was the most frequently associated with PCS (80%). Using logistic regression, only 2 g cefazolin intraoperative irrigation (p=0.024) and unruptured aneurysm clipping surgery (p<0.001) were associated with early PCS. The seizure rate of unruptured aneurysm clipping surgery using 2 g cefazolin intraoperative irrigation was 32.9%. Conclusion Intraoperative cefazolin irrigation must be avoided in patients undergoing craniotomy, especially for clipping of unruptured aneurysms, because of the increased risk of early PCS.
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Affiliation(s)
- Ji Hwan Jang
- Department of Neurosurgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Kyung Sun Song
- Department of Neurosurgery, Neurovascular Center of New Korea Hospital, Gimpo, Korea
| | - Jae Seung Bang
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - O-Ki Kwon
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young Seob Chung
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Boramae Hospital, Seoul, Korea
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Broggi M, Acerbi F, Ferroli P. Technical Advances in Aneurysm Surgery: Continuous Evolution and Patient Selection Are the Key for Better Outcomes. World Neurosurg 2015; 86:56-8. [PMID: 26428328 DOI: 10.1016/j.wneu.2015.09.066] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 09/19/2015] [Indexed: 11/18/2022]
Affiliation(s)
- Morgan Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy.
| | - Francesco Acerbi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Paolo Ferroli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
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Di Santo M, Vaz G, Doquier MA, Raftopoulos C. Evaluation of a clip-reinforced wrapping technique with collagen-impregnated Dacron for intracranial aneurysms inaccessible to other treatment. Clin Neurol Neurosurg 2015; 138:151-6. [PMID: 26342209 DOI: 10.1016/j.clineuro.2015.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 02/19/2015] [Revised: 06/08/2015] [Accepted: 07/05/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To describe our clip-reinforced wrapping technique (CRW) with collagen-impregnated Dacron and report our experience in intracranial aneurysms (IA) untreatable by coil embolization (CE) or surgical clipping (SC). METHODS Between July 2003 and November 2010, CRW was performed on 20 IAs in 18 patients using a collagen-impregnated Dacron fabric (Hemashield(®), USA) fixed with a clip around the parent vessel and the IA. RESULTS Two patients (11%) died of complications from their subarachnoid hemorrhage and preexisting conditions. In the remaining 16 patients, after an average follow-up of 45 months (min: 27, max: 77), 16 (89%) out of the 18 treated aneurysms were no longer visible and two were reduced and stable. CONCLUSION Our preliminary results suggest that CRW with Hemashield could be an accurate and safe alternative technique for some IA without any other treatment option. IMPLICATIONS Description of an alternative surgical technique for otherwise untreatable intracranial aneurysms.
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Affiliation(s)
- M Di Santo
- Department of Neurosurgery, University Hospital St-Luc, Université catholique de Louvain, Avenue Hippocrate 10, 1200 Brussels, Belgium.
| | - G Vaz
- Department of Neurosurgery, University Hospital St-Luc, Université catholique de Louvain, Avenue Hippocrate 10, 1200 Brussels, Belgium.
| | - M-A Doquier
- Department of Neuroanesthesia, UCL, University Hospital St-Luc, Université catholique de Louvain, Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - C Raftopoulos
- Department of Neurosurgery, University Hospital St-Luc, Université catholique de Louvain, Avenue Hippocrate 10, 1200 Brussels, Belgium.
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Park S, Yang N, Seo E. The effectiveness of lumbar cerebrospinal fluid drainage to reduce the cerebral vasospasm after surgical clipping for aneurysmal subarachnoid hemorrhage. J Korean Neurosurg Soc 2015; 57:167-73. [PMID: 25810855 PMCID: PMC4373044 DOI: 10.3340/jkns.2015.57.3.167] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [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: 07/13/2014] [Revised: 07/21/2014] [Accepted: 12/15/2014] [Indexed: 11/28/2022] Open
Abstract
Objective Removal of blood from subarachnoid space with a lumbar drainage (LD) may decrease development of cerebral vasospasm. We evaluated the effectiveness of a LD for a clinical vasospasm and outcomes after clipping of aneurysmal subarachnoid hemorrhage (SAH). Methods Between July 2008 and July 2013, 234 patients were included in this study. The LD group consisted of 126 patients, 108 patients in the non LD group. We investigated outcomes as follow : 1) clinical vasospasm, 2) angioplasty, 3) cerebral infarction, 4) Glasgow outcome scale (GOS) score at discharge, 5) GOS score at 6-month follow-up, and 6) mortality. Results Clinical vasospasm occurred in 19% of the LD group and 42% of the non LD group (p<0.001). Angioplasty was performed in 17% of the LD group and 38% of the non LD group (p=0.001). Cerebral infarctions were detected in 29% and 54% of each group respectively (p<0.001). The proportion of GOS score 5 at 6 month follow-up in the LD group was 69%, and it was 58% in the non LD group (p=0.001). Mortality rate showed 5% and 10% in each group respectively. But, there was no difference in shunt between the two groups. Conclusion LD after aneurysmal SAH shows marked reduction of clinical vasospasm and need for angioplasty. With this technique we have shown favorable GOS score at 6 month follow-up.
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Affiliation(s)
- Soojeong Park
- Department of Neurosurgery, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Narae Yang
- Department of Neurosurgery, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Euikyo Seo
- Department of Neurosurgery, School of Medicine, Ewha Womans University, Seoul, Korea
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Zali A, Khoshnood RJ, Zarghi A. De novo aneurysms in long-term follow-up computed tomographic angiography of patients with clipped intracranial aneurysms. World Neurosurg 2013; 82:722-5. [PMID: 23827320 DOI: 10.1016/j.wneu.2013.06.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [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: 09/15/2012] [Revised: 01/20/2013] [Accepted: 06/25/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE This study was undertaken to evaluate de novo aneurysm formation in the long-term follow-up of patients with clipped aneurysms. METHODS Of 459 patients who underwent clipping of ruptured cerebral aneurysms at our institution between 1997 and 2008, 119 patients were available in good condition and agreed to undergo 64-detector row computed tomographic (CT) angiography. In addition, eight patients underwent CT angiography for new subarachnoid hemorrhage. RESULTS The mean ± standard deviation interval from surgery was 7.2 ± 2.3 years for CT angiography controlled patients. De novo aneurysms were detected in 5 of 119 (4.5%) patients and 4 of 8 patients with new subarachnoid hemorrhage. A history of multiple aneurysms was associated with de novo aneurysm formation (P < 0.001). CONCLUSION The risk of de novo aneurysm formation in patients with clipped aneurysms is significant in long-term follow-up. CT angiography can be used as a noninvasive method for detection of de novo aneurysms in these patients.
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Affiliation(s)
- Alireza Zali
- Department of Neurosurgery, Functional Neurosurgery Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Reza Jalili Khoshnood
- Department of Neurosurgery, Functional Neurosurgery Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Afsaneh Zarghi
- Department of Neuroscience, Functional Neurosurgery Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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