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Pahl FH, Oliveira MFD, Brock RS, Lucio JED. Application of indocyanine green video angiography in surgical treatment of intracranial aneurysms. ARQUIVOS DE NEURO-PSIQUIATRIA 2015. [DOI: 10.1590/0004-282x20150069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Indocyanine green (ICG) video angiography has been used for several medical indications in the last decades. It allows a real time evaluation of vascular structures during the surgery. This study describes the surgical results of a senior vascular neurosurgeon. We retrospectively searched our database for all aneurysm cases treated with the aid of intraoperative ICG from 2009 to 2014. A total of 61 aneurysms in 56 patients were surgically clipped using intraoperative ICG. Clip reposition after ICG happened in 2 patients (3.2%). Generally, highly variable clip adjustment rates of 2%–38% following ICG have been reported since the introduction of this imaging technique. The application of ICG in vascular neurosurgery is still an emerging challenge. It is an adjunctive strategy which facilitates aneurismal evaluation and treatment in experienced hands. Nevertheless, a qualified vascular neurosurgeon is still the most important component of a high quality work.
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Thompson BG, Brown RD, Amin-Hanjani S, Broderick JP, Cockroft KM, Connolly ES, Duckwiler GR, Harris CC, Howard VJ, Johnston SCC, Meyers PM, Molyneux A, Ogilvy CS, Ringer AJ, Torner J. Guidelines for the Management of Patients With Unruptured Intracranial Aneurysms: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2015; 46:2368-400. [PMID: 26089327 DOI: 10.1161/str.0000000000000070] [Citation(s) in RCA: 599] [Impact Index Per Article: 66.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE The aim of this updated statement is to provide comprehensive and evidence-based recommendations for management of patients with unruptured intracranial aneurysms. METHODS Writing group members used systematic literature reviews from January 1977 up to June 2014. They also reviewed contemporary published evidence-based guidelines, personal files, and published expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulated recommendations using standard American Heart Association criteria. The guideline underwent extensive peer review, including review by the Stroke Council Leadership and Stroke Scientific Statement Oversight Committees, before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee. RESULTS Evidence-based guidelines are presented for the care of patients presenting with unruptured intracranial aneurysms. The guidelines address presentation, natural history, epidemiology, risk factors, screening, diagnosis, imaging and outcomes from surgical and endovascular treatment.
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Unruptured Cerebral Aneurysms: Evaluation and Management. ScientificWorldJournal 2015; 2015:954954. [PMID: 26146657 PMCID: PMC4471401 DOI: 10.1155/2015/954954] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 11/30/2014] [Accepted: 12/15/2014] [Indexed: 11/21/2022] Open
Abstract
The evolution of imaging techniques and their increased use in clinical practice have led to a higher detection rate of unruptured intracranial aneurysms. The diagnosis of an unruptured intracranial aneurysm is a source of significant stress to the patient because of the concerns for aneurysmal rupture, which is associated with substantial rates of morbidity and mortality. Therefore, it is important that decisions regarding optimum management are made based on the comparison of the risk of aneurysmal rupture with the risk associated with intervention. This review provides a comprehensive overview of the epidemiology, pathophysiology, natural history, clinical presentation, diagnosis, and management options for unruptured intracranial aneurysms based on the current evidence in the literature. Furthermore, the authors discuss the genetic abnormalities associated with intracranial aneurysm and current guidelines for screening in patients with a family history of intracranial aneurysms. Since there is significant controversy in the optimum management of small unruptured intracranial aneurysms, we provided a systematic approach to their management based on patient and aneurysm characteristics as well as the risks and benefits of intervention.
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Gölitz P, Struffert T, Ganslandt O, Lang S, Knossalla F, Doerfler A. Contrast-enhanced angiographic computed tomography for detection of aneurysm remnants after clipping: a comparison with digital subtraction angiography in 112 clipped aneurysms. Neurosurgery 2015; 74:606-13; discussion 613-4. [PMID: 24584137 DOI: 10.1227/neu.0000000000000326] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND For preclusion of remnants after aneurysm clipping, a reliable, noninvasive imaging technique is desirable. OBJECTIVE To evaluate the reliability of optimized angiographic computed tomography with intravenous contrast agent injection (ivACT) in detecting remnants after aneurysmal clipping compared with digital subtraction angiography (DSA), the gold standard. METHODS We included 84 patients with 112 clipped cerebral aneurysms of the anterior circulation. For treatment, 116 clips of cobalt and 57 clips of titanium alloy were used. In each patient, we performed an ivACT with dual rotational acquisition and a DSA. Data from ivACT were postprocessed with a dual-volume technique with newly implemented reconstructions modes. Aneurysm remnants were measured, classified, and correlated with DSA by 2 raters. RESULTS In total, 12 remnants were revealed by DSA, meaning a prevalence of 11%. IvACT demonstrated a sensitivity of 75% to 92% and a specificity of 99% in detecting remnants up to a minimal size of 0.7 × 0.3 mm. Classification of remnants by ivACT was identical to that by DSA, and assessment of size showed a significant correlation with DSA (P < .001). No significant differences between cobalt and titanium alloy were revealed concerning artifacts. CONCLUSION Optimized ivACT with enhanced postprocessing demonstrated high sensitivity and specificity in detecting remnants after aneurysm clipping in the anterior circulation. Classification and assessment of remnant size and detection of relevant parent artery stenosis showed high accuracy of ivACT compared with DSA. Our results indicate that ivACT might become a noninvasive alternative to DSA for postsurgical control.
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Affiliation(s)
- Philipp Gölitz
- *Department of Neuroradiology, ‡Department of Neurosurgery, §Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
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Roessler K, Krawagna M, Dörfler A, Buchfelder M, Ganslandt O. Essentials in intraoperative indocyanine green videoangiography assessment for intracranial aneurysm surgery: conclusions from 295 consecutively clipped aneurysms and review of the literature. Neurosurg Focus 2014; 36:E7. [PMID: 24484260 DOI: 10.3171/2013.11.focus13475] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Indocyanine green (ICG) videoangiography (VA) in cerebral aneurysm surgery allows confirmation of blood flow in parent, branching, and perforating vessels as well as assessment of remnant aneurysm parts after clip application. A retrospective analysis and review of the literature were conducted to determine the current essential advantages of ICG-VA in aneurysm surgery. METHODS The authors retrospectively evaluated all aneurysm cases treated with the aid of intraoperative ICG-VA at a single institution between 2007 and 2013. They also analyzed the literature published since the initial description of ICG-VA in 2003. RESULTS Two hundred forty-six procedures were performed in 232 patients harboring 295 aneurysms. The patients, whose mean age was 54 years, consisted of 159 women and 73 men. One hundred twenty-four surgeries were performed after subarachnoid hemorrhage, and 122 were performed for incidental aneurysms. Single aneurysms were clipped in 185 patients, and multiple aneurysms were clipped in 47 (mean aneurysm diameter 6.9 mm, range 2-40 mm). No complications associated with ICG-VA occurred. Intraoperative microvascular Doppler ultrasonography was performed before ICG-VA in all patients, and postoperative digital subtraction angiography (DSA) studies were available in 121 patients (52.2%) for retrospective comparative analysis. In 22 (9%) of 246 procedures, the clip position was modified intraoperatively as a consequence of ICG-VA. Stenosis of the parent vessels (16 procedures) or occlusion of the perforators (6 procedures), not detected by micro-Doppler ultrasonography, were the most common problems demonstrated on ICG-VA. In another 11 procedures (4.5%), residual perfusion of the aneurysm was observed and one or more additional clips were applied. Vessel stenosis or a compromised perforating artery occurred independent of aneurysm location and was about equally common in middle cerebral artery and anterior communicating artery aneurysms. In 2 procedures (0.8%), aneurysm puncture revealed residual blood flow within the lesion, which had not been detected by the ICG-VA. In the postoperative DSA studies, unexpected small (< 2 mm) aneurysm neck remnants, which had not been detected on intraoperative ICG-VA, were found in 11 (9.1%) of 121 patients. However, these remnants remained without consequence except in 1 patient with a 6-mm residual aneurysm dome, which was subsequently embolized with coils. CONCLUSIONS In a large cohort of consecutive patients, ICG-VA proved to be a helpful intraoperative tool and led to a significant intraoperative clip modification rate of 15%. However, small, < 2-mm-wide neck remnants and a 6-mm residual aneurysm were missed by intraoperative ICG-VA in up to 10% of patients. Results in this study confirm that DSA is indispensable for postoperative quality assessment in complex aneurysm surgery.
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Tan T, Tee JW, Han TF. Cell-mediated allergy to cerebral aneurysm clip causing extensive cerebral edema. J Neurosurg 2014; 121:924-8. [DOI: 10.3171/2014.6.jns132405] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors report the first case of vasogenic cerebral edema due to a cell-mediated hypersensitivity reaction to a nickel-containing aneurysm clip. The patient initially presented for elective clipping of a right middle cerebral artery aneurysm, and on long-term follow-up she demonstrated relapsing-remitting cerebral edema. Four years post–aneurysm clipping, she underwent an exploratory craniotomy given unsuccessful conservative management of her headaches and imaging evidence of cerebral edema with mass effect. During surgery, gross parenchymal edema and inflammatory nodules were observed. Histopathology was consistent with a cell-mediated (Type IV) hypersensitivity reaction. Concerns regarding nickel allergy are often reported in the cardiac literature. This case highlights the possibility of nickel hypersensitivity when using nickel-containing aneurysm clips, especially in patients with known nickel allergies.
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Kono K, Fujimoto T, Terada T. Proximal stenosis may induce initiation of cerebral aneurysms by increasing wall shear stress and wall shear stress gradient. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2014; 30:942-950. [PMID: 24706583 DOI: 10.1002/cnm.2637] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Revised: 02/02/2014] [Accepted: 03/10/2014] [Indexed: 06/03/2023]
Abstract
Hemodynamic parameters, such as wall shear stress (WSS), WSS gradient (WSSG), aneurysm formation indicator (AFI), or gradient oscillatory number (GON), have been proposed to be linked to initiation of cerebral aneurysms. However, how such conditions occur in humans is unclear. We encountered a rare and interesting case to address this issue. A patient had a newly formed aneurysm with proximal stenosis, which was confirmed by serial imagings. We made two pre-aneurysm models: one with stenosis and the other without stenosis. We performed computational fluid dynamics simulations for these models. Owing to jet flow caused by the stenosis, the maximum WSS and WSSG on the aneurysm initiation site were approximately doubled and tripled, respectively. However, the oscillatory shear index (OSI), AFI, and GON did not change substantially by the stenosis. Computer simulations using artificial vascular models with different degrees of proximal stenosis at different distances demonstrated that oscillatory shear index, AFI, and GON did not change substantially by the stenosis. These results showed that proximal stenosis caused high WSS and high WSSG at the aneurysm initiation site, possibly leading to aneurysm initiation. Proximal stenosis may be a potential factor to induce initiation of one class of cerebral aneurysms by increasing WSS and WSSG.
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Affiliation(s)
- Kenichi Kono
- Department of Neurosurgery, Wakayama Rosai Hospital, 93-1 Kinomoto, Wakayama 640-8505, Japan
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Chung J, Park IS, Park H, Hwang SH, Jung JM, Han JW. Endovascular coil embolization after clipping: endovascular treatment of incompletely clipped or recurred cerebral aneurysms. J Cerebrovasc Endovasc Neurosurg 2014; 16:262-7. [PMID: 25340029 PMCID: PMC4205253 DOI: 10.7461/jcen.2014.16.3.262] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Revised: 09/11/2014] [Accepted: 09/18/2014] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The presence of a cerebral aneurysm remnant after surgical clipping is associated with a risk of regrowth or rupture. For these recurred aneurysms, coil embolization can be considered as a treatment option. We retrospectively reviewed cases of ruptured or regrown aneurysms after clipping treated by endovascular coil embolization. MATERIALS AND METHODS We conducted a retrospective review of patients with ruptured or recurred aneurysm after clipping, who underwent coil embolization between January 1995 and December 2013. We evaluated clinical information and the outcomes of these cases. RESULTS Eight patients were treated by endovascular coil embolization after surgical clipping. Six aneurysms were located in the anterior communicating artery, one in the posterior communicating artery, and one in the middle cerebral artery bifurcation. All patients were initially treated by surgical clipping because of a ruptured aneurysm. Aneurysm recurrence at the initial clipping site was detected in all cases. The median interval from initial to second presentation was 42 months. In four patients, aneurysms were detected before rupture and the four remaining patients presented with recurrent subarachnoid hemorrhage. All patients were treated by coil embolization and showed successful occlusion of aneurysms without complications. CONCLUSION Endovascular coil embolization can be a safe and successful treatment option for recurred aneurysms after clipping.
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Affiliation(s)
- Jaehwan Chung
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Jinju, Korea
| | - In Sung Park
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Jinju, Korea. ; Gyeongsang Institute of Health Science, Jinju, Korea
| | - Hyun Park
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Soo-Hyun Hwang
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Jin-Myung Jung
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Jong-Woo Han
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Jinju, Korea
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Jeong HW, Seo JH, Kim ST, Jung CK, Suh SI. Clinical practice guideline for the management of intracranial aneurysms. Neurointervention 2014; 9:63-71. [PMID: 25426300 PMCID: PMC4239410 DOI: 10.5469/neuroint.2014.9.2.63] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 08/05/2014] [Indexed: 11/29/2022] Open
Abstract
Purpose An intracranial aneurysm, with or without subarachnoid hemorrhage (SAH), is a relevant health problem. The rupture of an intracranial aneurysm is a critical concern for individual health; even an unruptured intracranial aneurysm is an anxious condition for the individual. The aim of this guideline is to present current and comprehensive recommendations for the management of intracranial aneurysms, with or without rupture. Materials and Methods We performed an extensive literature search, using Medline. We met in person to discuss recommendations. This document is reviewed by the Task Force Team of the Korean Society of Interventional Neuroradiology (KSIN). Results We divided the current guideline for ruptured intracranial aneurysms (RIAs) and unruptured intracranial aneurysms (UIAs). The guideline for RIAs focuses on diagnosis and treatment. And the guideline for UIAs focuses on the definition of a high-risk patient, screening, principle for treatment and selection of treatment method. Conclusion This guideline provides practical, evidence-based advice for the management of patients with an intracranial aneurysm, with or without rupture.
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Affiliation(s)
- Hae Woong Jeong
- Department of Radiology, Busan Paik Hospital, Inje University, Busan, Korea
| | - Jung Hwa Seo
- Department of Neurology, Busan Paik Hospital, Inje University, Busan, Korea
| | - Sung Tae Kim
- Department of Neurosurgery, Busan Paik Hospital, Inje University, Busan, Korea
| | - Cheol Kyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang-Il Suh
- Department of Radiology, Korea University Guro Hospital, Seoul, Korea
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Re-exploration of the craniotomy after surgical treatment of unruptured intracranial aneurysms. Acta Neurochir (Wien) 2014; 156:869-77. [PMID: 24682633 DOI: 10.1007/s00701-014-2059-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 03/07/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Unplanned re-exploration of the craniotomy after surgical treatment of unruptured intracranial aneurysms (UIAs) is sometimes required, but the underlying causes and rates of these procedures are seldom reported. This study retrospectively analyzed the causes of such re-explorations to identify methods for decreasing their necessity. METHOD From January 2000 to December 2011, 1,720 patients with a total of 1,938 UIAs underwent surgical treatment at our institution. From this cohort, 26 patients (1.5 %) with 38 UIAs required re-exploration. Clinical data, aneurysm characteristics, treatment methods, and the incidence and causes of re-exploration of the craniotomy were analyzed for these 26 patients. RESULTS Several causes of re-exploration were identified: compromised distal blood flow (eight patients, 0.47 %), hemorrhagic venous infarction (four patients, 0.23 %), brain retraction injury (three patients, 0.17 %), newly identified aneurysms (three patients, 0.17 %), bleeding from an incompletely clipped aneurysm (two patients, 0.12 %), epidural hematoma (two patients, 0.12 %), failed aneurysm clipping (two patients, 0.12 %) and other causes (two patients, 0.12 %). Annual re-exploration incidence rates ranged from 0 to 3.1 %. Annual incidence rates gradually decreased following the introduction of several intraoperative monitoring systems. CONCLUSIONS Precise surgical planning and careful operative techniques can reduce the incidence of unplanned re-exploration of the craniotomy. The introduction of various intraoperative monitoring systems can also contribute to a reduction in this incidence.
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Budai C, Cirillo L, Patruno F, Dall'olio M, Princiotta C, Leonardi M. Flat panel angiography images in the post-operative follow-up of surgically clipped intracranial aneurysms. Neuroradiol J 2014; 27:203-6. [PMID: 24750710 DOI: 10.15274/nrj-2014-10022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 02/01/2014] [Indexed: 11/12/2022] Open
Abstract
Cerebral aneurysms must be monitored for varying periods after surgical and/or endovascular treatment and the duration of follow-up will depend on the type of therapy and the immediate post-operative outcome. Surgical clipping for intracranial aneurysms is a valid treatment but the metal clips generate artefacts so that follow-up monitoring still relies on catheter angiography. This study reports our preliminary experience with volumetric angiography using a Philips Allura Xper FD biplane system in the post-operative monitoring of aneurysm residues or major vascular changes following the surgical clipping of intracranial aneurysms. Volumetric angiography yields not only volume-rendered (VR) images, but a volume CT can also be reconstructed at high spatial and contrast resolution from a single acquisition, significantly enhancing the technique's diagnostic power. Between August 2012 and April 2013, we studied 19 patients with a total of 26 aneurysms treated by surgical clipping alone or in combination with endovascular treatment. All patients underwent standard post-operative angiographic follow-up including a rotational volumetric acquisition. Follow-up monitoring disclosed eight aneurysm residues whose assessment was optimal after surgical clipping both in patients with one metal clip and in those with two or more clips. In addition, small residues (1.3 mm) could be monitored together with any change in the calibre or course of vessels located adjacent to the clips. In conclusion, flat panel volume CT is much more reliable than the old 3D acquisitions that yielded only VR images. This is particularly true in patients with small aneurysm residues or lesions with multiple metal clips.
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Affiliation(s)
- Caterina Budai
- Neuroradiology Department, IRCCS Institute of Neurological Sciences of Bologna; Bologna, Italy -
| | - Luigi Cirillo
- Neuroradiology Department, IRCCS Institute of Neurological Sciences of Bologna; Bologna, Italy - Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna; Bologna, Italy
| | - Francesco Patruno
- Neuroradiology Department, IRCCS Institute of Neurological Sciences of Bologna; Bologna, Italy
| | - Massimo Dall'olio
- Neuroradiology Department, IRCCS Institute of Neurological Sciences of Bologna; Bologna, Italy
| | - Ciro Princiotta
- Neuroradiology Department, IRCCS Institute of Neurological Sciences of Bologna; Bologna, Italy
| | - Marco Leonardi
- Neuroradiology Department, IRCCS Institute of Neurological Sciences of Bologna; Bologna, Italy - Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna; Bologna, Italy
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3D Rotational Angiography in Follow-Up of Clipped Intracranial Aneurysms. ISRN RADIOLOGY 2014; 2014:935280. [PMID: 24967299 PMCID: PMC4045552 DOI: 10.1155/2014/935280] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 11/05/2013] [Indexed: 11/18/2022]
Abstract
Introduction. 3D Rotational Angiography (RA) is indispensable for evaluation of intracranial aneurysms, providing infinite viewing angles and defining the aneurysm morphology. Its role in follow-up of clipped aneurysms remains unclear. We aimed to compare the aneurysm residue/recurrence detection rate of 3D RA with 2D digital subtraction angiography (DSA). Methods. 47 patients harboring 54 clipped aneurysms underwent both 2D DSA and 3D RA. The residual/recurrent aneurysms were classified into five grades and the images of both modalities were compared. Results. The residual/recurrent aneurysm detection rate was 53.70% (29/54 aneurysms) with 2D DSA and 66.67% (36/54 aneurysms) with 3D RA (P = 0.05). In 12 aneurysms, 3D RA upgraded the residue/recurrence among which nine had been completely not detected on 2D DSA and were found to have grade one or two residual necks on the 3D RA, and, in three cases, a small neck on 2D DSA turned out to be aneurysm sac on 3D RA. In a total of 5 aneurysms, the classification was downgraded by 3D RA. Conclusion. 3D RA picks up more aneurysm residue/recurrence; hence, both 2D DSA and 3D RA should be performed in follow-up evaluation of clipped aneurysms.
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Wenz H, Al Mahdi MM, Ehrlich G, Scharf J, Schmiedek P, Seiz M. De novo aneurysm of the anterior communicating artery presenting with subarachnoid hemorrhage 7 years after initial cryptogenic subarachnoid hemorrhage: a case report and review of the literature. Clin Neuroradiol 2014; 25:93-7. [PMID: 24384679 DOI: 10.1007/s00062-013-0278-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 12/12/2013] [Indexed: 11/25/2022]
Abstract
Spontaneous subarachnoid hemorrhage (SAH) is usually caused by a ruptured cerebral aneurysm. Despite the use of initial four-vessel cerebral digital subtraction angiography (DSA), 15 % of all cases remain idiopathic. According to the initial computed tomographic scan, the spontaneous SAH can be divided into a perimesencephalic group associated with a benign nature and a nonperimesencephalic group with a similar clinical course as aneurysmal SAH. We present a case of a 49-year-old man with a de novo aneurysm formation of the anterior communicating artery with SAH 7 years after initial cryptogenic nonperimesencephalic SAH. This observation suggests that in some cases, long-term angiographic studies might be justified.
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Affiliation(s)
- H Wenz
- Department of Neuroradiology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany,
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Kono K, Masuo O, Nakao N, Meng H. De Novo Cerebral Aneurysm Formation Associated With Proximal Stenosis. Neurosurgery 2013; 73:E1080-90. [DOI: 10.1227/neu.0000000000000065] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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116
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Lai LT, Gragnaniello C, Morgan MK. Outcomes for a case series of unruptured anterior communicating artery aneurysm surgery. J Clin Neurosci 2013; 20:1688-92. [DOI: 10.1016/j.jocn.2013.02.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 02/23/2013] [Indexed: 11/28/2022]
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Etminan N, Buchholz BA, Dreier R, Bruckner P, Torner JC, Steiger HJ, Hänggi D, Macdonald RL. Cerebral aneurysms: formation, progression, and developmental chronology. Transl Stroke Res 2013; 5:167-73. [PMID: 24323717 DOI: 10.1007/s12975-013-0294-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Revised: 10/06/2013] [Accepted: 10/08/2013] [Indexed: 02/08/2023]
Abstract
The prevalence of unruptured intracranial aneurysms (UIAs) in the general population is up to 3%. Existing epidemiological data suggests that only a small fraction of UIAs progress towards rupture over the lifetime of an individual, but the surrogates for subsequent rupture and the natural history of UIAs are discussed very controversially at present. In case of rupture of an UIA, the case fatality is up to 50%, which therefore continues to stimulate interest in the pathogenesis of cerebral aneurysm formation and progression. Actual data on the chronological development of cerebral aneurysm has been especially difficult to obtain and, until recently, the existing knowledge in this respect is mainly derived from animal or mathematical models or short-term observational studies. Here, we review the current data on cerebral aneurysm formation and progression as well as a novel approach to investigate the developmental chronology of cerebral aneurysms.
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Affiliation(s)
- Nima Etminan
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Dusseldorf, Germany,
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Lai LT, Morgan MK. Use of indocyanine green videoangiography during intracranial aneurysm surgery reduces the incidence of postoperative ischaemic complications. J Clin Neurosci 2013; 21:67-72. [PMID: 24090515 DOI: 10.1016/j.jocn.2013.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 03/31/2013] [Accepted: 04/02/2013] [Indexed: 11/16/2022]
Abstract
Microscope-integrated near-infrared indocyanine green videoangiography (ICGVA) has been shown to be a useful adjunct for intracranial aneurysm surgery. That the routine application of this technique reduces the risk of postoperative ischaemic complication, however, has not been reported. We present a retrospective matched-pair comparison of ICGVA guided aneurysm surgery versus historic control surgical cohort treated by the same author. Index patients and controls were matched for aneurysm size, location, patient demographics, risk factors, comorbidities, and surgical treatments. Ninety-one eligible patients with 100 intracranial aneurysms were treated using ICGVA assistance. There were no statistically significant differences between the two groups in terms of patient age, sex, risk factors, comorbidities and aneurysm characteristics. Of the 100 aneurysms in the ICGVA group, 107 investigations of ICGVA were performed. In 79 aneurysms (79.0%), ICGVA was considered useful but did not affect surgical management. In six patients (6.0%), ICGVA led to a crucial change of intraoperative strategies. In nine patients (9.0%), it was considered critical in assuring patency of small perforators. ICGVA was of no benefit in four patients (4.0%) and was misleading in two (2.0%). Postoperative ischaemic complications occurred in three patients (3.3%) in the ICGVA group compared with seven patients (7.7%) in the control group (p<0.001). Our study supports the use of ICGVA in aneurysm surgery as a safe and effective modality of intraoperative blood flow assessment. With all limitations of a retrospective matched-pair comparison, the use of ICGVA during routine aneurysm surgery reduces the incidence of postoperative ischaemic complications.
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Affiliation(s)
- Leon Tat Lai
- The Australian School of Advanced Medicine, 2 Technology Place, Macquarie University, Sydney, NSW 2109, Australia.
| | - Michael Kerin Morgan
- The Australian School of Advanced Medicine, 2 Technology Place, Macquarie University, Sydney, NSW 2109, Australia
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Covey J, Noble AJ, Schenk T. Family and friends' fears of recurrence: impact on the patient's recovery after subarachnoid hemorrhage. J Neurosurg 2013; 119:948-54. [DOI: 10.3171/2013.5.jns121688] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Patients with subarachnoid hemorrhage (SAH) and their close friends and family may be excessively fearful that the patient will have a recurrence, and such fears could play a critical role in the poor recovery shown by many patients The authors examined whether these fears could account for significant variance in psychosocial outcomes.
Methods
The authors prospectively studied a sample of 69 patients with SAH alongside their spouse, other family member, and/or close friend identified as their significant other (SO). The patient/SO pairs were assessed at 13 months postictus for their fears of recurrence and for health-related quality of life on the 8 domains of the 36-Item Short Form Health Survey.
Results
The SOs were found to be significantly more fearful of SAH recurrence than the patients. The SO's fears also explained unique variance in the patient's recovery on 4 of the 36-Item Short Form Health Survey domains over and above the patient's own fears, demographic and/or neurological variables, and the patient's history of psychiatric or neurological problems. The domains affected reflected activity-based and functional aspects of the patient's quality of life as opposed to more general characteristics of their emotional well-being or physical health state.
Conclusions
The patient's recovery may be compromised if their spouse, close family, and/or friends are excessively fearful about their suffering a recurrence. Perhaps the SO's fears cause them to be overprotective of the patient and to restrict their day-to-day activities. Attention must therefore be given to the experience of having a loved one suffer from an SAH, and alleviating the caregiver's fears could help to promote a better outcome for the patient.
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Affiliation(s)
- Judith Covey
- 1Department of Psychology, Durham University, Stockton-on-Tees
| | - Adam J. Noble
- 2Department of Clinical Neuroscience, Institute of Psychiatry, King's College London, United Kingdom; and
| | - Thomas Schenk
- 3Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany
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Takemoto K, Tateshima S, Golshan A, Gonzalez N, Jahan R, Duckwiler G, Vinuela F. Endovascular treatment of pediatric intracranial aneurysms: a retrospective study of 35 aneurysms. J Neurointerv Surg 2013; 6:432-8. [PMID: 23986132 DOI: 10.1136/neurintsurg-2013-010852] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Koichiro Takemoto
- Division of Interventional Neuroradiology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Satoshi Tateshima
- Division of Interventional Neuroradiology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Ali Golshan
- Division of Interventional Neuroradiology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Nestor Gonzalez
- Division of Interventional Neuroradiology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Reza Jahan
- Division of Interventional Neuroradiology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Gary Duckwiler
- Division of Interventional Neuroradiology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Fernando Vinuela
- Division of Interventional Neuroradiology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
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Li K, Cho YD, Kang HS, Kim JE, Han MH, Lee YM. Endovascular management for retreatment of postsurgical intracranial aneurysms. Neuroradiology 2013; 55:1345-53. [PMID: 23949553 DOI: 10.1007/s00234-013-1270-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 08/06/2013] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Incomplete surgical treatment of intracranial aneurysms and recurrent postsurgical aneurysms are associated with a risk of rebleeding, and additional treatment is generally recommended. Surgical retreatment may carry a risk of procedural complications due to technical difficulty. We present here our experience with the endovascular approach for the retreatment of intracranial aneurysms that were initially treated with open surgery. METHODS From January 2002 through January 2013, a total of 43 patients with 43 postsurgical index aneurysms were identified and underwent subsequent endovascular treatment. Clinical and radiological data were retrospectively reviewed. RESULTS Thirty-one patients were surgically clipped before endovascular coiling and 12 patients were nonclipped, which included wrapping. Hemorrhagic presentation occurred in 21 patients prior to coiling. The interval between the initial surgical treatment and coiling varied from 0 days to 264 months (median, 9 months). Endovascular coiling resulted in the successful occlusion of 36 aneurysms (84 %). Procedure-related complications included asymptomatic thrombus formation in six patients, symptomatic cerebral infarction in two patients, and retroperitoneal hemorrhage in one patient. Delayed cerebral infarction occurred in two patients with a deployed stent. The procedure-related permanent morbidity and mortality rates were 6.9 and 0 %, respectively. Radiological follow-up evaluations beyond 6 months were available in 26 patients (60 %), which revealed major recanalization in three patients (11.5 %). There was no rebleeding during the follow-up period, which ranged from 3 to 115 months (mean, 34.5 months). CONCLUSION Endovascular embolization may serve as a safe, efficacious, and durable treatment option in the management of postsurgical intracranial aneurysms.
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Affiliation(s)
- Ke Li
- Department of Interventional Radiology, 1st Affiliated Hospital of Dalian Medical University, Dalian, China
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Teleb MS, Pandya DJ, Castonguay AC, Eckardt G, Sweis R, Lazzaro MA, Issa MA, Fitzsimmons BF, Lynch JR, Zaidat OO. Safety and predictors of aneurysm retreatment for remnant intracranial aneurysm after initial endovascular embolization. J Neurointerv Surg 2013; 6:490-4. [DOI: 10.1136/neurintsurg-2013-010836] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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124
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Lai LT, Morgan MK. Outcomes for unruptured ophthalmic segment aneurysm surgery. J Clin Neurosci 2013; 20:1127-33. [DOI: 10.1016/j.jocn.2012.12.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 01/04/2013] [Indexed: 12/12/2022]
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Ishikawa T. What is the role of clipping surgery for ruptured cerebral aneurysms in the endovascular era? A review of recent technical advances and problems to be solved. Neurol Med Chir (Tokyo) 2013; 50:800-8. [PMID: 20885114 DOI: 10.2176/nmc.50.800] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Craniotomy and clipping have been robust treatments for ruptured cerebral aneurysm for more than 50 years, with satisfactory overall outcomes. Technical advances, such as developments in microsurgical tools and equipment, adjunctive therapy, and novel monitoring methods enable safer and more efficient treatment. However, overall surgical results have not shown any major improvements, as outcomes are mainly determined by the damage from initial bleeding, and new treatment strategies are not always free from associated complications and problems. Recent advances in endovascular treatment are shifting the treatment for ruptured cerebral aneurysm from craniotomy and clipping to intravascular coil embolization. However, craniotomy and clipping are very important for the treatment of ruptured cerebral aneurysm. This paper discusses recent advances and future perspectives in the field of clipping surgery for ruptured aneurysms.
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Affiliation(s)
- Tatsuya Ishikawa
- Department of Neurological Surgery, Research Institute for Brain and Blood Vessels-Akita, 6-10 Senshu-Kubota-machi, Akita, Japan.
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Carvi y Nievas MN, Hattingen J, Hoellerhage HG. Interdisciplinary treatment selection in admitted patients with acute subarachnoid hemorrhage. Neurol Res 2013; 31:582-92. [DOI: 10.1179/174313209x382250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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127
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Carvi y Nievas MN. Assessment of the clipping efficacy of intracranial aneurysms: analysis of the employed methodology in relation to case difficulty. Neurol Res 2013; 29:506-16. [PMID: 17535574 DOI: 10.1179/016164107x164148] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE To assess intracranial aneurysms clipping efficacy (CE) employing different angiographic techniques in relation to the case difficulty. METHOD In the past 6 years, 152 patients harboring 179 aneurysms who underwent surgical clipping in our department were angiographically examined to confirm aneurysm occlusion. Intraoperative angiography (IA), post-operative conventional (PCA) and three-dimensional angiography were single or sequentially performed based on the surgeon's concern about case difficulty. The percentage of visualized angiographic abnormalities (PVAA) assessing CE and their impact on corrective treatment were retrospectively analysed. RESULTS The PVAA of IA was 67.8% (19 of 28 aneurysms). Eighteen of them (eight aneurysm remnants, four parent vessel stenosis, two distal branch occlusions and five clip slippage phenomena) underwent immediate corrective treatment (clip reposition in 11 cases, complementary clipping in three cases and combined treatment in four cases). The impact on corrective treatment was 94.7%. The PVAA of PCA was 18.4% (33 of 179 aneurysms). Fifteen patients presented aneurysm remnants, six presented parent vessel stenosis, five presented distal branch occlusions and seven presented clip slippage phenomena. The impact of this technique on corrective treatment was 15.1% (five of 33 angiographic abnormalities). In only one case, PCA demonstrated an aneurysm remnant which was missed on IA. Twenty patients were additionally examined with three-dimensional angiography. The impact on corrective treatment of three-dimensional angiography was 25% (five of 20 examined patients with angiographic abnormalities). CONCLUSION In pre-selected difficult cases, IA provides high PVAA and increased impact on corrective treatment. In non-selected patients, PCA shows low PVAA and reduced impact on corrective treatment. The complementary assessment with multiplanar three-dimensional angiography increases the impact on corrective treatment and facilitates decisions about the final case management.
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Malatesta E, Nuzzi NP, Divenuto I, Fossaceca R, Lombardi M, Cerini P, Guzzardi G, Stecco A, Andreula C, Carriero A. Endovascular treatment of intracranial aneurysms with flow-diverter stents: preliminary single-centre experience. Radiol Med 2013; 118:971-83. [PMID: 23801392 DOI: 10.1007/s11547-013-0944-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Accepted: 08/06/2012] [Indexed: 10/26/2022]
Abstract
PURPOSE This paper reports our preliminary experience with the endovascular treatment of intracranial aneurysms using flow-diverter stents (FDs) and compares it with the literature data. MATERIALS AND METHODS From May 2009 to April 2012, 28 patients (6 men and 22 women; mean age, 54 years) with a total of 35 aneurysms were treated with FDs. We evaluated postprocedural technical success and long-term efficacy, with follow-up examinations performed at 3-7 days [computed tomography (CT)/magnetic resonance (MR) angiography] and at 3, 6 and 12 months (digital subtraction angiography, DSA). A total of 43 FDs were placed, 36 Pipeline and 7 Silk. RESULTS A total of 30 procedures were performed (two patients were treated twice). Technical success was 96.6%, with one case of postprocedural death; the aneurysm exclusion rate at 3, 6 and 12 months was 60%, 73% and 89%, respectively. There was no case of acute stent thrombosis, and only two cases of nonsignificant stenosis. All covered side branches were patent, except one case of steno-occlusion of the ophthalmic artery. CONCLUSIONS Our results are consistent with the literature and demonstrate the effectiveness and safety of FDs in selected cases of cerebral aneurysm (wide neck, fusiform, blister-like).
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Affiliation(s)
- Emanuele Malatesta
- Radiodiagnostic and Interventional Radiology Institute, Amedeo Avogadro University of Eastern Piedmont, AOU Maggiore della Carità, Novara, Italy,
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Assessment of long-term results of intracranial aneurysm clipping by means of computed tomography angiography. Neurol Neurochir Pol 2013; 47:18-26. [PMID: 23487290 DOI: 10.5114/ninp.2012.31549] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND PURPOSE The aim of this retrospective study was to assess the effectiveness of aneurysm clipping by computed tomography angiography (CTA) in a long-term follow-up. MATERIAL AND METHODS The CTA examination was performed in 119 patients who had 143 aneurysms clipped. The examinations were performed 3 to 11 years (mean 6 years) after clipping using a GE Lightspeed PRO16 scanner. RESULTS In all cases but one, good quality CTA images, suitable for evaluation of the arteries around the clip site, were obtained. Complete aneurysm closure without neck remnant or regrowth was confirmed in 137 (96%) aneurysms. In 4 (3%) cases, neck remnants were detected (2 on the anterior communicating artery [AComA] and 2 on the middle cerebral artery [MCA]). A total clip slippage from the aneurysm dome was revealed in 1 case. One case of aneurysm re-rupture was noted, 11 years after clipping. The rebleeding was caused by AComA aneurysm regrowth. Among these 6 patients with unsatisfactory clipping, 2 required further treatment and 4 remain under observation. Nineteen 'de novo' aneurysms in other locations were found in 14 (12%) patients. Summing up all of the pathological findings in the study group, there were 18 (15%) patients who needed further management including close surveillance or re-treatment. CONCLUSIONS Computed tomography angiography is a simple and reliable method of aneurysm clipping evaluation. The long- term follow-up CTA confirmed the permanent and complete obliteration of 96% of the aneurysms. The rate of unsatisfactory aneurysm closure was 4%, but only 1.4% needed re-treatment during a mean follow-up of 6 years. The annual risk of aneurysm re-rupture was 0.1%.
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Koroknay-Pál P, Niemelä M, Lehto H, Kivisaari R, Numminen J, Laakso A, Hernesniemi J. De Novo and Recurrent Aneurysms in Pediatric Patients With Cerebral Aneurysms. Stroke 2013; 44:1436-9. [DOI: 10.1161/strokeaha.111.676601] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Long-term angiographic follow-up studies on pediatric aneurysm patients are scarce.
Methods—
We gathered long-term clinical and angiographic follow-up data on all pediatric aneurysm patients (≤18 years at diagnosis) treated at the Department of Neurosurgery, Helsinki University Central Hospital, between 1937 and 2009.
Results—
Fifty-nine patients with cerebral aneurysms in childhood had long-term clinical and radiological follow-up (median, 34 years; range, 4–56 years). Twenty-four patients (41%) were diagnosed with altogether 25 de novo and 11 recurrent aneurysms, with 9 (25%) of the aneurysms being symptomatic. New subarachnoid hemorrhage occurred in 7 patients; 4 of these patients died. Eight patients (33%) had multiple new aneurysms. The annual rate of hemorrhage was 0.4%, and the annual rate for the development of de novo or recurrent aneurysm was 1.9%. There were no de novo aneurysms in 7 patients with previously unruptured aneurysms. However, 1 recurrent aneurysm was diagnosed. Current and previous smoking (risk ratio, 2.44; 95% confidence interval, 1.07–5.55) was the only statistically significant risk factor for de novo and recurrent aneurysm formation in patients with previous subarachnoid hemorrhage, whereas hypertension, sex, or age at onset had no statistically significant effect. Smoking was also a statistically significant risk factor for new subarachnoid hemorrhage.
Conclusions—
Patients with ruptured intracranial aneurysms in childhood have a high risk for new aneurysms and new subarachnoid hemorrhage, especially if they start to smoke as adults. Life-long angiographic follow-up is mandatory.
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Affiliation(s)
- Päivi Koroknay-Pál
- From the Department of Neurosurgery, Helsinki University Central Hospital, Finland (P.K.-P., M.N., H.L., R.K., A.L., J.H.); and Helsinki Medical Imaging Center, Helsinki University Central Hospital, Finland (J.N.)
| | - Mika Niemelä
- From the Department of Neurosurgery, Helsinki University Central Hospital, Finland (P.K.-P., M.N., H.L., R.K., A.L., J.H.); and Helsinki Medical Imaging Center, Helsinki University Central Hospital, Finland (J.N.)
| | - Hanna Lehto
- From the Department of Neurosurgery, Helsinki University Central Hospital, Finland (P.K.-P., M.N., H.L., R.K., A.L., J.H.); and Helsinki Medical Imaging Center, Helsinki University Central Hospital, Finland (J.N.)
| | - Riku Kivisaari
- From the Department of Neurosurgery, Helsinki University Central Hospital, Finland (P.K.-P., M.N., H.L., R.K., A.L., J.H.); and Helsinki Medical Imaging Center, Helsinki University Central Hospital, Finland (J.N.)
| | - Jussi Numminen
- From the Department of Neurosurgery, Helsinki University Central Hospital, Finland (P.K.-P., M.N., H.L., R.K., A.L., J.H.); and Helsinki Medical Imaging Center, Helsinki University Central Hospital, Finland (J.N.)
| | - Aki Laakso
- From the Department of Neurosurgery, Helsinki University Central Hospital, Finland (P.K.-P., M.N., H.L., R.K., A.L., J.H.); and Helsinki Medical Imaging Center, Helsinki University Central Hospital, Finland (J.N.)
| | - Juha Hernesniemi
- From the Department of Neurosurgery, Helsinki University Central Hospital, Finland (P.K.-P., M.N., H.L., R.K., A.L., J.H.); and Helsinki Medical Imaging Center, Helsinki University Central Hospital, Finland (J.N.)
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Hokari M, Kuroda S, Nakayama N, Houkin K, Ishikawa T, Kamiyama H. Long-term prognosis in patients with clipped unruptured cerebral aneurysms―increased cerebrovascular events in patients with surgically treated unruptured aneurysms. Neurosurg Rev 2013; 36:567-71; discussion 571-2. [DOI: 10.1007/s10143-013-0465-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 10/07/2012] [Accepted: 01/06/2013] [Indexed: 11/27/2022]
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Abstract
Unruptured intracranial aneurysms (UIA) are a common finding, occurring in about 2% of the population, making them very likely to be seen by most practitioners, and present a challenge in the recommendations for optimal management and screening. The consequences of aneurysm rupture are dire, with high likelihood of significant morbidity and mortality. Most aneurysms do not rupture and patients harboring these lesions often remain asymptomatic. There are effective surgical and endovascular interventions to prevent rupture, but these procedures carry a risk of adverse complications. This article addresses the challenges of screening and management of UIAs.
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133
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Crobeddu E, Lanzino G, Kallmes DF, Cloft HJ. Review of 2 decades of aneurysm-recurrence literature, part 2: Managing recurrence after endovascular coiling. AJNR Am J Neuroradiol 2013; 34:481-5. [PMID: 22422182 PMCID: PMC7964895 DOI: 10.3174/ajnr.a2958] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Cerebral aneurysms are treated to prevent hemorrhage or rehemorrhage. Angiographic recurrences following endovascular therapy have been a problem since the advent of this treatment technique, even though posttreatment hemorrhage remains rare. Notwithstanding its unclear clinical significance, angiographic recurrence remains not only a prime focus in the literature but also frequently leads to potentially risky retreatments. The literature regarding aneurysm recurrence following endovascular therapy, spanning 2 decades, is immense and immensely confusing. We review the topic of recurrence following endovascular treatment of cerebral aneurysms in an effort to distill it down to fundamental material relevant to clinical practice.
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Affiliation(s)
- E Crobeddu
- Department of Radiology, Mayo Clinic, Rochester, Minnesota 55905, USA
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Abstract
Subarachnoid hemorrhage (SAH) is a devastating cerebrovascular disease. Outcome after SAH is mainly determined by the initial severity of the hemorrhage. Neuroimaging, in particular computed tomography, and aneurysm repair techniques, such as coiling and clipping, as well as neurocritical care management, have improved during the last few years. The management of a patient with SAH should have an interdisciplinary approach with case discussions between the neurointensivist, interventionalist and the neurosurgeon. The patient should be treated in a specialized neurointensive care unit of a center with sufficient SAH case volume. Poor-grade patients can be observed for complications and delayed cerebral ischemia through continuous monitoring techniques in addition to transcranial Doppler ultrasonography such as continuous electroencephalography, brain tissue oxygenation, cerebral metabolism, cerebral blood flow and serial vascular imaging. Neurocritical care should focus on neuromonitoring for delayed cerebral ischemia, management of hydrocephalus, seizures and intracranial hypertension, as well as of medical complications such as hyperglycemia, fever and anemia.
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Affiliation(s)
- Katja E Wartenberg
- Neurocritical Care Unit, Department of Neurology, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Strasse 40, 06120 Halle (Saale), Germany
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Abstract
BACKGROUND Surgical clipping with complete occlusion of the aneurysm and preservation of parent, branching, and perforating vessels remains the most definitive treatment for intracranial aneurysms. OBJECTIVE To evaluate the benefit of endoscopic application during microsurgical procedures in a retrospective study. METHODS One hundred eighty aneurysms were microsurgically treated in 124 operations. Three different applications of endoscopic visualization were used, depending on the respective requirements: inspection before clipping, clipping under endoscopic view, and postclipping evaluation. RESULTS Of 1380 aneurysms, 292 procedures were done with application of the endoscope. Of these 292, a complete data set, including video recording of the procedures for retrospective evaluation, was available in 180 cases. In these, the endoscope provided a favorable enhancement of the visual field, particularly in complex or deep-seated lesions. No adverse effects were observed. Before clipping, the endoscope was used to gain additional topographic information in 150 of 180 cases (83%). Clipping under endoscopic view was performed in 4 cases. After clipping, endoscopic inspection was performed in 130 of 180 procedures. Depending on the endoscopic findings, rearrangement of the applied clip or additional clipping was found to be necessary in 26 of 130 cases (20.0%). CONCLUSION Endoscopic enhancement of the visual field provided by the endoscope before, during, and after microsurgical aneurysm occlusion may be a safe and effective application to increase the quality of treatment. Although unexpected findings concerning completeness of aneurysm occlusion and compromise of involved vessels could be diminished by endoscopic assessment, total prevention was not accomplished.
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Affiliation(s)
- Gerrit Fischer
- Neurochirurgische Klinik, Universitaetsmedizin, Johannes Gutenberg-Universitaet, Mainz, Germany.
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Cavalcanti DD, Abla AA, Martirosyan NL, McDougall CG, Spetzler RF, Albuquerque FC. Endovascular management of distal ACA aneurysms: single-institution clinical experience in 22 consecutive patients and literature review. AJNR Am J Neuroradiol 2013; 34:1593-9. [PMID: 23391842 DOI: 10.3174/ajnr.a3408] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Distal ACA aneurysms remain difficult to treat with endovascular therapy, but improved technology and experience allows for the treatment of some of these aneurysms with excellent results. The purpose of this study was to assess the status of endovascular treatment of distal ACA aneurysms by comparing our results with recent endovascular and microsurgical series of distal ACA aneurysms. MATERIALS AND METHODS Between 2000 and 2008, a total of 22 consecutive patients (14 women; mean age, 58.4 years) with distal ACA aneurysms underwent coil placement at Barrow Neurological Institute. Clinical presentations, radiographic findings, endovascular management, and outcomes were reviewed retrospectively. RESULTS Of the 22 patients, 13 (59%) presented with subarachnoid hemorrhage. Six patients were HH grade I or II, 1 was grade III, 5 were grade IV, and 1 was grade V. Frontal lobe hematomas occurred in 5 patients with ruptured aneurysms. The mean aneurysm size was 7.5 mm (range, 2.8-25 mm); 55% were smaller than 7 mm. Twelve aneurysms (55%) arose from the origin of the callosomarginal artery (55%). Complete occlusion was achieved in 50% of the cases and near-complete occlusion in 45%. The few periprocedural complications included 1 retroperitoneal hematoma and 1 intraoperative rupture. Four patients had thromboembolic events adequately treated intraprocedurally with abciximab. No deaths occurred in the patients treated. CONCLUSIONS The characteristics of the patients and aneurysms treated in our series were comparable to previous reports of endovascular treatment of ACA aneurysms with respect to rupture status. Periprocedural morbidity and mortality rates in our series fared well compared with previous reports, as did our combined rate of complete or near-complete occlusions. Recent advances in endovascular devices and techniques have improved outcomes of distal ACA aneurysms.
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Affiliation(s)
- D D Cavalcanti
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
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Washington CW, Zipfel GJ, Chicoine MR, Derdeyn CP, Rich KM, Moran CJ, Cross DT, Dacey RG. Comparing indocyanine green videoangiography to the gold standard of intraoperative digital subtraction angiography used in aneurysm surgery. J Neurosurg 2013; 118:420-7. [DOI: 10.3171/2012.10.jns11818] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The purpose of aneurysm surgery is complete aneurysm obliteration while sparing associated arteries. Indocyanine green (ICG) videoangiography is a new technique that allows for real-time evaluation of blood flow in the aneurysm and vessels. The authors performed a retrospective study to compare the accuracy of ICG videoangiography with intraoperative angiography (IA), and determine if ICG videoangiography can be used without follow-up IA.
Methods
From June 2007 through September 2009, 155 patients underwent craniotomies for clipping of aneurysms. Operative summaries, angiograms, and operative and ICG videoangiography videos were reviewed. The number, size, and location of aneurysms, the ICG videoangiography and IA findings, and the need for clip adjustment after ICG videoangiography and IA were recorded. Discordance between ICG videoangiography and IA was defined as ICG videoangiography demonstrating aneurysm obliteration and normal vessel flow, but post-IA showing either an aneurysmal remnant and/or vessel occlusion requiring clip adjustment.
Results
Thirty-two percent of patients (49 of 155) underwent both ICG videoangiography and IA. The post-ICG videoangiography clip adjustment rate was 4.1% (2 of 49). The overall rate of ICG videoangiography–IA agreement was 75.5% (37 of 49) and the ICG videoangiography–IA discordance rate requiring post-IA clip adjustment was 14.3% (7 of 49). Adjustments were due to 3 aneurysmal remnants and 4 vessel occlusions. These adjustments were attributed to obscuration of the residual aneurysm or the affected vessel from the field of view and the presence of dye in the affected vessel via collateral flow. Although not statistically significant, there was a trend for ICG videoangiography–IA discordance requiring clip adjustment to occur in cases involving the anterior communicating artery complex, with an odds ratio of 3.3 for ICG videoangiography–IA discordance in these cases.
Conclusions
These results suggest that care should be taken when considering ICG videoangiography as the sole means for intraoperative evaluation of aneurysm clip application. The authors further conclude that IA should remain the gold standard for evaluation during aneurysm surgery. However, a combination of ICG videoangiography and IA may ultimately prove to be the most effective strategy for maximizing the safety and efficacy of aneurysm surgery.
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Affiliation(s)
| | | | | | - Colin P. Derdeyn
- 1Departments of Neurological Surgery,
- 2Neurology, and
- 3Radiology, Washington University Center for Stroke and Cerebrovascular Disease, Washington University School of Medicine, St. Louis, Missouri
| | - Keith M. Rich
- 1Departments of Neurological Surgery,
- 3Radiology, Washington University Center for Stroke and Cerebrovascular Disease, Washington University School of Medicine, St. Louis, Missouri
| | - Christopher J. Moran
- 1Departments of Neurological Surgery,
- 3Radiology, Washington University Center for Stroke and Cerebrovascular Disease, Washington University School of Medicine, St. Louis, Missouri
| | - DeWitte T. Cross
- 1Departments of Neurological Surgery,
- 3Radiology, Washington University Center for Stroke and Cerebrovascular Disease, Washington University School of Medicine, St. Louis, Missouri
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Choi SH, Park CW, Kim YB, Kim EY, You CJ, Kim WK. The Comparative Study of Microsurgical Cerebral Aneurysm Clip Implants; Titanium Clip vs. Stainless Steel Clip. J Cerebrovasc Endovasc Neurosurg 2012; 14:79-83. [PMID: 23210032 PMCID: PMC3471257 DOI: 10.7461/jcen.2012.14.2.79] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Revised: 05/14/2012] [Accepted: 06/04/2012] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To perform a comparative study between two groups of populations, titanium (T) group versus stainless steel (S) group, who were clipped with titanium and stainless steel materials, respectively, the incidence of regrowth from the original aneurysms, the clip slippage, and post-clipping seizure attack were analyzed. The patients were followed more than 5 years after microsurgical cerebral aneurysms clipping. METHODS Data from 1986 through 2008 were extensively reviewed on a consecutive series of 3,770 patients who referred for ruptured/unruptured cerebral aneurysms. Forty-seven patients in the S group and 48 in the T group who met inclusion criteria, were selected for this study. RESULTS The incidence of regrowth were noted that two out of total 47 patients (4.3%) in the S group, and none in the T group. The clip slippage was not observed in both groups. And there was no statistical difference (p = 0.242) in terms of regrowth between two groups. Seven out of 47 cases (14.9%) developed post-clipping seizure in the S group. On the other hand, two (4.2%) of 48 patients presented the symptom in the T group. Also, there was no significant difference (p = 0.091) between two groups. CONCLUSIONS The metallic types of clip employed for the microsurgical cerebral aneurysm clipping does not have any significant clinical outcome differences in this study.
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Affiliation(s)
- Sung Ho Choi
- Department of Neurosurgery, Gil Hospital, Gachon University, Incheon, Korea
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140
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Kemp WJ, Fulkerson DH, Payner TD, Leipzig TJ, Horner TG, Palmer EL, Cohen-Gadol AA. Risk of hemorrhage from de novo cerebral aneurysms. J Neurosurg 2012; 118:58-62. [PMID: 23061385 DOI: 10.3171/2012.9.jns111512] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT A small percentage of patients will develop a completely new or de novo aneurysm after discovery of an initial aneurysm. The natural history of these lesions is unknown. The authors undertook this statistical evaluation a large cohort of patients with both ruptured and unruptured de novo aneurysms with the aim of analyzing risk factors for rupture and estimating a risk of subarachnoid hemorrhage (SAH). METHODS A review of a prospectively maintained database of all aneurysm patients treated by the vascular neurosurgery service of Goodman Campbell Brain and Spine from 1976-2010 was performed. Of the 4718 patients, 611 (13%) had long-term follow-up imaging. The authors identified 27 patients (4.4%) with a total of 32 unruptured de novo aneurysms from routine surveillance imaging. They identified another 10 patients who presented with a new SAH from a de novo aneurysm after treatment of their original aneurysm. The total study group was thus 37 patients with a total of 42 de novo aneurysms. The authors then compared the 27 patients with incidentally discovered aneurysms with the 10 patients with SAH. A statistical analysis was performed, comparing the 2 groups with respect to patient and aneurysm characteristics and risk factors. RESULTS Thirty-seven patients were identified as having true de novo aneurysms. This group had a female predominance and a high percentage of smokers. These 37 patients had a total of 42 de novo aneurysms. Ten of these 42 aneurysms hemorrhaged. De novo aneurysms in both the SAH and non-SAH group were anatomically small (< 10 mm). The estimated risk of hemorrhage over 5 years was 14.5%, higher than the expected SAH risk of small, unruptured aneurysms reported in the ISUIA (International Study of Unruptured Intracranial Aneurysms) trial. There was no statistically significant correlation between hemorrhage and any of the following risk factors: hypertension, diabetes, tobacco and alcohol use, polycystic kidney disease, or previous SAH. There was a statistically significant between-groups difference with respect to patient age, with the mean patient age being significantly older in the SAH aneurysm group than in the non-SAH group (p = 0.047). This is likely reflective of longer follow-up and discovery time, as the mean length of time between initial treatment and discovery of the de novo aneurysm was longer in the SAH group (p = 0.011). CONCLUSIONS While rare, de novo aneurysms may have a risk for SAH that is comparatively higher than the risk associated with similarly sized, small, initially discovered unruptured saccular aneurysms. The authors therefore recommend long-term follow-up for all patients with aneurysms, and they consider a more aggressive treatment strategy for de novo aneurysms than for incidentally discovered initial aneurysms.
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Affiliation(s)
- William J Kemp
- Indiana University School of Medicine, Indianapolis, Indiana 46202, USA
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141
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Balamurugan S, Agrawal A, Kato Y, Sano H. Intra operative indocyanine green video-angiography in cerebrovascular surgery: An overview with review of literature. Asian J Neurosurg 2012; 6:88-93. [PMID: 22347330 PMCID: PMC3277076 DOI: 10.4103/1793-5482.92168] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Microscope integrated Near infra red Indocyanine green video angiography (NIR ICG VA) has been frequently used in cerebrovascular surgery. It is believed to be a simple and reliable method with acquisition of real time high spatial resolution images. The aim of this review article was to evaluate the efficacy of intra operative Indocyanine green video angiography (ICG VA) in Aneurysm, brain arteriovenous malformations (AVM) and extracranial-intracranial (EC-IC) bypass surgeries and also to analyze its limitations. Intra operative imaging is a very useful tool in guiding surgery; thus, avoiding surgical morbidity. Now-a-days, many cerebrovascular units are using ICG VA rather than Doppler and intra operative DSA in most of their aneurysm surgeries, and surgeons are incorporating this technique for AVM and in EC-IC bypass surgeries too. This article is an overview of the beneficial effects of ICG VA in cerebrovascular surgery and will also point out its limitations in various circumstances. Intra operative ICG VA gives high resolution, real time images of arterial, capillary, and venous flow of cerebral vasculature. Although it gives adequate information about the clipped neck, parent/branching artery and perforator involvement, it has some limitations like viewing the neck residuals located behind the aneurysm, thick walled atherosclerotic vessels, and thrombosed aneurysms. In AVM surgery, it is useful in detecting the residual nidus in diffuse type AVM, but cannot be relied in deep seated AVMs and it gives exact information about the anastomosis site in EC-IC bypass, thus, avoiding early bypass graft failure. NIR ICG VA is a simple, reliable, and quick method to pick up subtle findings in cerebrovascular procedures. But in selected cases of aneurysms, endoscopy and intra operative Digital substraction angiography (DSA) may be helpful, whereas in deep seated AVMs, navigation may be required as an adjunct to confirm intra operative findings.
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Affiliation(s)
- S Balamurugan
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Japan
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142
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Bruneau M, Appelboom G, Rynkowski M, Van Cutsem N, Mine B, De Witte O. Endoscope-integrated ICG technology: first application during intracranial aneurysm surgery. Neurosurg Rev 2012; 36:77-84; discussion 84-5. [PMID: 22918545 DOI: 10.1007/s10143-012-0419-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2012] [Revised: 05/23/2012] [Accepted: 07/15/2012] [Indexed: 10/28/2022]
Abstract
Microscopic indocyanine green videoangiography (mICG-VA) has gained wide acceptance during intracranial aneurysm surgery by lowering rates of incomplete clipping and occlusion of surrounding vessels. However, mICG-VA images are limited to the microscopic view and some deeper areas, including the aneurysm sac/neck posterior side, cannot be efficiently assessed as they are hidden by the aneurysm, clips, or surrounding structures. Contrarily, endoscopes allow a wider area of visualization, but neurosurgical endoscopes to date only provided visual data. We describe the first application of endoscope ICG-integrated technology (eICG) applied in an initial case of anterior communicating artery aneurysm clipping. This new technique provided also relevant information regarding aneurysm occlusion and patency of parent and branching vessels and small perforating arteries. eICG-VA provided additional information compared to mICG-VA by magnifying areas of interest and improving the ability to view less accessible regions, especially posterior to the aneurysm clip. Obtaining eICG sequences required currently the microscope to be moved away from the operating field. eICG-VA was only recorded under infrared illumination which prevented tissue handling, but white-infrared light views could be interchanged instantaneously. Further development of angled endoscopes integrating the ICG technology and dedicated filters blocking the microscopic light could improve visualization capacities even further. In conclusion, as a result of its ability to reveal structures around corners, the eICG-VA technology could be beneficial when used in combination with mICG-VA to visualize and confirm vessel patency in areas that were previously hidden from the microscope.
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Affiliation(s)
- Michaël Bruneau
- Department of Neurosurgery, Erasme Hospital, Université Libre de Bruxelles-ULB, Route de Lennik, 808, 1070, Brussels, Belgium.
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143
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Aydın Y, Cavuşoğlu H, Kahyaoğlu O, Müslüman AM, Yılmaz A, Türkmenoğlu ON, Can SM, Yüce I. Clip ligation of unruptured intracranial aneurysms: a prospective midterm outcome study. Acta Neurochir (Wien) 2012; 154:1135-44. [PMID: 22644505 DOI: 10.1007/s00701-012-1397-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 05/15/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND We conducted a prospective study to investigate the clinical and radiological outcome in a surgical case series of 176 patients with 203 unruptured intracranial aneurysms (UIA). METHODS The success of aneurysm obliteration was assessed within 2 weeks after surgery by digital subtraction angiography (DSA). Patients also underwent angiography 5 years after surgery. Clinical outcomes were assessed using the modified Rankin Scale (mRS). All predictors of poor surgical outcomes were assessed using an exact logistic regression. RESULTS Overall, 83 % of the patients had a good outcome (mRS score 0 or 1); 10.8 % of the patients had a slight disability (mRS score 2), and 6.2 % of the patients had a moderate or moderate-severe disability (mRS score 3 or 4). The mortality rate was 0 % overall. The most important predictors of outcome were presence of history of ischemic cerebrovascular disease and postoperative stroke. Complete aneurysm occlusion was achieved in 93.5 % of all aneurysms. Sixty percent of treated aneurysms were checked with late follow-up DSA. No cases of hemorrhage from a surgically obliterated UIA were documented in this series during the 7.3 ± 1.4 (SD)-year follow-up period. CONCLUSIONS If patients are carefully selected and individually assigned to their optimum treatment modality, IUAs can be obliterated by surgery with a low percentage of unfavorable outcomes.
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Affiliation(s)
- Yunus Aydın
- Clinic of Neurosurgery, Şişli Etfal Education and Research Hospital, Istanbul, 34077, Turkey
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144
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Roach CJ, Russell CL, Hanson EH, Bluett B, Orrison WW. Appearance and impact of post-operative intracranial clips and coils on whole-brain CT angiography and perfusion. Eur J Radiol 2012; 81:960-7. [DOI: 10.1016/j.ejrad.2011.01.118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Revised: 01/17/2011] [Accepted: 01/28/2011] [Indexed: 11/25/2022]
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145
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Gölitz P, Struffert T, Ganslandt O, Saake M, Lücking H, Rösch J, Knossalla F, Doerfler A. Optimized angiographic computed tomography with intravenous contrast injection: an alternative to conventional angiography in the follow-up of clipped aneurysms? J Neurosurg 2012; 117:29-36. [PMID: 22519433 DOI: 10.3171/2012.3.jns111895] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECT The purpose of this study was to evaluate the diagnostic accuracy of an optimized angiographic CT (ACT) program with intravenous contrast agent injection (ivACT) in the assessment of potential aneurysm remnants after neurosurgical clipping compared with conventional digital subtraction angiography (DSA). METHODS The authors report on 14 patients with 19 surgically clipped cerebral aneurysms who were scheduled to undergo angiographic follow-up. For each patient, the authors performed ivACT with dual rotational acquisition and conventional angiography including a 3D rotational run. The ivACT and 3D DSA data were reconstructed with different imaging modes, including a newly implemented subtraction mode with motion correction. Thereafter, the data sets were merged by the dual-volume technique, and freely rotatable 3D images were obtained for further analysis. Observed aneurysm remnants were electronically measured and classified for each modality by 2 experienced neuroradiologists. RESULTS Digital subtraction angiography and ivACT both provided high-quality images without motion artifacts. Artifact disturbances from the aneurysm clips led to a compromised, but still sufficient, image quality in 1 case. The ivACT assessed all aneurysm remnants as true-positive up to a minimal size of 2.6×2.4 mm in accordance with the DSA findings. There was a tendency for ivACT to overestimate the size of the aneurysm remnants. All cases without aneurysm remnants on DSA were scored correctly as true-negative by ivACT. CONCLUSIONS By using an optimized image acquisition protocol as well as enhanced postprocessing algorithms, the noninvasive ivACT seems to achieve results comparable to those of conventional angiography in the follow-up of clipped cerebral aneurysms. The authors have shown that ivACT can provide reliable diagnostic information about potential aneurysm remnants after neurosurgical clipping with high sensitivity and specificity, sufficient for clinical decision making, at least for aneurysms in the anterior circulation located distal to the internal carotid artery. These preliminary results may be a promising step to replace conventional angiography by a noninvasive imaging technique in selected cases after aneurysm clipping.
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Affiliation(s)
- Philipp Gölitz
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany.
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146
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[Indications and surgical treatments for failed coiled aneurysms]. Neurochirurgie 2012; 58:187-98. [PMID: 22464903 DOI: 10.1016/j.neuchi.2012.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 02/13/2012] [Indexed: 11/23/2022]
Abstract
The possibility of treating intra-cranial aneurysms (ICA) through an endovascular approach is a great progress. But, as any technique, it has its own limitations. Multidisciplinary neurovascular teams are regularly confronted with ICA where embolization is a poor option or even failed (a residue of more than 5% at six months follow-up or after recanalization). Another potential failure is a coil extrusion into the parent vessel with thrombo-embolic risks. Our team and others in the world developed strategies to manage these complex cases. After a brief review of the literature, we describe our experience and present a modified Gurian classification. This classification allows a better identification of the various failed coiled aneurysms types and their potential surgical treatments.
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147
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Siasios I, Kapsalaki EZ, Fountas KN. The role of intraoperative micro-Doppler ultrasound in verifying proper clip placement in intracranial aneurysm surgery. Neuroradiology 2012; 54:1109-18. [PMID: 22415343 DOI: 10.1007/s00234-012-1023-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Accepted: 02/24/2012] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Aneurysmal subarachnoid hemorrhage constitutes a clinical entity associated with high mortality and morbidity. It is widely accepted that improper clip placement may have as a result of incomplete aneurysm occlusion and/or partial or complete obstruction of an adjacent vessel. Various modalities, including intraoperative or postoperative digital subtracting angiography, near-infrared indocyanine green angiography, micro-Doppler ultrasonography (MDU), and neurophysiological studies, have been utilized for verifying proper clip placement. The aim of our study was to review the role of MDU during aneurysmal surgery. METHODS A literature search was performed using any possible combination of the following terms: "aneurysm," "brain," "cerebral," "clip," "clipping," "clip malpositioning," "clip repositioning," "clip suboptimal positioning," "Doppler," "intracranial," "microsurgery," "micro-Doppler," "residual neck," "ultrasonography," "ultrasound," and "vessel occlusion". Additionally, reference lists from the retrieved articles were reviewed for identifying any additional articles. Case reports and miniseries were excluded. RESULTS A total of 19 series employing intraoperative MDU during aneurysmal microsurgery were retrieved. All studies demonstrated that MDU accuracy is extremely high. The highest reported false-positive rate of MDU was 2 %, while the false-negative rate was reported as high as 1.6 %. It has been demonstrated that the presence of subarachnoid hemorrhage, specific anatomic locations, and large size may predispose to improper clip placement. Intraoperative MDU's technical limitations and weaknesses are adequately identified, in order to minimize the possibility of any misinterpretations. CONCLUSION Intraoperative MDU constitutes a safe, accurate, and low cost imaging modality for evaluating blood flow and for verifying proper clip placement during microsurgical clipping.
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Affiliation(s)
- Ioannis Siasios
- Department of Neurosurgery, University Hospital of Larisa, Biopolis, 41110 Larissa, Greece
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148
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Noble AJ, Baisch S, Covey J, Mukerji N, Nath F, Schenk T. Subarachnoid hemorrhage patients' fears of recurrence are related to the presence of posttraumatic stress disorder. Neurosurgery 2012; 69:323-32; discussion 332-3. [PMID: 21415779 DOI: 10.1227/neu.0b013e318216047e] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Subarachnoid hemorrhage (SAH) patients illustrate a chronic fear of recurrence. A third of patients develop posttraumatic stress disorder (PTSD) after SAH, and PTSD after other conditions is associated with a more negative outlook on life. OBJECTIVE We examined whether recurrence fears are related to PTSD and whether this is associated with the patients making more negative health appraisals. We also examined the helpfulness of current treatments. METHODS Two SAH samples were generated. Sample 1 (n = 82) was assessed 13 months after ictus for PTSD, cognition, fear of recurrence, and beliefs concerning future health. Sample 2 (n = 60) was assessed 18 months after ictus for PTSD and to determine how much current treatments increased their confidence about not having another SAH. RESULTS Thirty-four percent of sample 1 had PTSD. Although clinically and cognitively comparable, PTSD patients feared recurrence more and were comparatively more pessimistic about their chances of further SAH. Thirty-six percent of sample 2 had PTSD. These most fearful patients reported finding current treatments the least helpful. CONCLUSION Fear of recurrence after SAH is related to PTSD. Participants with PTSD were more pessimistic about their future health. Treatment for PTSD could alleviate fears of SAH recurrence and promote better outcome.
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Affiliation(s)
- Adam J Noble
- Institute of Psychiatry, King's College London, London, United Kingdom.
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149
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Evidence-Based Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage English Edition. Neurol Med Chir (Tokyo) 2012; 52:355-429. [DOI: 10.2176/nmc.52.355] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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150
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Khan SNH, Nichols C, DePowell JJ, Abruzzo TA, Ringer AJ. Comparison of coil types in aneurysm recurrence. Clin Neurol Neurosurg 2012; 114:12-6. [DOI: 10.1016/j.clineuro.2011.07.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2010] [Revised: 07/03/2011] [Accepted: 07/20/2011] [Indexed: 10/17/2022]
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