Does age affects the surgical outcome in patients with unruptured cerebral aneurysms? A 2-year retrospective study from a single center in Japan

Background:

The management of unruptured cerebral aneurysms (UCA) in elderly population is a challenge. With a very high life expectancy and high risk of rupture in Japan, the need for identifying the best treatment modality is essential to help the patients in decision-making.

Methods:

This was a 2-year single-center retrospective comparative analysis of the outcomes of surgical clipping (SC) in patients aged above 75 and <75 years. The modified Rankin score was used to stratify the patients and to analyze the functional outcome. Functional status at discharge was the primary end point.

Results:

There were 224 patients with 239 aneurysms. About 12.5% of the patients were more than 75 years with a mean age of 77.85. The mean age of patients <75 years was 60.96, and it was statistically significant. The overall male-to-female ratio was 1:3.3. The most common location was the middle cerebral artery followed by internal carotid artery at the posterior communicating and ophthalmic segments, and 22 patients had aneurysms of the posterior circulation. Nearly 77% of the aneurysms were <6 mm. There was no significant difference in size of the aneurysm as the age increased to more than 75 years. There were complications in 6 patients, and there was no mortality in the study population. There was no statistically significant difference in the outcome between the groups.

Conclusions:

SC can be considered a safe option for UCA in the aging population.

Multimodality Techniques in Microsurgical Clipping as the Gold Standard Treatment in the Management of Basilar Tip Aneurysm: A Case Series

Introduction:

Basilar aneurysms represent 5%–7% of all intracranial aneurysms. The main goal of open surgery is to achieve complete obliteration of the aneurysmal sac using minimal invasive technique while emphasizing on avoidance of complication.

Materials and Methods:

We performed a retrospective cohort study of nine cases of unruptured basilar tip aneurysm referred to the Fujita Health University Banbuntane-Hotokukai Hospital, Japan. The objective of the study was to analyze the surgical outcomes of unruptured basilar tip aneurysm.

Results:

Nine patients with unruptured basilar tip aneurysm were referred to our hospital between 2015 and 2017. The median size of the aneurysm and age were 4.00 mm (interquartile range [IQR] = 3.25–6.75 mm) and 58 years (IQR = 54–70 years), respectively. Five patients (55.6%) were presented with multiple intracranial aneurysms. Surgical adjuncts such as intraoperative neuromonitoring, intraoperative indocyanine green (ICG) angiography with dual-image videoangiography (DIVA), and neuroendoscope were used. Two patients developed transient postoperative oculomotor nerve palsy which resolved spontaneously. The median duration of surgery and days of hospitalization were 292 min (IQR = 237.5–350.5 min) and 12 days (IQR = 12–25 days), respectively. There was no mortality recorded in this case series.

Conclusion:

Microsurgical clipping of basilar tip aneurysm is safe in unruptured basilar tip aneurysm with a low risk of postoperative mortality or morbidity. All complications reported in this case series were transient with no long-term sequalae. The improved safety profile of microsurgical technique is due to the availability of intraoperative neuromonitoring, neuroendoscope, ICG, and DIVA. The application of multimodality technique in neurovascular surgery has also helped to achieve complication avoidance. The obliteration of the aneurysmal sac helps to restore the laminar blood flow in the bifurcation and distal blood vessels and improves the brain perfusion.

Adenosine-induced Flow Arrest to Facilitate Intracranial Complex Aneurysm Clip Ligation: Review of the Literature

Complex intracranial aneurysms (CIAs) rank high among the most technically demanding neurosurgical pathologies. Microsurgery and clip ligation can be challenging in CIAs as circumferential visualization of the aneurysm, parent vessels, branches, perforators, and other neurovascular structures is important to prevent residual aneurysms or strokes from vessel or perforator occlusion. Decompression of the aneurysm sac is often required for CIAs. We reviewed the literature and PubMed advanced search showed 13 results of adenosine-induced flow arrest to facilitate intracranial complex aneurysm clip ligation which included three independent case reports and ten cases in a case series from 1999 to May 2016. Few case series have described the use of adenosine in intracranial aneurysm surgery. Satisfactory aneurysm decompression was achieved in all cases, and all aneurysms were clipped successfully. We recommend that adenosine cardiac arrest is a relatively novel method for decompression of intracranial aneurysms to facilitate clip application. With appropriate safety precautions, it is a reasonable alternative method when temporary clipping of proximal vessels is not desirable or not possible.

Study of Incidence and Factors: Risk and Preventive, of Chronic Subdural Hematoma/hygroma in Clipped Patients of Unruptured Intracranial Aneurysms - An Institutional Experience

Introduction

One of the underreported complications of clipping of unruptured aneurysm is chronic subdural hematoma/hygroma (CSDH). It can cause sudden deterioration and might need emergency evacuation. Recently, very few papers have studied its incidence and predisposing factors. We are reporting our institutional experience of it along with the study of its risk factors and possible pathogenesis.

Methodology

Totally 91 postoperative patients of unruptured aneurysms were retrospectively analyzed. Totally 21 patients had CSDH who were operated. In rest seventy patients, there was no CSDH.

Results

Male sex, old age, anticoagulant use, presence of pneumocephalus and dead space were significantly associated with occurrence of CSDH, whereas arachnoidoplasty significantly protected against it. There was no significant relation of CSDH with Gorei-san use.

Conclusions

We recommend arachnoidoplasty should be carried out in all patients of clipping of unruptured aneurysm. Male patients or/and patients with dead space with pneumocephalus must be given extra attention like avoiding any dead space in postoperative period, doing arachnoidoplasty and regular follow up till 1^st year.

Study of predisposing risk factors and etiology of chronic subdural hematoma in clipped patients of unruptured intracranial aneurysms – an institutional experience

Introduction: Chronic subdural hematoma in clipped patients of unruptured intracranial aneurysms might lead to sudden neurological deterioration and may need emergency evacuation. We studied the effects of various factors in its etiology. Materials and methods: A retrospective study of 91operated clipped patients of unruptured aneurysms in the year 2014-2015 was taken. Various predisposing factors were studied. Results: Goreisan use was not associated with any reduction in post operative CSDH formation. Arachnoidoplasty and reduced post operative dead space contributed in a reduced formation of CSDH. Conclusion: Older male patients with aneurysms who had been treated with anticoagulant drugs should be considered candidates for additive ARP to prevent the development of postoperative CSDH.

Long term prognosis of ventriculoatrial shunt for idiopathic normal pressure hydrocephalus in the elderly

Objective: A retrospective study was conducted to access the long-term prognosis of inserting the Ventriculoatrial (VA) shunt in the elderly for the idiopathic normal pressure hydrocephalus (iNPH). Material and Methods: Retrospective data is collected from April 2004 to August 2015, and 1065 patients were selected. Patients who underwent surgical examination or surgery in suspected iNPH were included. Tap test is done in all cases and found to be effective for 968 cases and 656 VA shunts for 614 cases. Out of 614 cases there are 440 cases in which patient age were over 75 years. Of these 440 cases only 141 cases were able to observe 03 years or more after the surgery, 37 deaths and 05 cases with survival and unknown prognosis were found among them. So we analyzed this group mainly in 99 cases that the prognosis after 03 years was known. We access the outcome of VA shunt by the modified Rankin scale (mRS), iNPH grading scale (iNPHGS) and complications in the operative 656 cases and in 03 years follow up of 141 patients. Results: Of 141, there are 78 males and 63 females. Age at the time of VA shunt insertion was 81.5±4.1 years and age at final follow-up was 85.2±4.4 years. The proportion of patients who achieved a favorable outcome by complications was 97.9% in 03 years follow-up period and 87.7% in which follow-up is less than 03 years. At the time of VA shunt insertion out of 141, 57 patients lies between 75-79 years, 57 between 80-84, 24 between 85 to 89, and only 03 were found to be 90 years or more. At the time of final follow-up at 03 years, 15 patients lies between 75 to 79 years, 56 between 80 to 84 years, 57 between 85 to 89 years and 23 patents were found to be 90 years or greater. 70 cases or almost 50% exceeded 85 years. At the time of VA shunt 1, 11, 39, 51, 36, 3, 0 patients were in 0 to 6 modified Rankin Scale Score respectively and at 03 years follow-up 8, 19, 32, 29, 9, 2, 37 were in 0 to 6 mRS respectively. Comparison of the study is done with SIPHONI study on VP shunt and LP shunt. Conclusion: Patients suspected of having idiopathic normal pressure hydrocephalus were treated by VA shunt and found no significant difference in serious adverse effects. This study shows that VA shunt is an effective choice for iNPH in the late elderly population, but it needs more randomized control trial to establish its efficacy.

Implantation of Xenogeneic Transgenic Neural Plate Tissues into Parkinsonian Rat Brain

Xenografting must be considered as a means of establishing neural transplantation therapy and of securing fetal neural tissues as donor material. The early stage (embryonic day 8.5, E8.5) embryonic mesencephalic neural plate (NP) from transgenic mice was examined for possible application in effective xenografting therapy. As recipients, Parkinsonian rats treated with 6-hydroxydopamine were used, and as donors, GT4-2 mice into which a β-galactosidase gene was introduced to allow brain tissue differentiation from the recipients by X-gal staining. Three microscopic pieces of E8.5 GT4-2 mice NP were injected into the striatum of the Parkinsonian rats. Some hosts were given immunosuppressants (cyclophosphamide and FK506) (IS group), others were not (non-IS group). Amphetamine-induced rotation was examined at days 11 and 21 after grafting (D11 and D21, respectively), and morphological investigations were performed using hematoxylin-eosin (H-E), X-gal, and thyrosine hydroxylase (TH) staining. The rotations were counted in 30 of the 38 transplanted rats before and after grafting. Histological data were obtained from 19 of these 30 rats. In 11 of them the grafts survived (survival group) and in the remaining 8, the grafts were unsuccessful (rejection group). In the survival group at D11, the mean number of rotations made by transplanted rats expressed as a percentage of the number before grafting (rotation percentage) decreased to 43.8% (n = 9), which, in comparison with the average of 125.9% (n = 6) in the rejection group, reveals significant behavioral recovery (p < 0.01). The rotation percentage at D21 was 23.8% in the survival group (n = 4) and 84.5% in the rejection group (n = 3). Behavioral recovery was thus seen to improve with time in the survival group. In the IS group (n = 19), the rotation percentages averaged 74.9% (D11, n = 15) and 51.1% (D21, n = 7), while the non-IS group averages were 136.7% (D11, n = 9) and 140.7% (D21, n = 9), indicating a tendency for better behavioral recovery in the IS group than in the non-IS group (p < 0.05). Fifteen IS group rats were studied histologically, 10 (sacrificed on D11, D21) from the survival group and 5 (sacrificed on D11, D21) from the rejection group. In the non-IS group (n = 4), there was a graft in only one rat sacrificed on D11. There were many X-gal positive and TH positive cells in the grafts, suggesting that mouse NP survived, and differentiated into TH positive neurons in the rat brain. Xenografted NP has the potential to cure central nervous system diseases.

Surgical treatment of large and giant cavernous carotid aneurysms

Cavernous carotid aneurysms (CCAs) are uncommon pathologic entities. Extradural place and the skull base location make this type of an aneurysm different in clinical features and treatment techniques. Direct aneurysm clipping is technically difficult and results in a significant postoperative neurological deficit. Therefore, several techniques of indirect surgical treatment were developed with different surgical outcomes, such as proximal occlusion of internal carotid artery (ICA) or trapping with or without bypass (superficial temporal artery-middle cerebral artery bypass or high-flow bypass). High-flow bypass with proximal ICA occlusion seems to be the most appropriate surgical treatment for CCA because of the high rate of symptom improvement, aneurysm thrombosis, and minimal postoperative complications. However, in cases of CCA presented with direct carotid-cavernous fistula, the appropriate surgical treatment is high-flow bypass with aneurysm trapping, which the fistula can be obliterated immediately after surgery.

Reversibility of energy metabolism and intracellular pH after cerebral ischaemia evaluated by 31P-MRS

We have previously developed a reproducible model of transient forebrain ischaemia in rats by bilateral carotid artery occlusion combined with temporary increase of ICP. With this model, reversibility of the energy metabolism and intracellular pH (pHi) was investigated by 31P-MRS during 120 min of recirculation in three groups of, respectively, 30, 60, and 120 min of ischaemia. With the induction of ischaemia, ATP and phosphocreatine (PCr) disappeared, and measurement of pHi showed severe acidosis in all rats. In the 30 min ischaemia group, both energy metabolism and pHi recovered almost completely. In the 60 min ischaemia group, ATP recovered to 74% of control values, but pHi showed full recovery. In the 120 min ischaemia group, ATP recovered to about 50% of control values, and recovery of pHi was variable. Showing logarithmical changes during recirculation in ATP and PCr, the rate of metabolic recovery was fast during 60 min of recirculation, but it decreased and reached plateau thereafter in all groups. Recovery of pHi was affected by ATP levels, and was precipitously accelerated as ATP levels exceeded 50% of pre-ischaemic values. These results suggest that prolongation of the duration of ischaemia limits the restoration of the energy state, and the quality of pHi recovery after cerebral ischaemia is affected by the degree of ATP recovery during 60 min of recirculation.

Surgical treatment of unruptured dissecting intracranial aneurysms of vertebral-posterior inferior cerebellar artery region

A lack of published surgical experience and higher symptomatic recurrence than previously recognized prompted the authors to present their experience with the surgical treatment of unruptured intracranial dissecting aneurysms (UIDAs). Hospital records, neuroimaging studies, operative reports, and follow-up records were retrospectively reviewed. All patients underwent surgical exploration of the lesion with proximal clipping of the parent artery through a far-lateral suboccipital craniotomy with or without partial condylar resection. The surgical treatment of vertebral artery-posterior inferior cerebellar artery UIDAs has acceptable risk regarding perioperative mortality and morbidity. The incidence of aneurysmal recurrence or the need for retreatment seems to be less than that associated with anticoagulation/antiplatelet therapy or endovascular treatment.

Comparison of computational fluid dynamics findings with intraoperative microscopy findings in unruptured intracranial aneurysms- An initial analysis

Context:

The increase in the detection of unruptured cerebral aneurysms has led to management dilemma. Prediction of risk based on the size of the aneurysm is not always accurate. There is no objective way of predicting rupture of aneurysm so far. Computational fluid dynamics (CFDs) was proposed as a tool to identify the rupture risk.

Aims:

To know the correlation of CFD findings with intraoperative microscopic findings and to know the relevance of CFD in the prediction of rupture risk and in the management of unruptured intracranial aneurysms.

Settings and Design:

A prospective study involving nine cases over a period of 6 months as an initial analysis.

Subjects and Methods:

Both males and females were included in the study. Preoperative analysis was performed using computed tomography angiogram, magnetic resonance imaging in all cases and digital substraction angiogram in some cases. Intraoperatively microscopic examination of the aneurysm wall was carried out and images recorded. The correlation was done between microscopic and CFD images.

Results:

Seven cases were found intraoperatively to have a higher risk of rupture based on the thinning of the wall. Two cases had an atherosclerotic wall. All cases had low wall shear stress (WSS).Only two cases with atherosclerotic wall had a correlation with low WSS.

Conclusions:

While the pressure measured with CFD technique is a good predictor of rupture risk, the WSS component is controversial. Multicentric trials involving a larger subset of population are needed before drawing any definite conclusions. On-going development in the CFD analysis may help to predict the rupture chances accurately in future.

Phase II/III study of second-line chemotherapy comparing irinotecan-alone with S-1 plus irinotecan in advanced gastric cancer refractory to first-line treatment with S-1 (JACCRO GC-05)

BACKGROUND

In Japan, S-1 plus cisplatin has been used as first-line therapy for advanced gastric cancer (AGC). Patients with no response to first-line treatment with S-1 often receive a taxane-alone or irinotecan-alone as second-line treatment. However, second-line treatment with S-1 plus irinotecan is widely used in patients with AGC resistant to first-line S-1-based chemotherapy. The goal of this trial was to determine whether the consecutive use of S-1 plus irinotecan improves survival when compared with irinotecan-alone as second-line treatment for AGC.

PATIENTS AND METHODS

Patients who had disease progression during first-line S-1-based chemotherapy were randomly assigned to receive S-1 plus irinotecan or irinotecan-alone. The S-1 plus irinotecan group received oral S-1 (40-60 mg/m(2)) on days 1-14 and intravenous irinotecan (150 mg/m(2)) on day 1 of a 21-day cycle. The irinotecan-alone group received the same dose of irinotecan intravenously on day 1 of a 14-day cycle. The primary end point was overall survival (OS).

RESULTS

From February 2008 to May 2011, a total of 304 patients were enrolled. The median OS was 8.8 months in the S-1 plus irinotecan group and 9.5 months in the irinotecan-alone group. This difference was not significant (hazard ratio for death, 0.99; 95% confidence interval 0.78-1.25; P = 0.92). Grade 3 or higher toxicities were more common in the S-1 plus irinotecan group than in the irinotecan-alone group.

CONCLUSION

The consecutive use of S-1 plus irinotecan is not recommended as second-line treatment in patients who are refractory to S-1-based first-line chemotherapy. ClinicalTrials.gov ID: NCT00639327.