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Ma YH, He YL, Lin S, Pan YW, Zhang CW. Systematic evaluation of neuro-ophthalmic outcomes of the ophthalmic artery covered by flow-diverter. Front Neurol 2025; 16:1479229. [PMID: 40170895 PMCID: PMC11958711 DOI: 10.3389/fneur.2025.1479229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2024] [Accepted: 03/06/2025] [Indexed: 04/03/2025] Open
Abstract
Carotid-ophthalmic aneurysms (COA) are complex and severe intracranial arterial lesions, and their treatment and management have always been a focus of clinical research. In recent years, the introduction of flow diverters (FD) has provided a revolutionary method for the treatment of intracranial aneurysms (IA). Although FD has achieved significant success in reducing the risk of COA rupture, the complex anatomical structure and critical function of the ophthalmic artery (OphA) mean that covering the OphA with FD may lead to adverse ophthalmic outcomes. This review aims to systematically examine the ocular complications and their mechanisms when FD covers the OphA in the treatment of COA, emphasizing the potential risks that clinicians should be aware of when applying FD treatment, to reduce complications and improve the overall prognosis of patients.
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Affiliation(s)
- Yu-Hu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yong-Lin He
- Department of Neurosurgery, The Second Hospital of Lanzhou University, Lanzhou, China
| | - Sen Lin
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ya-Wen Pan
- Department of Neurosurgery, The Second Hospital of Lanzhou University, Lanzhou, China
| | - Chang-Wei Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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2
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Alayli A, Monsour M, Schimmel S, Pressman E, Klocksieben F, Mokin M, Guerrero WR, Vakharia K. Safety and efficacy of staged primary coiling followed by delayed flow diversion of ruptured intracranial aneurysms: A systematic review and meta-analysis. Interv Neuroradiol 2024:15910199241305426. [PMID: 39704468 DOI: 10.1177/15910199241305426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2024] Open
Abstract
BACKGROUND Ruptured intracranial aneurysms lead to significant mortality and morbidity. Recent advancements have suggested staged coiling with subsequent flow diverter stent placement may reduce the risk of hemorrhage with dual antiplatelet therapy (DAPT) or stent thrombosis in the acute inflammatory phase after aneurysm rupture while still appropriately mitigating risk of aneurysmal rehemorrhage. MATERIALS AND METHODS A systematic review and single-arm meta-analysis was conducted. Studies reporting patients receiving coiling followed by delayed flow diverter placement on a separate day were included. RESULTS Five studies, comprising 94 patients, were included for meta-analysis. Average time between procedures ranged from 9.8 to 169 days; 24% (95% CI: 10-41%) of patients had a poor functional neurologic outcome (modified Rankin Scale > 2) at discharge compared to 4% (0-11%) at last follow-up. There was one incidence of rehemorrhage between treatments, 0% (0-4%). Vasospasm after coiling was the most common adverse event, 16% (1-41%). There was low risk of ischemic complications [1% (0-8%) with coil placement and 5% (1-11%) with stent placement]. Intraprocedural intracranial hemorrhage was also rare (two patients during coil placement; no cases during stent placement). There were no significant differences if flow diversion was performed less than or greater than 100 days from coiling. CONCLUSIONS Our study highlights the benefit of primary coiling with staged flow diversion for the management of ruptured intracranial aneurysms with a low risk for complications. Namely, the rate of rebleeding between treatments was exceptionally low. We advocate for the greater consideration of this treatment combination in the treatment of ruptured intracranial aneurysms.
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Affiliation(s)
- A Alayli
- Department of Neurosurgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - M Monsour
- Department of Neurosurgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - S Schimmel
- Department of Neurosurgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - E Pressman
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - F Klocksieben
- Research Methodology and Biostatistics Core, University of South Florida, Tampa, FL, USA
| | - M Mokin
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - W R Guerrero
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - K Vakharia
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
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3
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Ma YH, He YL, Zhang XY, Shang R, Hu HT, Wang T, Lin S, Pan YW, Zhang CW. Comparative Analysis of Stent-Assisted Versus Non-Stent-Assisted Coiling in the Management of Ruptured Intracranial Aneurysms: A Systematic Review and Meta-Analysis. Transl Stroke Res 2024:10.1007/s12975-024-01314-0. [PMID: 39630412 DOI: 10.1007/s12975-024-01314-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2024] [Revised: 11/18/2024] [Accepted: 11/22/2024] [Indexed: 03/17/2025]
Abstract
OBJECTIVE To systematically evaluate the safety and efficacy of SAC compared to non-SAC in the treatment of RIA, integrating evidence from high-quality studies to guide clinical practice. METHODS A meta-analysis was conducted to compare SAC with coiling alone and BAC in the treatment of RIA. Primary outcomes were immediate and follow-up aneurysm occlusion rates, along with perioperative hemorrhagic and ischemic complication rates. RESULTS A total of thirteen retrospective cohort studies were included, comprising 3,086 patients, with 1,078 in the SAC group and 2,008 in the non-SAC group. The immediate complete occlusion rates were similar between the SAC and non-SAC groups (59.1% vs. 61.4%; RR = 1.00; 95% CI [0.94, 1.07]; p = 0.92). However, the SAC group demonstrated a significantly higher long-term complete occlusion rate (61.3% vs. 40.6%; RR = 1.44; 95% CI [1.22, 1.69]; p < 0.001). The incidence of ischemic complications was greater in the SAC group (12.2% vs. 10.0%; RR = 1.68; 95% CI [1.37, 2.07]; p < 0.001), as was the incidence of hemorrhagic complications (7.3% vs. 5.1%; RR = 1.55; 95% CI [1.15, 2.08]; p = 0.004). Perioperative mortality was also elevated in the SAC group (6.7% vs. 6.8%; RR = 1.37; 95% CI [1.00, 1.88]; p = 0.048), with a non-significant trend towards higher long-term mortality (9.8% vs. 9.2%; RR = 1.35; 95% CI [0.98, 1.87]; p = 0.068). Functional outcomes at discharge (76.0% vs. 71.0%; RR = 0.97; 95% CI [0.92, 1.02]; p = 0.237), six months (57.8% vs. 60.8%; RR = 0.93; 95% CI [0.81, 1.07]; p = 0.296), and at the last follow-up (RR = 1.01; 95% CI [0.97, 1.06]; p = 0.592) were comparable between the two groups. CONCLUSIONS SAC significantly improves long-term occlusion rates for RIA compared to non-SAC, despite a higher incidence of complications. Careful patient selection and optimization of antiplatelet therapy may enhance the safety and efficacy of SAC for RIA treatment.
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Affiliation(s)
- Yu-Hu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yong-Lin He
- Department of Neurosurgery, The Second Hospital of Lanzhou University, Lanzhou, China
| | - Xiao-Yue Zhang
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Rui Shang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hai-Tao Hu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ting Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Sen Lin
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ya-Wen Pan
- Department of Neurosurgery, The Second Hospital of Lanzhou University, Lanzhou, China
| | - Chang-Wei Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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4
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Ünsal C, Güçlü G, Olcay AB, Hassankhani A, Bilgin C, Hakyemez B. How Flow Diverter Selection Can Affect the Flow Changes within a Jailed Ophthalmic Artery: A Computational Fluid Dynamics Study. Asian J Neurosurg 2024; 19:426-434. [PMID: 39205892 PMCID: PMC11349421 DOI: 10.1055/s-0044-1787868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
Abstract
Introduction Flow diverter (FD) stents are widely used to treat giant aneurysms by reducing blood flow into the aneurysm sac. However, choosing the optimal FD for a patient can be challenging when a nearby artery, such as the ophthalmic artery (OA), is jailed by the FD placement. This study compares the impact of two FD stents with different effective metal surface area (EMSA) values on OA occlusion. Materials and Methods A numerical model of a 59-year-old female patient with a giant aneurysm in the left internal carotid artery and a jailed OA was created based on clinical data. Two FD stents, FRED4017 and FRED4518, with different EMSA values at the aneurysm neck and OA inlet, were virtually deployed in the model. Blood flow and occlusion amount in the OA were simulated and compared between the two FD stents. Results FRED4017 had higher EMSA values than FRED4518 at the aneurysm neck (35% vs. 24.6%) and lower EMSA values at the OA inlet (15% vs. 21.2%). FRED4017 caused more occlusion in the OA than FRED4518 (40% vs. 28%), indicating a higher risk of ocular ischemic syndrome. Conclusion The EMSA value of FD stents affects the blood flow and occlusion amount in the jailed OA. Therefore, selecting an FD stent with a low EMSA value at the OA inlet may be beneficial for patients with a nearby jailed artery at the aneurysm neck.
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Affiliation(s)
- Can Ünsal
- Numerical Simulation and Spray Targeting Division, Department of Engineering, Bosch, Bursa, Türkiye
| | - Görkem Güçlü
- Department of Mechanical Engineering, Southern Methodist University, Dallas, Texas, United States
| | - Ali Bahadir Olcay
- Department of Mechanical Engineering, Faculty of Engineering, Yeditepe University, Istanbul, Türkiye
| | - Amir Hassankhani
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, California, United States
| | - Cem Bilgin
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, United States
| | - Bahattin Hakyemez
- Department of Radiology, Uludag University School of Medicine, Bursa, Türkiye
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Lanzino G, Rabinstein AA. Advances and Future Trends in the Diagnosis and Management of Subarachnoid Hemorrhage. Neurol Clin 2024; 42:705-716. [PMID: 38937037 DOI: 10.1016/j.ncl.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
Major advances in neurocritical care and the modalities used to treat aneurysms have led to improvement in the outlook of patients with aneurysmal subarachnoid hemorrhage. Yet, several knowledge gaps remain widely open. Variability in practices stems from the lack of solid evidence to guide management, which recent guidelines from professional organizations aim to mitigate. In this article, the authors review some of these gaps in knowledge, highlight important messages from recent management guidelines, emphasize aspects of our practice that we consider particularly useful to optimize patient outcomes, and suggest future areas of research.
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Affiliation(s)
- Giuseppe Lanzino
- Department of Neurological Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Department of Radiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Gaub M, Murtha G, Lafuente M, Webb M, Luo A, Birnbaum LA, Mascitelli JR, Al Saiegh F. Flow Diversion for Endovascular Treatment of Intracranial Aneurysms: Past, Present, and Future Directions. J Clin Med 2024; 13:4167. [PMID: 39064207 PMCID: PMC11278297 DOI: 10.3390/jcm13144167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Revised: 07/04/2024] [Accepted: 07/12/2024] [Indexed: 07/28/2024] Open
Abstract
Flow diversion for intracranial aneurysms emerged as an efficacious and durable treatment option over the last two decades. In a paradigm shift from intrasaccular aneurysm embolization to parent vessel remodeling as the mechanism of action, the proliferation of flow-diverting devices has enabled the treatment of many aneurysms previously considered untreatable. In this review, we review the history and development of flow diverters, highlight the pivotal clinical trials leading to their regulatory approval, review current devices including endoluminal and intrasaccular flow diverters, and discuss current and expanding indications for their use. Areas of clinical equipoise, including ruptured aneurysms and wide-neck bifurcation aneurysms, are summarized with a focus on flow diverters for these pathologies. Finally, we discuss future directions in flow diversion technology including bioresorbable flow diverters, transcriptomics and radiogenomics, and machine learning and artificial intelligence.
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Affiliation(s)
| | | | | | | | | | | | | | - Fadi Al Saiegh
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC 7843, San Antonio, TX 78229, USA; (M.G.); (G.M.); (M.L.); (M.W.); (A.L.); (L.A.B.); (J.R.M.)
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7
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Rantamo A, Gallé C, Numminen J, Virta J, Tanskanen P, Lindroos AC, Resendiz-Nieves J, Lehecka M, Niemelä M, Haeren R, Raj R. Flow diversion of ruptured intracranial aneurysms: a single-center study with a standardized antithrombotic treatment protocol. Acta Neurochir (Wien) 2024; 166:130. [PMID: 38467916 PMCID: PMC10927838 DOI: 10.1007/s00701-024-06029-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 02/28/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND The use of antithrombotic medication following acute flow diversion for a ruptured intracranial aneurysm (IA) is challenging with no current guidelines. We investigated the incidence of treatment-related complications and patient outcomes after flow diversion for a ruptured IA before and after the implementation of a standardized antithrombotic medication protocol. METHODS We conducted a single-center retrospective study including consecutive patients treated for acutely ruptured IAs with flow diversion during 2015-2023. We divided the patients into two groups: those treated before the implementation of the protocol (pre-protocol) and those treated after the implementation of the protocol (post-protocol). The primary outcomes were hemorrhagic and ischemic complications. A secondary outcome was clinical outcome using the modified Ranking Scale (mRS). RESULTS Totally 39 patients with 40 ruptured IAs were treated with flow diversion (69% pre-protocol, 31% post-protocol). The patient mean age was 55 years, 62% were female, 63% of aneurysms were in the posterior circulation, 92% of aneurysms were non-saccular, and 44% were in poor grade on admission. Treatment differences included the use of glycoprotein IIb/IIIa inhibitors (pre-group 48% vs. post-group 100%), and the use of early dual antiplatelets (pre-group 44% vs. 92% post-group). The incidence of ischemic complications was 37% and 42% and the incidence of hemorrhagic complications was 30% and 33% in the pre- and post-groups, respectively, with no between-group differences. There were three (11%) aneurysm re-ruptures in the pre-group and none in the post-group. There were no differences in mortality or mRS 0-2 between the groups at 6 months. CONCLUSION We found no major differences in the incidence of ischemic or hemorrhagic complications after the implementation of a standardized antithrombotic protocol for acute flow diversion for ruptured IAs. There is an urgent need for more evidence-based guidelines to optimize antithrombotic treatment after flow diversion in the setting of subarachnoid hemorrhage.
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Affiliation(s)
- Anni Rantamo
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland.
| | - Camille Gallé
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
- Department of Neurosurgery, Maastricht University Medical Center, PO box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Jussi Numminen
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
| | - Jyri Virta
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
| | - Päivi Tanskanen
- Anaesthesiology and Intensive Care Medicine, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Ann-Christine Lindroos
- Anaesthesiology and Intensive Care Medicine, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Julio Resendiz-Nieves
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
| | - Martin Lehecka
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
| | - Mika Niemelä
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
| | - Roel Haeren
- Department of Neurosurgery, Maastricht University Medical Center, PO box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Po Box 320, 00029 HUS, Helsinki, Finland
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8
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Fan Y, Lei J, Fei F, Liu J, Liu Y. A novel flow diverter device (Tubridge) for the treatment of intracranial aneurysms: a systematic review and meta-analysis. Neurosurg Rev 2023; 46:198. [PMID: 37561213 DOI: 10.1007/s10143-023-02100-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/20/2023] [Accepted: 07/24/2023] [Indexed: 08/11/2023]
Abstract
The flow diverter (FD) device has become a feasible and effective option for treating intracranial aneurysms. This study aimed to evaluate the efficacy and safety of Tubridge FD (TFD) in treating intracranial aneurysms and provide evidence for further research and clinical application. Electronic databases, including PubMed, Web of Science, Embase, and the Cochrane Library from inception to July 31, 2022, were searched. The eligible studies should include TFD investigations in treating intracranial aneurysms. Pooled technical success rate, complete occlusion rate, improvement rate, stable rate, symptom elimination rate, and adverse events rate were calculated with either the fixed-effects model or the random-effects model, depending on the results of tests for heterogeneity. Egger's tests were performed to assess the potential publication bias. A total of 7 studies (145 patients) were included in this study. The pooled technical success rate was 0.98, the complete occlusion rate was 0.79, the improvement rate was 0.21, and the stable rate was 0.05. One included study reported that the surgery-related mortality rate in the Tubridge group was higher than that in the control group (3.66% vs. 1.61%), while the surgery-related morbidity rate in the Tubridge group was 2.4% and that in the control group was 0. Findings of this meta-analysis indicate that TFD manifests promising and effective performance with acceptable adverse events in the treatment of intracranial aneurysms.
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Affiliation(s)
- Yingjun Fan
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jun Lei
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Fan Fei
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jun Liu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yanhui Liu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China.
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9
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Hoh BL, Ko NU, Amin-Hanjani S, Chou SHY, Cruz-Flores S, Dangayach NS, Derdeyn CP, Du R, Hänggi D, Hetts SW, Ifejika NL, Johnson R, Keigher KM, Leslie-Mazwi TM, Lucke-Wold B, Rabinstein AA, Robicsek SA, Stapleton CJ, Suarez JI, Tjoumakaris SI, Welch BG. 2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2023; 54:e314-e370. [PMID: 37212182 DOI: 10.1161/str.0000000000000436] [Citation(s) in RCA: 280] [Impact Index Per Article: 140.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
AIM The "2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage" replaces the 2012 "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage." The 2023 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with aneurysmal subarachnoid hemorrhage. METHODS A comprehensive search for literature published since the 2012 guideline, derived from research principally involving human subjects, published in English, and indexed in MEDLINE, PubMed, Cochrane Library, and other selected databases relevant to this guideline, was conducted between March 2022 and June 2022. In addition, the guideline writing group reviewed documents on related subject matter previously published by the American Heart Association. Newer studies published between July 2022 and November 2022 that affected recommendation content, Class of Recommendation, or Level of Evidence were included if appropriate. Structure: Aneurysmal subarachnoid hemorrhage is a significant global public health threat and a severely morbid and often deadly condition. The 2023 aneurysmal subarachnoid hemorrhage guideline provides recommendations based on current evidence for the treatment of these patients. The recommendations present an evidence-based approach to preventing, diagnosing, and managing patients with aneurysmal subarachnoid hemorrhage, with the intent to improve quality of care and align with patients' and their families' and caregivers' interests. Many recommendations from the previous aneurysmal subarachnoid hemorrhage guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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10
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Roethlisberger M, Aghlmandi S, Rychen J, Chiappini A, Zumofen DW, Bawarjan S, Stienen MN, Fung C, D'Alonzo D, Maldaner N, Steinsiepe VK, Corniola MV, Goldberg J, Cianfoni A, Robert T, Maduri R, Saliou G, Starnoni D, Weber J, Seule MA, Gralla J, Bervini D, Kulcsar Z, Burkhardt JK, Bozinov O, Remonda L, Marbacher S, Lövblad KO, Psychogios M, Bucher HC, Mariani L, Bijlenga P, Blackham KA, Guzman R. Impact of Very Small Aneurysm Size and Anterior Communicating Segment Location on Outcome after Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2023; 92:370-381. [PMID: 36469672 DOI: 10.1227/neu.0000000000002212] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 08/31/2022] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Very small anterior communicating artery aneurysms (vsACoA) of <5 mm in size are detected in a considerable number of patients with aneurysmal subarachnoid hemorrhage (aSAH). Single-center studies report that vsACoA harbor particular risks when treated. OBJECTIVE To assess the clinical and radiological outcome(s) of patients with aSAH diagnosed with vsACoA after aneurysm treatment and at discharge. METHODS Information on n = 1868 patients was collected in the Swiss Subarachnoid Hemorrhage Outcome Study registry between 2009 and 2014. The presence of a new focal neurological deficit at discharge, functional status (modified Rankin scale), mortality rates, and procedural complications (in-hospital rebleeding and presence of a new stroke on computed tomography) was assessed for vsACoA and compared with the results observed for aneurysms in other locations and with diameters of 5 to 25 mm. RESULTS This study analyzed n = 1258 patients with aSAH, n = 439 of which had a documented ruptured ACoA. ACoA location was found in 38% (n = 144/384) of all very small ruptured aneurysms. A higher in-hospital bleeding rate was found in vsACoA compared with non-ACoA locations (2.8 vs 2.1%), especially when endovascularly treated (2.1% vs 0.5%). In multivariate analysis, aneurysm size of 5 to 25 mm, and not ACoA location, was an independent risk factor for a new focal neurological deficit and a higher modified Rankin scale at discharge. Neither very small aneurysm size nor ACoA location was associated with higher mortality rates at discharge or the occurrence of a peri-interventional stroke. CONCLUSION Very small ruptured ACoA have a higher in-hospital rebleeding rate but are not associated with worse morbidity or mortality.
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Affiliation(s)
- Michel Roethlisberger
- Departments of Neurosurgery and Interventional Neuroradiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Soheila Aghlmandi
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jonathan Rychen
- Departments of Neurosurgery and Interventional Neuroradiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Alessio Chiappini
- Departments of Neurosurgery and Interventional Neuroradiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Daniel W Zumofen
- Department of Neurological Surgery, Maimonides Medical Center, New York, USA
| | - Schatlo Bawarjan
- Department of Neurosurgery, University Hospital of Göttingen, Göttingen, Germany
| | - Martin N Stienen
- Department of Neurosurgery and Department of Neuroradiology, University Hospital of Zurich, Zurich, Switzerland.,Departments of Neurosurgery and Neuroradiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Christian Fung
- Department of Neurosurgery, University Hospital of Freiburg, Freiburg Germany.,Departments of Neurosurgery and Neuroradiology, University Hospital of Bern, Bern Switzerland
| | - Donato D'Alonzo
- Departments of Neurosurgery and Neuroradiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Nicolai Maldaner
- Department of Neurosurgery and Department of Neuroradiology, University Hospital of Zurich, Zurich, Switzerland
| | - Valentin K Steinsiepe
- Departments of Neurosurgery and Neuroradiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Marco V Corniola
- Departments of Neurosurgery and Neuroradiology, University Hospital of Geneva, Geneva Switzerland
| | - Johannes Goldberg
- Departments of Neurosurgery and Neuroradiology, University Hospital of Bern, Bern Switzerland
| | - Alessandro Cianfoni
- Departments of Neurosurgery and Neuroradiology, Neurocenter of Southern Switzerland, Ospedale regionale, Lugano, Switzerland
| | - Thomas Robert
- Departments of Neurosurgery and Neuroradiology, Neurocenter of Southern Switzerland, Ospedale regionale, Lugano, Switzerland
| | - Rodolfo Maduri
- Clinique de Genolier, Swiss Medical Network, Genolier, Switzerland
| | - Guillaume Saliou
- Departments of Neurosurgery and Neuroradiology, University Hospital of Lausanne, Switzerland
| | - Daniele Starnoni
- Departments of Neurosurgery and Neuroradiology, University Hospital of Lausanne, Switzerland
| | - Johannes Weber
- Departments of Neurosurgery and Neuroradiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Martin A Seule
- Departments of Neurosurgery and Neuroradiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Jan Gralla
- Departments of Neurosurgery and Neuroradiology, University Hospital of Bern, Bern Switzerland
| | - David Bervini
- Departments of Neurosurgery and Neuroradiology, University Hospital of Bern, Bern Switzerland
| | - Zsolt Kulcsar
- Department of Neurosurgery and Department of Neuroradiology, University Hospital of Zurich, Zurich, Switzerland
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Oliver Bozinov
- Department of Neurosurgery and Department of Neuroradiology, University Hospital of Zurich, Zurich, Switzerland.,Departments of Neurosurgery and Neuroradiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Luca Remonda
- Departments of Neurosurgery and Neuroradiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Serge Marbacher
- Departments of Neurosurgery and Neuroradiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Karl-Olof Lövblad
- Departments of Neurosurgery and Neuroradiology, University Hospital of Geneva, Geneva Switzerland
| | - Marios Psychogios
- Departments of Neurosurgery and Interventional Neuroradiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Luigi Mariani
- Departments of Neurosurgery and Interventional Neuroradiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Philippe Bijlenga
- Departments of Neurosurgery and Neuroradiology, University Hospital of Geneva, Geneva Switzerland
| | - Kristine A Blackham
- Departments of Neurosurgery and Interventional Neuroradiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Raphael Guzman
- Departments of Neurosurgery and Interventional Neuroradiology, University Hospital Basel, University of Basel, Basel, Switzerland
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11
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Entezami P, Dalfino JC, Boulos AS, Yamamoto J, Holden DN, Field NC, Rock AK, Najera E, Paul AR. Use of intravenous cangrelor in the treatment of ruptured and unruptured cerebral aneurysms: an updated single-center analysis and pooled analysis of current studies. J Neurointerv Surg 2022:neurintsurg-2022-018986. [PMID: 35732485 DOI: 10.1136/neurintsurg-2022-018986] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/25/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Intracranial stent placement for the treatment of cerebral aneurysms is increasingly utilized in both ruptured and unruptured scenarios. Intravenous (IV) cangrelor is a relatively new antiplatelet agent that was initially approved for coronary interventions. In addition to our institution, five other centers have published their results using IV cangrelor in neurointerventional procedures. This article combines the aneurysm treatment data from all prior studies to provide insight into the safety and efficacy of cangrelor for intracranial aneurysm treatment. METHODS A prospectively maintained database was reviewed to identify all cases of IV cangrelor administration during aneurysm embolization. 20 additional patients were identified who had not been previously published. In addition, a literature search was performed to identify prior publications regarding cangrelor in neurointervention. The data from these were combined with our institutional results in a pooled-analysis. RESULTS Overall, 85 patients who received IV cangrelor during aneurysm embolization were identified, including 46 ruptured and 39 unruptured cases. The asymptomatic and symptomatic intracranial hemorrhage rates were 4% (2/46) for ruptured cases and 2.6% (1/39) for unruptured cases. The rate of retroperitoneal hematoma and gastrointestinal bleeding was 0%. There were no incidents of intraprocedural thromboembolic complication or intraprocedural in-stent thrombosis in either cohort. One subject suffered an ischemic stroke at 24 hours secondary to in-stent thrombosis in a ruptured case. CONCLUSIONS IV cangrelor during aneurysm embolization appears to be safe, with a symptomatic intracranial hemorrhage rate of 4% in ruptured cases and 2.6% in unruptured cases. More research is needed to determine the ideal dosing regimen.
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Affiliation(s)
- Pouya Entezami
- Neurosurgery, Albany Medical Center, Albany, New York, USA
| | - John C Dalfino
- Neurosurgery, Albany Medical Center, Albany, New York, USA
| | - Alan S Boulos
- Neurosurgery, Albany Medical Center, Albany, New York, USA
| | | | - Devin N Holden
- Department of Pharmacy, Albany Medical Center, Albany, New York, USA
| | | | - Andrew K Rock
- Neurosurgery, Albany Medical Center, Albany, New York, USA
| | - Edinson Najera
- Neurosurgery, Albany Medical Center, Albany, New York, USA
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