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Cho WC, Choi JH, Lee KS, Kim BS, Shin YS. Risk Factors for the Recurrence of Distal Anterior Cerebral Artery Aneurysms After Endovascular Treatment. World Neurosurg 2024; 186:e481-e486. [PMID: 38583568 DOI: 10.1016/j.wneu.2024.03.161] [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: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 04/09/2024]
Abstract
OBJECTIVE We aimed to investigate risk factors for the recurrence of distal anterior cerebral artery (DACA) aneurysms after endovascular treatment (EVT). METHODS The clinical and radiologic outcomes of DACA aneurysms treated with endovascular methods at a single tertiary hospital from September 2008 to December 2021 were retrospectively reviewed. We measured the angle between 2 distal branches of DACA aneurysms and categorized the angle as follows: 1) wide-angle (≥180°), and 2) narrow-angle type configuration (<180°). Univariate and multivariate analyses were performed to demonstrate the relationships between characteristics of DACA aneurysm and recurrence risk. RESULTS In total, 132 DACA aneurysms were treated in our institution. Among these, 47 DACA aneurysms after EVT were included in this study. Forty patients underwent coil embolization without stent, 7 for stent-assisted coil embolization. At the last follow-up (mean 30.2 ± 24.2 months), overall recurrence rate was 23.4% (n = 11). Recurrence rate of the wide-angle type (9 of 23, 39.1%) was significantly greater than narrow-angle type (2 of 24, 8.3%) (P = 0.041; odds ratio 8.174, 95% confidence interval 1.094-61.066). Irregular shape of the DACA aneurysm also showed significantly greater recurrence rate (P = 0.011; odds ratio 10.663, 95% confidence interval 1.701-66.838) after endovascular treatment. CONCLUSIONS The wide-angle between 2 distal branches of DACA aneurysm and irregular shape might be independent risk factors for the recurrence after endovascular treatment for DACA aneurysms.
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Affiliation(s)
- Woo Cheul Cho
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, South Korea
| | - Jai Ho Choi
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, South Korea.
| | - Kwan Sung Lee
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, South Korea
| | - Bum-Soo Kim
- Department of Radiology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, South Korea
| | - Yong Sam Shin
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, South Korea
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2
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Sannwald LW, Moskopp ML, Moskopp D. A Step-by-Step Dissection of Cerebral Pathologies for Neurosurgical Trainees: The Middle Cerebral Artery Bifurcation Aneurysm. J Neurol Surg A Cent Eur Neurosurg 2024; 85:202-214. [PMID: 36940721 DOI: 10.1055/s-0042-1760397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage remains one of the most prevalent causes of strokes in the young causing a high socioeconomic damage. Both emergent and elective treatments of intracranial aneurysms remain essential challenges for neurovascular centers. We aim to present conceptual education on clip ligation of middle cerebral artery bifurcation aneurysms in an accessible and structured way to maximize the educational takeaway of residents from aneurysm cases. METHODS After 30 years of experience of the senior author in cerebrovascular surgery in three centers, we closely reviewed an exemplary case of elective right middle cerebral artery bifurcation aneurysm clipping and contrasted it to an alternative microneurosurgical approach to illustrate key principles of microneurosurgical clip ligation for neurosurgical trainees. RESULTS Dissection of the sylvian fissure, subfrontal approach to the optic-carotid complex, proximal control, aneurysm dissection, dissection of kissing branches, dissection of aneurysm fundus, temporary and permanent clipping, as well as aneurysm inspection and resection are highlighted as key steps of clip ligation. This proximal-to-distal approach is contrasted to the distal-to-proximal approach. Additionally, general principles of intracranial surgery such as use of retraction, arachnoid dissection, and draining of cerebrospinal fluid are addressed. CONCLUSION Due to a constantly decreasing case load in the era of neurointerventionalism, the paradox of facing increased complexity with decreased experience must be met with a sophisticated practical and theoretical education of neurosurgical trainees early on and with a low threshold.
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Affiliation(s)
| | - Mats Leif Moskopp
- Department of Neurosurgery, Vivantes Klinikum im Friedrichshain, Berlin, Berlin, Germany
- Institute of Physiology, TU Dresden Faculty of Medicine Carl Gustav Carus, Dresden, Sachsen, Germany
| | - Dag Moskopp
- Department of Neurosurgery, Vivantes Klinikum im Friedrichshain, Berlin, Berlin, Germany
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Toader C, Kakucs C, Dobrin N, Covache-Busuioc RA, Bratu BG, Popa AA, Glavan LA, Corlatescu AD, Grama MGN, Costin HP, Ciurea AV. Cerebral Aneurysm Characteristics and Surgical Outcomes: An In-Depth Analysis of 346 Cases Operated Using Microsurgical Clipping. Cureus 2024; 16:e56933. [PMID: 38665760 PMCID: PMC11043903 DOI: 10.7759/cureus.56933] [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] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
This comprehensive study analyzes 346 surgically treated intracranial aneurysms, emphasizing the importance of understanding risk factors and prevalent characteristics in patients. Intracranial aneurysms, primarily of the saccular or berry type, significantly contribute to nontraumatic subarachnoid hemorrhages and demonstrate a rising incidence due to advances in imaging techniques. The study highlights a gender discrepancy in aneurysm occurrence and a higher prevalence in individuals over 30 years old. The research delves into various aspects, including aneurysm localization, diameter, neck dimensions, and rupture status, with a focus on the anterior communicating artery and middle communicating artery as predominant locations. Significant findings include the prevalence of ruptured aneurysms and the impact of arterial hypertension, atherosclerosis, obesity, and diabetes on aneurysm epidemiology. The study also investigates the occurrence of vasospasm, a significant factor in delayed morbidity and mortality in aneurysmal subarachnoid hemorrhage. The utilization of the Glasgow Outcome Scale and other quantification scales aids in understanding the severity and postoperative outcomes of intracranial aneurysms. Challenges such as the incidence of reopenings and postoperative osteomyelitis are addressed, underlining the need for refined protocols and multidisciplinary approaches in treatment. The study's results contribute to the existing knowledge base on intracranial aneurysms, emphasizing the importance of ongoing research and tailored treatment strategies. The comprehensive nature of this analysis, covering preoperative, intraoperative, and postoperative factors, provides valuable insights into the complex interplay of risk factors and clinical outcomes in patients with intracranial aneurysms.
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Affiliation(s)
- Corneliu Toader
- Department of Neurosurgery, "Carol Davila" University of Medicine and Pharmacy, Bucharest, ROU
- Department of Neurosurgery, National Institute of Neurology and Neurovascular Diseases, Bucharest, ROU
| | - Cristian Kakucs
- Department of Neurosurgery, "Transilvania" University of Brasov, Faculty of General Medicine, Brasov, ROU
- Department of Neurosurgery, Clinical Emergency Hospital of Brasov, Brasov, ROU
| | - Nicolaie Dobrin
- Department of Neurosurgery, Clinical Emergency Hospital "Prof. Dr. Nicolae Oblu", Iasi, ROU
| | | | - Bogdan-Gabriel Bratu
- Department of Neurosurgery, "Carol Davila" University of Medicine and Pharmacy, Bucharest, ROU
| | - Andrei Adrian Popa
- Department of Neurosurgery, "Carol Davila" University of Medicine and Pharmacy, Bucharest, ROU
| | - Luca-Andrei Glavan
- Department of Neurosurgery, "Carol Davila" University of Medicine and Pharmacy, Bucharest, ROU
| | | | | | - Horia-Petre Costin
- Department of Neurosurgery, "Carol Davila" University of Medicine and Pharmacy, Bucharest, ROU
| | - Alexandru Vladimir Ciurea
- Department of Neurosurgery, "Carol Davila" University of Medicine and Pharmacy, Bucharest, ROU
- Department of Neurosurgery, Sanador Clinical Hospital, Bucharest, ROU
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4
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Drexler R, Sauvigny T, Pantel TF, Ricklefs FL, Catapano JS, Wanebo JE, Lawton MT, Sanchin A, Hecht N, Vajkoczy P, Raygor K, Tonetti D, Abla A, El Naamani K, Tjoumakaris SI, Jabbour P, Jankowitz BT, Salem MM, Burkhardt JK, Wagner A, Wostrack M, Gempt J, Meyer B, Gaub M, Mascitelli JR, Dodier P, Bavinzski G, Roessler K, Stroh N, Gmeiner M, Gruber A, Figueiredo EG, da Silva Coelho ACS, Bervitskiy AV, Anisimov ED, Rzaev JA, Krenzlin H, Keric N, Ringel F, Park D, Kim MC, Marcati E, Cenzato M, Westphal M, Dührsen L. Global Outcomes for Microsurgical Clipping of Unruptured Intracranial Aneurysms: A Benchmark Analysis of 2245 Cases. Neurosurgery 2024; 94:369-378. [PMID: 37732745 PMCID: PMC10766286 DOI: 10.1227/neu.0000000000002689] [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: 04/18/2023] [Accepted: 07/27/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Benchmarks represent the best possible outcome and help to improve outcomes for surgical procedures. However, global thresholds mirroring an optimal and reachable outcome for microsurgical clipping of unruptured intracranial aneurysms (UIA) are not available. This study aimed to define standardized outcome benchmarks in patients who underwent clipping of UIA. METHODS A total of 2245 microsurgically treated UIA from 15 centers were analyzed. Patients were categorized into low- ("benchmark") and high-risk ("nonbenchmark") patients based on known factors affecting outcome. The benchmark was defined as the 75th percentile of all centers' median scores for a given outcome. Benchmark outcomes included intraoperative (eg, duration of surgery, blood transfusion), postoperative (eg, reoperation, neurological status), and aneurysm-related factors (eg, aneurysm occlusion). Benchmark cutoffs for aneurysms of the anterior communicating/anterior cerebral artery, middle cerebral artery, and posterior communicating artery were determined separately. RESULTS Of the 2245 cases, 852 (37.9%) patients formed the benchmark cohort. Most operations were performed for middle cerebral artery aneurysms (53.6%), followed by anterior communicating and anterior cerebral artery aneurysms (25.2%). Based on the results of the benchmark cohort, the following benchmark cutoffs were established: favorable neurological outcome (modified Rankin scale ≤2) ≥95.9%, postoperative complication rate ≤20.7%, length of postoperative stay ≤7.7 days, asymptomatic stroke ≤3.6%, surgical site infection ≤2.7%, cerebral vasospasm ≤2.5%, new motor deficit ≤5.9%, aneurysm closure rate ≥97.1%, and at 1-year follow-up: aneurysm closure rate ≥98.0%. At 24 months, benchmark patients had a better score on the modified Rankin scale than nonbenchmark patients. CONCLUSION This study presents internationally applicable benchmarks for clinically relevant outcomes after microsurgical clipping of UIA. These benchmark cutoffs can serve as reference values for other centers, patient registries, and for comparing the benefit of other interventions or novel surgical techniques.
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Affiliation(s)
- Richard Drexler
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias F. Pantel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franz L. Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joshua S. Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - John E. Wanebo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T. Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Aminaa Sanchin
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nils Hecht
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Kunal Raygor
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Daniel Tonetti
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Adib Abla
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula I. Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Brian T. Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Pennsylvania Medicine, Philadelphia, Pennsylvania, USA
| | - Mohamed M. Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Pennsylvania Medicine, Philadelphia, Pennsylvania, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Pennsylvania Medicine, Philadelphia, Pennsylvania, USA
| | - Arthur Wagner
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Michael Gaub
- Department of Neurosurgery, University of Texas Health and Science Center at San Antonio, San Antonio, Texas, USA
| | - Justin R. Mascitelli
- Department of Neurosurgery, University of Texas Health and Science Center at San Antonio, San Antonio, Texas, USA
| | - Philippe Dodier
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Gerhard Bavinzski
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Karl Roessler
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Nico Stroh
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Matthias Gmeiner
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Andreas Gruber
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Eberval G. Figueiredo
- Division of Neurological Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | | | | | | | - Harald Krenzlin
- Department of Neurosurgery, University Hospital Mainz, Mainz, Germany
| | - Naureen Keric
- Department of Neurosurgery, University Hospital Mainz, Mainz, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Hospital Mainz, Mainz, Germany
| | - Dougho Park
- Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang, Korea
| | - Mun-Chul Kim
- Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang, Korea
| | - Eleonora Marcati
- Department of Neurosurgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marco Cenzato
- Department of Neurosurgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lasse Dührsen
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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5
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Sauvigny J, Drexler R, Pantel TF, Ricklefs FL, Catapano JS, Wanebo JE, Lawton MT, Sanchin A, Hecht N, Vajkoczy P, Raygor K, Tonetti D, Abla A, El Naamani K, Tjoumakaris SI, Jabbour P, Jankowitz BT, Salem MM, Burkhardt JK, Wagner A, Wostrack M, Gempt J, Meyer B, Gaub M, Mascitelli JR, Dodier P, Bavinzski G, Roessler K, Stroh N, Gmeiner M, Gruber A, Figueiredo EG, Coelho ACSDS, Bervitskiy AV, Anisimov ED, Rzaev JA, Krenzlin H, Keric N, Ringel F, Park D, Kim MC, Marcati E, Cenzato M, Krause L, Westphal M, Dührsen L, Sauvigny T. Microsurgical Clipping of Unruptured Anterior Circulation Aneurysms-A Global Multicenter Investigation of Perioperative Outcomes. Neurosurgery 2024; 94:00006123-990000000-01023. [PMID: 38240568 PMCID: PMC11073773 DOI: 10.1227/neu.0000000000002829] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 11/13/2023] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Microsurgical aneurysm repair by clipping continues to be highly important despite increasing endovascular treatment options, especially because of inferior occlusion rates. This study aimed to present current global microsurgical treatment practices and to identify risk factors for complications and neurological deterioration after clipping of unruptured anterior circulation aneurysms. METHODS Fifteen centers from 4 continents participated in this retrospective cohort study. Consecutive patients who underwent elective microsurgical clipping of untreated unruptured intracranial aneurysm between January 2016 and December 2020 were included. Posterior circulation aneurysms were excluded. Outcome parameters were postsurgical complications and neurological deterioration (defined as decline on the modified Rankin Scale) at discharge and during follow-up. Multivariate regression analyses were performed adjusting for all described patient characteristics. RESULTS Among a total of 2192 patients with anterior circulation aneurysm, complete occlusion of the treated aneurysm was achieved in 2089 (95.3%) patients at discharge. The occlusion rate remained stable (94.7%) during follow-up. Regression analysis identified hypertension (P < .02), aneurysm diameter (P < .001), neck diameter (P < .05), calcification (P < .01), and morphology (P = .002) as preexisting risk factors for postsurgical complications and neurological deterioration at discharge. Furthermore, intraoperative aneurysm rupture (odds ratio 2.863 [CI 1.606-5.104]; P < .01) and simultaneous clipping of more than 1 aneurysm (odds ratio 1.738 [CI 1.186-2.545]; P < .01) were shown to be associated with an increased risk of postsurgical complications. Yet, none of the surgical-related parameters had an impact on neurological deterioration. Analyzing volume-outcome relationship revealed comparable complication rates (P = .61) among all 15 participating centers. CONCLUSION Our international, multicenter analysis presents current microsurgical treatment practices in patients with anterior circulation aneurysms and identifies preexisting and surgery-related risk factors for postoperative complications and neurological deterioration. These findings may assist in decision-making for the optimal therapeutic regimen of unruptured anterior circulation aneurysms.
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Affiliation(s)
- Jennifer Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Richard Drexler
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias F. Pantel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franz L. Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joshua S. Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - John E. Wanebo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T. Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Aminaa Sanchin
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nils Hecht
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Kunal Raygor
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Daniel Tonetti
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Adib Abla
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula I. Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Brian T. Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Mohamed M. Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Arthur Wagner
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Michael Gaub
- Department of Neurosurgery, University of Texas Health and Science Center at San Antonio, San Antonio, Texas, USA
| | - Justin R. Mascitelli
- Department of Neurosurgery, University of Texas Health and Science Center at San Antonio, San Antonio, Texas, USA
| | - Philippe Dodier
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Gerhard Bavinzski
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Karl Roessler
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Nico Stroh
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Matthias Gmeiner
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Andreas Gruber
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Eberval G. Figueiredo
- Division of Neurological Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | | | | | | | - Harald Krenzlin
- Department of Neurosurgery, University Medical Center Mainz, Mainz, Germany
| | - Naureen Keric
- Department of Neurosurgery, University Medical Center Mainz, Mainz, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center Mainz, Mainz, Germany
| | - Dougho Park
- Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang, Korea
| | - Mun-Chul Kim
- Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang, Korea
| | - Eleonora Marcati
- Department of Neurosurgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marco Cenzato
- Department of Neurosurgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Linda Krause
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lasse Dührsen
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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6
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Yang K, Begley SL, Lynch D, Turpin J, Aminnejad M, Farrokhyar F, Dehdashti AR. Long-term outcomes of surgical clipping of saccular middle cerebral artery aneurysms: a consecutive series of 92 patients. Neurosurg Rev 2023; 46:271. [PMID: 37843680 DOI: 10.1007/s10143-023-02167-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/17/2023] [Accepted: 09/24/2023] [Indexed: 10/17/2023]
Abstract
Despite advances in endovascular treatment, microsurgical clipping of middle cerebral artery (MCA) aneurysms remains appropriate. We review the high occlusion rate and treatment durability seen with surgical clipping of MCA aneurysms. We retrospectively reviewed patients who underwent microsurgical clipping of saccular MCA aneurysms by a single surgeon. Outcomes included aneurysm occlusion rate and durability, modified Rankin scale (mRS), and postoperative neurological morbidities. Ninety-two patients with 92 saccular MCA aneurysms were included, 50% of which were ruptured aneurysms. The mean follow-up period was 59 months. Complete aneurysm occlusion was achieved in all except one patient (99%) with near-complete occlusion. MCA aneurysm clipping was durable, with only one patient (1%) requiring retreatment after 4 years due to regrowth. Of the cohort, 79.3% achieved mRS 0-2 at last follow-up, including all with unruptured aneurysms. Poor outcome at discharge was associated with age > 65 (p = .03), postoperative neurological morbidities (p = .006), and aneurysm rupture (p < .001). Older age remained the single correlate for poor long-term outcome (p = .04). For ruptured aneurysms, predictors of poor long-term outcome included hemiparesis on presentation (p = .017), clinical vasospasm requiring treatment (p = .026), and infarction related to vasospasm (p = .041). Older age (p = .046) and complex anatomy (p = .036) were predictors of new postoperative neurological morbidities in the unruptured group. MCA aneurysm clipping is safe, durable, and should be considered first-line treatment for patients with saccular MCA aneurysms, especially in centers with abundant surgical experience.
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Affiliation(s)
- Kaiyun Yang
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr Manhasset, Hempstead, NY, 11030, USA
- Community Neurosciences Institute, Community Health Partners, Fresno, CA, USA
| | - Sabrina L Begley
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr Manhasset, Hempstead, NY, 11030, USA
| | - Daniel Lynch
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr Manhasset, Hempstead, NY, 11030, USA
| | - Justin Turpin
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr Manhasset, Hempstead, NY, 11030, USA
| | - Minoo Aminnejad
- Department of Surgery, Department of Health, Evidence, Impact, McMaster University, Hamilton, ON, Canada
| | - Forough Farrokhyar
- Department of Surgery, Department of Health, Evidence, Impact, McMaster University, Hamilton, ON, Canada
| | - Amir R Dehdashti
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr Manhasset, Hempstead, NY, 11030, USA.
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7
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Zhou Z, Yu J. Endovascular treatment of a supraclinoid internal carotid artery fenestration aneurysm: A case report and literature review. Heliyon 2023; 9:e17605. [PMID: 37408880 PMCID: PMC10318508 DOI: 10.1016/j.heliyon.2023.e17605] [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] [Received: 02/27/2023] [Revised: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 07/07/2023] Open
Abstract
Supraclinoid internal carotid artery (ICA) fenestration aneurysm is rare. Except for open surgery, endovascular treatment (EVT) is considered an alternative for such an aneurysm. However, experience with this procedure is lacking. Therefore, we reported such a case. A 61-year-old woman suffered subarachnoid hemorrhage. Digital subtracted angiography (DSA) showed bilateral middle cerebral artery (MCA) aneurysms and a saccular aneurysm associated with fenestration of the supraclinoid ICA. Two MCA aneurysms were treated with single coiling, and the supraclinoid ICA fenestration aneurysm was coiled under stent assistance. The postoperative recovery was uneventful. At this time, a literature review was performed on the role of EVT in supraclinoid ICA fenestration aneurysms. A total of 13 supraclinoid ICA fenestration aneurysms treated by EVT in 11 cases, including our case, were obtained. After EVT, good outcomes were obtained in all cases. To our knowledge, this is the first study to review the role of EVT for supraclinoid ICA fenestration aneurysms. Our case report and literature review indicated that EVT for such aneurysms may be feasible and act as a therapeutic alternative.
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Affiliation(s)
| | - Jinlu Yu
- Corresponding author. Department of Neurosurgery, The First Hospital of Jilin University, 1 Xinmin Avenue, Changchun, Jilin, 130021, China.
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8
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Jin D, Wang Q, Chan KF, Xia N, Yang H, Wang Q, Yu SCH, Zhang L. Swarming self-adhesive microgels enabled aneurysm on-demand embolization in physiological blood flow. SCIENCE ADVANCES 2023; 9:eadf9278. [PMID: 37172097 PMCID: PMC10181194 DOI: 10.1126/sciadv.adf9278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
The recent rise of swarming microrobotics offers great promise in the revolution of minimally invasive embolization procedure for treating aneurysm. However, targeted embolization treatment of aneurysm using microrobots has significant challenges in the delivery capability and filling controllability. Here, we develop an interventional catheterization-integrated swarming microrobotic platform for aneurysm on-demand embolization in physiological blood flow. A pH-responsive self-healing hydrogel doped with magnetic and imaging agents is developed as the embolic microgels, which enables long-term self-adhesion under biological condition in a controllable manner. The embolization strategy is initiated by catheter-assisted deployment of swarming microgels, followed by the application of external magnetic field for targeted aggregation of microrobots into aneurysm sac under the real-time guidance of ultrasound and fluoroscopy imaging. Mild acidic stimulus is applied to trigger the welding of microgels with satisfactory bio-/hemocompatibility and physical stability and realize complete embolization. Our work presents a promising connection between the design and control of microrobotic swarms toward practical applications in dynamic environments.
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Affiliation(s)
- Dongdong Jin
- School of Materials Science and Engineering, Harbin Institute of Technology (Shenzhen), Shenzhen, 518071, Guangdong, China
- Department of Mechanical and Automation Engineering, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong 999077, China
| | - Qinglong Wang
- Department of Mechanical and Automation Engineering, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong 999077, China
| | - Kai Fung Chan
- Chow Yuk Ho Technology Centre for Innovative Medicine, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong 999077, China
- Department of Biomedical Engineering, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong 999077, China
| | - Neng Xia
- Department of Mechanical and Automation Engineering, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong 999077, China
| | - Haojin Yang
- Department of Mechanical and Automation Engineering, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong 999077, China
| | - Qianqian Wang
- Department of Mechanical and Automation Engineering, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong 999077, China
- Jiangsu Key Laboratory for Design and Manufacture of Micro-Nano Biomedical Instruments, School of Mechanical Engineering, Southeast University, Nanjing 211000, China
| | - Simon Chun Ho Yu
- Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong 999077, China
- Vascular and Interventional Radiology Foundation Clinical Science Centre, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong 999077, China
| | - Li Zhang
- Department of Mechanical and Automation Engineering, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong 999077, China
- Chow Yuk Ho Technology Centre for Innovative Medicine, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong 999077, China
- Department of Biomedical Engineering, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong 999077, China
- T-Stone Robotics Institute, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong 999077, China
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9
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Duan G, Zhang Y, Yin H, Wu Y, Zhang X, Zhao R, Yang P, Zuo Q, Feng Z, Zhang L, Dai D, Fang Y, Zhao K, Huang Q, Hong B, Xu Y, Zhou Y, Li Q, Liu J. Predictors of recurrence and complications for the endovascular treatment of unruptured middle cerebral artery aneurysm: A high-volume center experience over 12 years. Eur J Radiol 2023; 163:110833. [PMID: 37080061 DOI: 10.1016/j.ejrad.2023.110833] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 04/02/2023] [Accepted: 04/07/2023] [Indexed: 04/22/2023]
Abstract
OBJECT To assess the safety and efficacy of endovascular treatment (EVT) of unruptured middle cerebral artery (MCA) aneurysms in a retrospective cohort in a high-volume center. Predictors of complications and recurrence were determined. METHODS Retrospectively reviewed our database of prospectively collected information for all patients with unruptured MCA aneurysms that were treated by endovascular approach from March 2008 to December 2020. A multivariate analysis was conducted to identify predictors of complications and recurrence. RESULTS Three hundred and fifty-one patients with 370 unruptured MCA aneurysms underwent EVT were included in this study. Seventy-three aneurysms (19.7%) were treated by coiling without stent, 297 (80.3%) with stent-assisted coiling. The procedures were performed with a technical success rate of 100%. Procedure-related neurological complications occurred in 15 patients (4.1%), including 1 patient died from post-procedural stent thrombosis. Age ≥ 65 years (P = 0.039; OR = 3.400; 95% CI, 1.065-10.860) and aneurysm size ≥ 5 mm (P = 0.009; OR = 15.524; 95% CI, 1.988-121.228) were significantly associated with ischemic complications of EVT. Three hundred and six aneurysms were (87.2%) completed image follow-up (235 DSA and 71 CE-MRA). The median angiographic follow-up time were 7.0 ± 4.3 months (range from 1 to 88 months). Follow-up angiograms showed that 249 aneurysms (81.4%) were completed occluded, 29 aneurysms (9.5%) were improved, 17 aneurysms (5.6%) were stable, and 11 aneurysms (3.6%) were recanalized and 10 of them accepted retreatments. Aneurysm size ≥ 10 mm was a predictor of recanalization (P = 0.004; OR = 11.213; 95% CI, 2.127-59.098) and stent-assisted coiling can significantly reduce recanalization (P = 0.004; OR = 0.105; 95% CI, 0.023-0.479). CONCLUSIONS EVT is a safe and effective therapeutics for unruptured MCA aneurysms management, and provides durable aneurysm occlusion rate during follow-up. Large MCA aneurysms have higher recurrence and ischemic complications risk after EVT. Stent-assisted coiling can significantly reduce the recurrence rate without increasing the risk of complications.
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Affiliation(s)
- Guoli Duan
- Department of Neurovascular Center, Changhai Hospital Affiliated to the Naval Medical University, Shanghai, China
| | - Yuhang Zhang
- Department of Neurovascular Center, Changhai Hospital Affiliated to the Naval Medical University, Shanghai, China
| | - Hongwei Yin
- Department of Neurovascular Center, Changhai Hospital Affiliated to the Naval Medical University, Shanghai, China
| | - Yina Wu
- Department of Neurovascular Center, Changhai Hospital Affiliated to the Naval Medical University, Shanghai, China
| | - Xiaoxi Zhang
- Department of Neurovascular Center, Changhai Hospital Affiliated to the Naval Medical University, Shanghai, China
| | - Rui Zhao
- Department of Neurovascular Center, Changhai Hospital Affiliated to the Naval Medical University, Shanghai, China
| | - Pengfei Yang
- Department of Neurovascular Center, Changhai Hospital Affiliated to the Naval Medical University, Shanghai, China
| | - Qiao Zuo
- Department of Neurovascular Center, Changhai Hospital Affiliated to the Naval Medical University, Shanghai, China
| | - Zhengzhe Feng
- Department of Neurovascular Center, Changhai Hospital Affiliated to the Naval Medical University, Shanghai, China
| | - Lei Zhang
- Department of Neurovascular Center, Changhai Hospital Affiliated to the Naval Medical University, Shanghai, China
| | - Dongwei Dai
- Department of Neurovascular Center, Changhai Hospital Affiliated to the Naval Medical University, Shanghai, China
| | - Yibin Fang
- Department of Neurovascular Center, Changhai Hospital Affiliated to the Naval Medical University, Shanghai, China; Department of Neurovascular Center, Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
| | - Kaijun Zhao
- Department of Neurovascular Center, Changhai Hospital Affiliated to the Naval Medical University, Shanghai, China; Department of Neurosurgery, East Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
| | - Qinghai Huang
- Department of Neurovascular Center, Changhai Hospital Affiliated to the Naval Medical University, Shanghai, China
| | - Bo Hong
- Department of Neurovascular Center, Changhai Hospital Affiliated to the Naval Medical University, Shanghai, China; Department of Neurovascular Center, Shanghai First People's Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yi Xu
- Department of Neurovascular Center, Changhai Hospital Affiliated to the Naval Medical University, Shanghai, China
| | - Yu Zhou
- Department of Neurovascular Center, Changhai Hospital Affiliated to the Naval Medical University, Shanghai, China.
| | - Qiang Li
- Department of Neurovascular Center, Changhai Hospital Affiliated to the Naval Medical University, Shanghai, China.
| | - Jianmin Liu
- Department of Neurovascular Center, Changhai Hospital Affiliated to the Naval Medical University, Shanghai, China.
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10
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Wang X, Han G, Wang H, Shang Y, Shi M, Wang X, Bao J, Wang Z, Tong X. Cerebral revascularization for complex middle cerebral artery aneurysms: surgical strategies and outcomes in a single center. Neurosurg Rev 2023; 46:68. [PMID: 36917348 DOI: 10.1007/s10143-023-01977-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/16/2023] [Accepted: 03/07/2023] [Indexed: 03/16/2023]
Abstract
Cerebral revascularization is the ultimate treatment for a subset of complex middle cerebral artery (MCA) aneurysms. The decision for the revascularization strategy should be made during the treatment process. This study aimed to summarize the revascularization strategies for different types of complex MCA aneurysms and their outcomes. The clinical data of patients with complex MCA aneurysms who underwent cerebral revascularization since 2015 were analyzed retrospectively. The aneurysms were classified according to the location and other main characteristics that affect the selection of surgical modalities. The corresponding surgical modalities and treatment outcomes were summarized. A total of 29 patients with 29 complex MCA aneurysms were treated with cerebral revascularization from 2015 to 2022. Treated aneurysms were located at the prebifurcation segment in 7 patients, bifurcation segment in 12 patients, and postbifurcation segment in 10 patients. Surgical modalities in the prebifurcation segment included four high-flow extracranial-to-intracranial (EC-IC) bypasses with aneurysm trapping or proximal occlusion, two IC-IC bypasses with aneurysm excision, and one combination bypass with aneurysm excision. In the bifurcation segment, surgical modalities included two low-flow EC-IC bypasses with aneurysm excision or trapping, six IC-IC bypasses with aneurysm excision, three combination bypasses with aneurysm excision, and one constructive clipping with IC-IC bypass. In the postbifurcation segment, surgical modalities included nine IC-IC bypasses with aneurysm excision and low-flow EC-IC bypass with aneurysm trapping. The revascularization strategy for prebifurcation aneurysms was determined based on the involvement of lenticulostriate arteries, whereas the strategy for bifurcation aneurysms was determined based on the number of distal bifurcations and the shape of the aneurysm. The location of the aneurysm determined the revascularization strategy for aneurysms in the postbifurcation segments. Angiography demonstrated that aneurysms were completely obliterated in 26 cases and shrank in 3 cases, and all bypasses except one were patent. The mean follow-up period was 47.5 months. Three patients developed hemiplegic paralysis, and one developed transient aphasia postoperatively due to cerebral ischemia. No new neurological dysfunction occurred in the other 25 patients with no recurrence or enlargement of aneurysms during the follow-up. Prebifurcation aneurysms involving the lenticulostriate arteries require proximal occlusion with high-flow bypass. Most of the other aneurysms can be safely excised or trapped by appropriate revascularization strategies according to their location and orientation.
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Affiliation(s)
- Xingdong Wang
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Guoqing Han
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Hu Wang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China.,Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
| | - Yanguo Shang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China.,Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
| | - Minggang Shi
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China.,Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
| | - Xuan Wang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China.,Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
| | - Jingang Bao
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Zhiqiang Wang
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Xiaoguang Tong
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China. .,Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China. .,Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China. .,Laboratory of Microneurosurgery, Tianjin Neurosurgical Institute, Tianjin, China. .,Tianjin Key Laboratory of Cerebral Vascular and Neural Degenerative Diseases, Tianjin, China.
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11
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Le K, Heskett C, De Stefano FA, Fry L, Lei C, Dharia A, Brake A, Chatley K, Peterson J, Ebersole K. An Analysis of Landmark Articles Regarding Aneurysms of the Middle Cerebral Artery. World Neurosurg 2023; 171:72-83. [PMID: 36473598 DOI: 10.1016/j.wneu.2022.11.135] [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: 10/18/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Aneurysms located on the middle cerebral artery (MCA) range from 22% to 31.5% in prevalence of all aneurysms in the anterior cerebral circulation. This bibliometric analysis summarizes the most cited articles on MCA aneurysms and highlights the landmark publications that contributed to evidence-based practice. METHODS In the execution of this bibliometric-based review article, the Scopus database was used to perform a title-specific, keyword-based search for all publications until August 2022. The keyword "(middle cerebral artery OR MCA) AND aneurysm" was used. Our results were arranged in descending order based on the citation count of the article. The 100 most cited articles were selected for analysis. Parameters included the following: title, citation count, citations per year, authors, specialty of first author, institution, country of origin, publishing journal, Source Normalized Impact per Paper, and Hirsch index. RESULTS The keyword-based search showed that 1206 articles on MCA aneurysms were published up to August 2022. The top 100 articles were published between 1940 and 2019. The top 100 most cited articles collected a total of 6232 citations with an average of 62.3 citations per article. The rate of self-citations accounted for an average of 5.75% of the total number of citations. CONCLUSIONS The bibliometric analysis provides a quantitative overview of how medical literature and interventions are analyzed in academic medicine. In the present study, we evaluated the global trends in research regarding MCA aneurysms by finding the top 100 most cited articles.
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Affiliation(s)
- Kevin Le
- University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Cody Heskett
- University of Kansas School of Medicine, Kansas City, Kansas, USA.
| | - Frank A De Stefano
- Department of Neurological Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Lane Fry
- University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Catherine Lei
- University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Anand Dharia
- Department of Neurological Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Aaron Brake
- University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Kevin Chatley
- Department of Neurological Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jeremy Peterson
- Department of Neurological Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Koji Ebersole
- Department of Neurological Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
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12
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Matsushige T, Hashimoto Y, Ogawa T, Makimoto G, Yoshiyama M, Hara T, Kobayashi S, Sakamoto S. The impact of high-resolution cone-beam CT findings on decision-making for the treatment of unruptured middle cerebral artery aneurysms. Neurosurg Rev 2022; 46:26. [PMID: 36575355 DOI: 10.1007/s10143-022-01933-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 11/24/2022] [Accepted: 12/21/2022] [Indexed: 12/29/2022]
Abstract
Even with the advent of endovascular treatment for intracranial aneurysms, microsurgical clipping continues to play a significant role in the treatment of middle cerebral artery (MCA) aneurysms. Securing perforators around unruptured intracranial aneurysms (UIAs) is essential for minimizing procedural risks in each treatment option. Therefore, we herein investigated whether the findings of high-resolution cone-beam computed tomography (HR-CBCT) have an impact on decision-making for the treatment of MCA UIAs. Patients with MCA UIAs between October 2017 and September 2021 were consecutively recruited for this study. All patients underwent HR-CBCT and 3D-DSA before treatment. The imaging quality of both modalities to visualize the microvasculature around aneurysms was evaluated. Specific findings on the microvasculature surrounding aneurysms on HR-CBCT were investigated to facilitate microsurgical clipping. Fifty-two MCA UIAs were treated, including 43 by microsurgical clipping and 9 by endovascular approaches. The overall imaging quality of HR-CBCT was superior to that of 3D-DSA. Regarding microsurgical insights, sensitivity and specificity for the visualization of small vessels around aneurysms were 79 and 100%, respectively, using HR-CBCT, and 57 and 93%, respectively, using 3D-DSA. The presence of a low-density band between adhesive vessels and aneurysm sacs was indicative of successful and safe microsurgical dissection between these structures. HR-CBCT enabled visualization of the intracranial microvasculature around MCA UIAs at the submillimeter level in vivo. In cases in which the tight adhesion of the microvasculature to the aneurysm sac is indicated by HR-CBCT, an endovascular approach may be considered in order to avoid the risks associated with securing perforators.
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Affiliation(s)
- Toshinori Matsushige
- Department of Neurosurgery and Interventional Neuroradiology, Hiroshima City North Medical Center Asa Citizens Hospital, 1-2-1 Kameyama-minami, Asakitaku, Hiroshima, 731 0293, Japan.
| | - Yukishige Hashimoto
- Department of Neurosurgery and Interventional Neuroradiology, Hiroshima City North Medical Center Asa Citizens Hospital, 1-2-1 Kameyama-minami, Asakitaku, Hiroshima, 731 0293, Japan
| | - Taichi Ogawa
- Department of Radiology, Hiroshima City North Medical Center Asa Citizens Hospital, Hiroshima, Japan
| | - Gosuke Makimoto
- Department of Radiology, Hiroshima City North Medical Center Asa Citizens Hospital, Hiroshima, Japan
| | - Michitsura Yoshiyama
- Department of Neurosurgery and Interventional Neuroradiology, Hiroshima City North Medical Center Asa Citizens Hospital, 1-2-1 Kameyama-minami, Asakitaku, Hiroshima, 731 0293, Japan
| | - Takeshi Hara
- Department of Neurosurgery and Interventional Neuroradiology, Hiroshima City North Medical Center Asa Citizens Hospital, 1-2-1 Kameyama-minami, Asakitaku, Hiroshima, 731 0293, Japan
| | - Shohei Kobayashi
- Department of Neurosurgery and Interventional Neuroradiology, Hiroshima City North Medical Center Asa Citizens Hospital, 1-2-1 Kameyama-minami, Asakitaku, Hiroshima, 731 0293, Japan
| | - Shigeyuki Sakamoto
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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13
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Lee SH, Park JS. Outcome of ruptured anterior communicating artery aneurysm treatment compared between surgical clipping and endovascular coiling: A single-center analysis. Medicine (Baltimore) 2022; 101:e30754. [PMID: 36197262 PMCID: PMC9509031 DOI: 10.1097/md.0000000000030754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
The optimal treatment modality for ruptured anterior communicating artery (ACoA) aneurysms is unclear. Therefore, in this study, we aimed to compare the outcomes of endovascular coiling and surgical clipping to treat ruptured ACoA aneurysms. A retrospective analysis of 213 consecutive patients with ruptured AcoA aneurysms, who were treated with coiling or clipping between January 2010 and December 2020, was conducted. Of the 213 patients, 94 and 119 underwent clipping and coiling, respectively. The mean age was higher in the coiling group than in the clipping group (60.3 ± 13.2 vs. 53.5 ± 13.4, P < .001). The mean diameter of the aneurysmal neck was larger in the clipping group (3.4 mm vs. 3.0 mm, P = .022), whereas the dome-to-neck ratio (1.53 ± 0.52 vs. 1.70 ± 0.60, P = .031) and aspect ratio (1.67 ± 0.51 vs. 1.92 ± 0.77, P = .005) were larger in the coiling group. The prevalence of vasospasm was higher in the clipping than in the coiling group (42.6% vs. 26.9%, P = .016). The coiling group had a shorter mean intensive care unit hospitalization (18.3 vs. 12.1, P = .002) and more frequently showed favorable outcomes (Glasgow Outcome Scale 4, 5; 57.4% vs 73.1%, P = .016) compared to the clipping group. Multivariable logistic analysis showed that good initial WFNS grade (odds ratio [OR] = 6.69, 95% confidence interval [CI]: 2.69-16.65, P < .001), treatment with coiling (OR = 3.67, 95% CI: 1.70-7.90, P = .001), and absence of the need for cerebrospinal fluid diversion (OR = 5.21, 95% CI: 2.38-11.39, P < .001) were independent predictors of favorable outcomes in patients with ruptured ACoA aneurysms. Ruptured ACoA aneurysms can be safely and effectively treated using both clipping and coiling modalities. However, it may be beneficial to consider coiling as the first option for treating these aneurysms.
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Affiliation(s)
- Sang Houn Lee
- Department of Neurosurgery and Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeollabuk-do, Republic of Korea
| | - Jung Soo Park
- Department of Neurosurgery and Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeollabuk-do, Republic of Korea
- * Correspondence: Jung Soo Park, Department of Neurosurgery and Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, 567 Baekje-daero, deokjin-gu, Jeonju-si, Jeollabuk-do, 561-756, Republic of Korea (e-mail: )
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14
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Woven EndoBridge in Wide-Neck Bifurcation Aneurysms: Digital Subtraction Angiography at 3-Year Follow-Up. J Clin Med 2022; 11:jcm11102879. [PMID: 35629006 PMCID: PMC9143363 DOI: 10.3390/jcm11102879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/30/2022] [Accepted: 05/12/2022] [Indexed: 02/06/2023] Open
Abstract
Introduction: The Woven EndoBridge (WEB) device is a self-expanding intrasaccular braided-wire device for the treatment of wide-neck bifurcation aneurysms (WNBAs). Even though this device has an excellent safety profile and a low risk of rebleeding, little is known about its long-term effects. Material and Methods: All patients treated with WEB due to ruptured WNBAs were subjected to follow-up digital subtraction angiography (DSA) at 2 and 3 years after device deployment. The degree of residual neck was assessed through BOSS, Lubicz, and WEBCAST scales. Data on modified Rankin scale (mRS), bleeding events, and ischemic events occurring during this time period were collected as well. Lastly, overall and procedure-related mortality rates were calculated. Results: A total of 21 patients were treated between 1 January 2016, and 31 December 2018. DSA demonstrated a patency grade of 57.1% and 61.1% at 2 and 3 years, respectively. The overall 2-year mortality rate due to causes unrelated to the aneurysm was 14.3%. None of the patients were retreated between the 2- and the 3-year follow-up. No rebleeding or stroke events occurred during the follow-up. Conclusions: WEB-treated ruptured aneurysms showed an excellent degree of stability over time. The overall mortality rate—unrelated to the procedure–observed in our sample was higher than what reported in the literature, a possible bias associated with the COVID-19 pandemic.
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15
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Nussbaum ES, Touchette JC, Madison MT, Goddard JK, Lassig JP, Meyers ME, Torok CM, Carroll JJ, Lowary J, Janjua T, Nussbaum LA. Procedural complications in patients undergoing microsurgical treatment of unruptured intracranial aneurysms: a single-center experience with 1923 aneurysms. Acta Neurochir (Wien) 2022; 164:525-535. [PMID: 34562151 DOI: 10.1007/s00701-021-04996-9] [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: 01/27/2021] [Accepted: 08/27/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND With the growing use of endovascular therapy (EVT) to manage unruptured intracranial aneurysms (IAs), detailed information regarding periprocedural complication rates of microsurgical clipping and EVT becomes increasingly important in determining the optimal treatment for individual cases. We report the complication rates associated with open microsurgery in a large series of unruptured IAs and highlight the importance of maintaining surgical skill in the EVT era. METHODS We reviewed all cases of unruptured IAs treated with open microsurgery by a single neurosurgeon between July 1997 and June 2019. We analyzed surgical complications, deaths, and patient-reported outcomes. RESULTS A total of 1923 unruptured IAs in 1750 patients (mean age 44 [range: 6-84], 62.0% [1085/1750] female) were treated surgically during the study period. Of the aneurysms treated, 84.9% (1632/1923) were small, 11.1% (213/1923) were large, and 4.1% (78/1923) were giant. Aneurysm locations included the middle cerebral artery (44.2% [850/1923]), internal carotid artery (29.1% [560/1923]), anterior cerebral artery (21.0% [404/1923]), and vertebrobasilar system (5.7% [109/1923]). The overall mortality rate was 0.3% (5/1750). Surgical complications occurred in 7.4% (129/1750) of patients, but only 0.4% (7/1750) experienced permanent disability. The majority of patients were able to return to their preoperative lifestyles with no modifications (95.9% [1678/1750]). CONCLUSIONS At a high-volume, multidisciplinary center, open microsurgery in carefully selected patients with unruptured IAs yields favorable clinical outcomes with low complication rates. The improvement of EVT techniques and the ability to refer cases for EVT when a high complication rate with open microsurgery was expected have contributed to an overall decrease in surgical complication rates. These results may serve as a useful point of reference for physicians involved in treatment decision-making for patients with unruptured IAs.
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16
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Sturiale CL, Scerrati A, Ricciardi L, Rustemi O, Auricchio AM, Norri N, Piazza A, Ranieri F, Tomatis A, Albanese A, Di Egidio V, Farneti M, Mangiola A, Marchese E, Raco A, Volpin L, Trevisi G. Clipping versus coiling for treatment of middle cerebral artery aneurysms: a retrospective Italian multicenter experience. Neurosurg Rev 2022; 45:3179-3191. [PMID: 35665868 PMCID: PMC9492556 DOI: 10.1007/s10143-022-01822-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 04/30/2022] [Accepted: 05/29/2022] [Indexed: 02/03/2023]
Abstract
Endovascular treatment has emerged as the predominant approach in intracranial aneurysms. However, surgical clipping is still considered the best treatment for middle cerebral artery (MCA) aneurysms in referral centers. Here we compared short- and long-term clinical and neuroradiological outcomes in patients with MCA aneurysms undergoing clipping or coiling in 5 Italian referral centers for cerebrovascular surgery. We retrospectively reviewed 411 consecutive patients admitted between 2015 and 2019 for ruptured and unruptured MCA aneurysm. Univariate and multivariate analyses of the association between demographic, clinical, and radiological parameters and ruptured status, type of surgical treatment, and clinical outcome at discharge and follow-up were performed. Clipping was performed in 340 (83%) cases, coiling in 71 (17%). Clipping was preferred in unruptured aneurysms and in those showing collateral branches originating from neck/dome. Surgery achieved a higher rate of complete occlusion at discharge and follow-up. Clipping and coiling showed no difference in clinical outcome in both ruptured and unruptured cases. In ruptured aneurysms age, presenting clinical status, intracerebral hematoma at onset, and treatment-related complications were significantly associated with outcome at both short- and long-term follow-up. The presence of collaterals/perforators originating from dome/neck of the aneurysms also worsened the short-term clinical outcome. In unruptured cases, only treatment-related complications such as ischemia and hydrocephalus were associated with poor outcome. Clipping still seems superior to coiling in providing better short- and long-term occlusion rates in MCA aneurysms, and at the same time, it appears as safe as coiling in terms of clinical outcome.
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Affiliation(s)
- Carmelo Lucio Sturiale
- grid.8142.f0000 0001 0941 3192Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, L.go A. Gemelli 8 – 00168, Rome, Italy
| | - Alba Scerrati
- grid.8484.00000 0004 1757 2064Department of Translational Medicine, University of Ferrara, Ferrara, Italy ,grid.416315.4Department of Neurosurgery, Sant’Anna University Hospital of Ferrara, Ferrara, Italy
| | - Luca Ricciardi
- grid.7841.aNESMOS Department, Neurosurgical Unit, Sapienza University of Rome, Italy
| | - Oriela Rustemi
- grid.416303.30000 0004 1758 2035Department of Neurosurgery, San Bortolo Hospital, Vicenza, Italy
| | - Anna Maria Auricchio
- grid.8142.f0000 0001 0941 3192Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, L.go A. Gemelli 8 – 00168, Rome, Italy
| | - Nicolò Norri
- grid.8484.00000 0004 1757 2064Department of Translational Medicine, University of Ferrara, Ferrara, Italy ,grid.416315.4Department of Neurosurgery, Sant’Anna University Hospital of Ferrara, Ferrara, Italy
| | - Amedeo Piazza
- grid.7841.aNESMOS Department, Neurosurgical Unit, Sapienza University of Rome, Italy
| | - Fabio Ranieri
- grid.416303.30000 0004 1758 2035Department of Neurosurgery, San Bortolo Hospital, Vicenza, Italy
| | | | - Alessio Albanese
- grid.8142.f0000 0001 0941 3192Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, L.go A. Gemelli 8 – 00168, Rome, Italy
| | | | - Marco Farneti
- grid.8484.00000 0004 1757 2064Department of Translational Medicine, University of Ferrara, Ferrara, Italy ,grid.416315.4Department of Neurosurgery, Sant’Anna University Hospital of Ferrara, Ferrara, Italy
| | - Annunziato Mangiola
- Neurosurgical Unit, Ospedale Spirito Santo, Pescara, Italy ,grid.412451.70000 0001 2181 4941Department of Neurosciences, Imaging and Clinical Sciences, G. D’Annunzio University, Chieti-Pescara, Italy
| | - Enrico Marchese
- grid.8142.f0000 0001 0941 3192Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, L.go A. Gemelli 8 – 00168, Rome, Italy
| | - Antonino Raco
- grid.7841.aNESMOS Department, Neurosurgical Unit, Sapienza University of Rome, Italy
| | - Lorenzo Volpin
- grid.416303.30000 0004 1758 2035Department of Neurosurgery, San Bortolo Hospital, Vicenza, Italy
| | - Gianluca Trevisi
- Neurosurgical Unit, Ospedale Spirito Santo, Pescara, Italy ,grid.412451.70000 0001 2181 4941Department of Neurosciences, Imaging and Clinical Sciences, G. D’Annunzio University, Chieti-Pescara, Italy
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17
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Darsaut TE, Keough MB, Boisseau W, Findlay JM, Bojanowski MW, Chaalala C, Iancu D, Weill A, Roy D, Estrade L, Lejeune JP, Januel AC, Carlson AP, Sauvageau E, Al-Jehani H, Orlov K, Aldea S, Piotin M, Gaberel T, Gevry G, Raymond J. Middle Cerebral Artery Aneurysm Trial (MCAAT): A randomized care trial comparing surgical and endovascular management of MCA aneurysm patients. World Neurosurg 2021; 160:e49-e54. [PMID: 34971833 DOI: 10.1016/j.wneu.2021.12.083] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Whether the best management of middle cerebral artery (MCA) aneurysm patients is surgical or endovascular remains uncertain, with little evidence to guide decision-making. A randomized care trial offering MCA aneurysm patients a 50% chance of surgical and a 50% chance of endovascular management may optimize outcomes in the presence of uncertainty. METHODS The Middle Cerebral Artery Aneurysm Trial (MCAAT) is an investigator-initiated, multi-center, parallel group, prospective, 1:1 randomized controlled clinical trial. All adult patients with MCA aneurysms, ruptured or unruptured, amenable to surgical and endovascular treatment can be included. The composite primary outcome is 'Treatment Success': i) occlusion or exclusion of the aneurysm using the allocated treatment modality; ii) no intracranial hemorrhage during follow-up; iii) no retreatment of the target aneurysm during follow-up, iv) no residual aneurysm on angiographic follow-up and v) independence (mRS <3) at 1 year. The trial tests two versions of the same hypothesis (one for ruptured and one for unruptured MCA aneurysm patients): Surgical management will lead to a 15% absolute increase in the proportion of patients reaching Treatment Success from 55% to 70% (ruptured) or from 75% to 90% (unruptured aneurysm patients) compared to endovascular treatment (any method). In this pragmatic trial, outcome evaluations are by treating physicians, except for 1 year angiographic results which will be core lab assessed. The trial will be monitored by an independent data safety monitoring committee to assure safety of participants. MCAAT is registered at clinicaltrials.gov: NCT05161377. CONCLUSION Patients with MCA aneurysms can be optimally managed within a care trial protocol.
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Affiliation(s)
- Tim E Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Canada
| | - Michael B Keough
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Canada
| | - William Boisseau
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - J Max Findlay
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Canada
| | - Michel W Bojanowski
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Chiraz Chaalala
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Daniela Iancu
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Alain Weill
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Daniel Roy
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Laurent Estrade
- Department of Interventional Neuroradiology, CHU de Lille, Hôpital Salengro, Lille, France
| | - Jean-Paul Lejeune
- Department of Neurosurgery, CHU de Lille, Hôpital Salengro, Lille, France
| | - Anne-Christine Januel
- Department of Interventional Neuroradiology, CHU de Toulouse, Hôpital Purpan, Toulouse, France
| | - Andrew P Carlson
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Health, Jacksonville, Florida, USA
| | - Hosam Al-Jehani
- Department of Neurosurgery and Radiology, King Fahad University Hospital, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia
| | - Kirill Orlov
- Endovascular Neurosurgery Research Center, Federal Center of Brain Research and Neurotechnologies of the Federal Medical Biological Agency of Russia, Moscow, Russia
| | - Sorin Aldea
- Department of Neurosurgery, Rothschild Foundation Hospital, Paris, France
| | - Michel Piotin
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | | | - Guylaine Gevry
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Jean Raymond
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
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18
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Elian MMM, Issa ASI, Ibrahim MA, Khalil OAEW, Youssef FH. Endovascular management of middle cerebral artery aneurysms (single-center case series study). THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2021. [DOI: 10.1186/s43055-021-00536-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Middle cerebral artery (MCA) aneurysms were usually subjected to treatment by surgery, while endovascular treatment (EVT) was performed only in chosen patients. We assessed the efficacy, safety, and durability in addition to the clinical outcome of EVT when it is regarded as the first-line treatment modality for MCA aneurysms.
Results
We recruited 30 patients with MCA aneurysms who underwent definitive management from July 2017 to July 2018. All those patients were treated endovascularly; 22 patients (73.3%) presented with subarachnoid hemorrhage, and 8 patients (26.7%) had different presentations, including isolated headaches and seizures. EVT was performed for all patients and required the use of a balloon, stent, or double catheter techniques in 13 cases and flow diverter stents alone in two cases. Clinical outcome was assessed by the modified Rankin Scale (mRS) at 3 months. Angiographic follow-up was done by a conventional angiography at 6 months and after 1 year. EVT was efficiently conducted, leading to an outstanding accomplishment (mRS = 1–2) in 29 patients. However, one patient had a thromboembolic complication, followed by death after severe chest infection that was not related to the procedure. Immediate anatomical results included complete aneurysmal occlusion with the establishment of normal cerebral circulation. Angiographic follow-up revealed 24 unchanged occlusions and 5 cases with recanalization that required further treatment.
Conclusion
EVT of MCA aneurysms is a viable treatment option with positive outcomes in most cases. Nevertheless, the employment of long-term imaging follow-up is compulsory for validating such early results, often with respect to anatomical and functional stability.
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19
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Chang M JE, Alejandro SA, Paganelli SL, Vela Rojas EJ, Viera Neves AP, Da Costa MD, Dória-Netto HL, Campos Filho JM, Chaddad-Neto F. Microsurgical Treatment for Posthemorrhagic Cavernoma of Frontal Lobe Coexisting with Unruptured Ipsilateral Middle Cerebral Artery Aneurysm. World Neurosurg 2021; 156:27. [PMID: 34508908 DOI: 10.1016/j.wneu.2021.08.143] [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: 08/17/2021] [Revised: 08/30/2021] [Accepted: 08/31/2021] [Indexed: 10/20/2022]
Abstract
Cerebral cavernous malformations, also known as cavernomas, are vascular abnormalities of the brain that are clinically associated with a variety of neurologic symptoms that may include hemorrhagic strokes. They are the most common vascular abnormality, representing 10%-25% of all vascular malformations.1 Lesions associated with cavernomas include developmental venous anomalies, capillary telangiectasias, and other vascular malformations2 but not intracranial aneurysms. The latter association is extremely rare; in fact, there is only 1 case reported in the literature, in which the cavernoma was obscured by the presence of a cerebral hemorrhage and an unruptured aneurysm, which was presumed to be the primary cause of the bleeding, thereby misleading the surgeons to treat only the aneurysm.2 There are different alternatives for the management of different types of lesions.3-5 In this 3-dimensional operative video (Video 1), we present a case of a cavernoma associated with hemorrhage coexisting with an unruptured aneurysm in which we achieved complete resolution of both with microsurgical treatment through a pterional approach.6 The patient consented to publication of images.
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Affiliation(s)
- José Ernesto Chang M
- Department of Neurosurgery, Universidade Federal de Sao Paulo, São Paulo-SP, Brazil
| | | | | | | | | | | | - Hugo Leonardo Dória-Netto
- Department of Neurosurgery, Universidade Federal de Sao Paulo, São Paulo-SP, Brazil; Hospital Beneficência Portuguesa de São Paulo, São Paulo-SP, Brazil
| | - José Maria Campos Filho
- Department of Neurosurgery, Universidade Federal de Sao Paulo, São Paulo-SP, Brazil; Hospital Beneficência Portuguesa de São Paulo, São Paulo-SP, Brazil
| | - Feres Chaddad-Neto
- Department of Neurosurgery, Universidade Federal de Sao Paulo, São Paulo-SP, Brazil; Hospital Beneficência Portuguesa de São Paulo, São Paulo-SP, Brazil.
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20
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Current Strategies in the Treatment of Intracranial Large and Giant Aneurysms. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021. [PMID: 33973024 DOI: 10.1007/978-3-030-63453-7_3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
INTRODUCTION Very large and giant aneurysms are among the most challenging cerebrovascular pathologies in neurosurgery. METHODS The aim of this paper is to review the current literature on the management of very large and giant aneurysms and to describe representative cases illustrating possible treatment strategies. RESULTS In view of the poor natural history, active management using multiprofessional individualized approaches is required to achieve aneurysm occlusion, relief of mass effect, and obliteration of the embolic source. Both reconstructive (clipping, coiling, stent-assisted coiling, flow diversion [FD]) and deconstructive techniques (parent artery occlusion [PAO], PAO in conjunction with bypass surgery, and strategies of flow modification) are available to achieve definitive treatment with acceptable morbidity. CONCLUSIONS Patients harboring such lesions should be managed at high-volume cerebrovascular centers by multidisciplinary teams trained in all techniques of open and endovascular neurosurgery.
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21
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Endoscopic Endonasal Approach for Clipping Anterior Communicating Artery Aneurysms From Cadaver Studies and Three-Dimensional Printed Models to a Clinical Case. J Craniofac Surg 2021; 32:2854-2858. [PMID: 34238881 DOI: 10.1097/scs.0000000000007848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES Anterior communicating artery (ACoA) aneurysm is one of the most common intracranial aneurysms, and it is also the aneurysm with the highest rupture rate. With the improvement of endoscopic techniques, it is possible to use an endoscopic endonasal approach (EEA) to clip ACoA aneurysms. For further analysis of the EEA for clipping ACoA aneurysms, we used cadaver heads and three-dimensional (3D)-printed models to finish the anatomical study, and we finally selected 1 clinical case to complete the clipping through the EEA. MATERIALS AND METHODS We first collected 3 cadaver heads to simulate the EEA. Then, the imaging data of 29 real cases of ACoA aneurysm were collected, and the model of an aneurysm was prepared by 3D printing technology; then, the EEA was used to simulate the clipping of the aneurysm model. Finally, a clinical case with 2 ACoA aneurysms was selected to adopt the EEA for clipping. RESULTS Both the cadaver head and 3D-printed aneurysm model could simulate aneurysm clipping with the EEA. The clinical case of the selected ACoA aneurysm can successfully complete the clipping through the EEA. CONCLUSIONS 3D-printed models are a good method to study the anatomical characteristics of a surgical approach. For specially selected ACoA aneurysms, the EEA is relatively simple method that can be used to clip the aneurysm successfully. The EEA for clipping ACoA aneurysms is a useful complement to the current traditional craniotomy approaches and endovascular embolization.
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22
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Li Z, Hu Q, Zhao L, Huang H, Zhang S, Zheng L, Wang G. Case Report: Ruptured Middle Cerebral Artery Aneurysm With Intrasylvian Hematoma Successfully Treated by Coil Embolization and Minimally Invasive Puncture and Drainage. Front Neurol 2021; 12:646990. [PMID: 34234732 PMCID: PMC8256150 DOI: 10.3389/fneur.2021.646990] [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] [Received: 12/28/2020] [Accepted: 05/20/2021] [Indexed: 11/22/2022] Open
Abstract
Up to one-third (12–35%) of patients with aneurysmal subarachnoid hemorrhage experience intracerebral hematoma. Ruptured middle cerebral artery (MCA) aneurysm with hematoma is usually accompanied by progressive cerebral swelling with poor outcomes; however, it can be successfully treated by coil embolization and minimally invasive puncture and drainage. From February 2012 to March 2019, six surgeries for ruptured MCA aneurysms with intrasylvian hematoma were performed at our clinic. All patients had intracranial hematomas of <30 ml and GCS scores >8. The patients were treated by coil embolization and minimally invasive puncture and drainage. The aneurysms in all patients were completely embolized and the hematomas were mostly removed by minimally invasive puncture. The Glasgow outcome scale (GOS) scores of all patients were more than 4 at discharge when they discharged. Coil embolization and minimally invasive puncture and drainage are viable treatments for ruptured MCA aneurysms with hematomas, especially if the patient is too old, in a complicated state to undergo craniotomy, is unwilling to undergo craniotomy, or is at a greater risk of bleeding 3 days after surgery.
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Affiliation(s)
- Zhen Li
- Department of Neurosurgery, Taian Central Hospital, Taian, China
| | - Quan Hu
- Department of Neurosurgery, Taian Central Hospital, Taian, China
| | - Li Zhao
- Color Ultrasonic Room, Taian Central Hospital, Taian, China
| | - Huayun Huang
- Department of Neurosurgery, Taian Central Hospital, Taian, China
| | - Shizhong Zhang
- Department of Neurosurgery, Taian Central Hospital, Taian, China
| | - Limin Zheng
- Department of Neurosurgery, Taian Central Hospital, Taian, China
| | - Guojun Wang
- Department of Neurosurgery, Taian Central Hospital, Taian, China
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23
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Lu X, Huang Y, Zhou P, Zhu W, Wang Z, Chen G. Cerebral revascularization for the management of complex middle cerebral artery aneurysm: A case series. Exp Ther Med 2021; 22:883. [PMID: 34194561 PMCID: PMC8237261 DOI: 10.3892/etm.2021.10315] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 05/12/2021] [Indexed: 11/06/2022] Open
Abstract
Complex middle cerebral artery (MCA) aneurysms, including aneurysms that are sizeable (large or giant), fusiform, wide-necked or calcified, remain a significant challenge during microsurgical clipping or endovascular coiling as treatment strategies. In the present study, a retrospective analysis of cases of this type of aneurysm treated between August 2012 and December 2019 was performed. From the hospital's database, a total of 13 patients (7 males and 6 females) with a mean age of 39.0 years (range, 13-65 years) were identified. The mean size of the aneurysms was 17.5 mm (range, 3.9-35.0 mm). A total of four patients (30.8%) had ruptured aneurysms and nine (69.2%) had unruptured aneurysms. All aneurysms were treated by proximal occlusion of the parent artery, trapping or excision combined with cerebral revascularization. The bypasses performed included 10 extracranial-intracranial bypasses and 3 intracranial-intracranial bypasses (1 end-to-end re-anastomosis, 1 interpositional graft and 1 end-to-side reimplantation). Postoperative angiography confirmed that the bypass patency was 92.3% and the clinical outcomes were indicated to be favorable, with a modified Rankin Scale score ≤2 in 12 out of 13 patients (92.3%) at the last follow-up. Taken together, the results of the present analysis suggested that treatment strategies for complex MCA aneurysms should depend on the status and characteristics of the aneurysm, including aneurysm size, location and morphology. For aneurysms that lack perforating arteries in the aneurysm dome, clip trapping or aneurysm excision with or without bypass are preferred as treatment strategies. When there are perforating arteries (particularly the lenticulostriate artery) arising from the aneurysm dome, however, the aneurysms should be treated with bypass followed by proximal occlusion of the parent artery or clip reconstruction.
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Affiliation(s)
- Xiaocheng Lu
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Yabo Huang
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Peng Zhou
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Weiwei Zhu
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Zhong Wang
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Gang Chen
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
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Pontes FGDB, da Silva EM, Baptista-Silva JC, Vasconcelos V. Treatments for unruptured intracranial aneurysms. Cochrane Database Syst Rev 2021; 5:CD013312. [PMID: 33971026 PMCID: PMC8109849 DOI: 10.1002/14651858.cd013312.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Unruptured intracranial aneurysms are relatively common lesions in the general population, with a prevalence of 3.2%, and are being diagnosed with greater frequency as non-invasive techniques for imaging of intracranial vessels have become increasingly available and used. If not treated, an intracranial aneurysm can be catastrophic. Morbidity and mortality in aneurysmal subarachnoid hemorrhage are substantial: in people with subarachnoid hemorrhage, 12% die immediately, more than 30% die within one month, 25% to 50% die within six months, and 30% of survivors remain dependent. However, most intracranial aneurysms do not bleed, and the best treatment approach is still a matter of debate. OBJECTIVES To assess the risks and benefits of interventions for people with unruptured intracranial aneurysms. SEARCH METHODS We searched CENTRAL (Cochrane Library 2020, Issue 5), MEDLINE Ovid, Embase Ovid, and Latin American and Caribbean Health Science Information database (LILACS). We also searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform from inception to 25 May 2020. There were no language restrictions. We contacted experts in the field to identify further studies and unpublished trials. SELECTION CRITERIA Unconfounded, truly randomized trials comparing conservative treatment versus interventional treatments (microsurgical clipping or endovascular coiling) and microsurgical clipping versus endovascular coiling for individuals with unruptured intracranial aneurysms. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion according to the above criteria, assessed trial quality and risk of bias, performed data extraction, and applied the GRADE approach to the evidence. We used an intention-to-treat analysis strategy. MAIN RESULTS We included two trials in the review: one prospective randomized trial involving 80 participants that compared conservative treatment to endovascular coiling, and one randomized controlled trial involving 136 participants that compared microsurgical clipping to endovascular coiling for unruptured intracranial aneurysms. There was no difference in outcome events between conservative treatment and endovascular coiling groups. New perioperative neurological deficits were more common in participants treated surgically (16/65, 24.6%; 15.8% to 36.3%) versus 7/69 (10.1%; 5.0% to 19.5%); odds ratio (OR) 2.87 (95% confidence interval (CI) 1.02 to 8.93; P = 0.038). Hospitalization for more than five days was more common in surgical participants (30/65, 46.2%; 34.6% to 58.1%) versus 6/69 (8.7%; 4.0% to 17.7%); OR 8.85 (95% CI 3.22 to 28.59; P < 0.001). Clinical follow-up to one year showed 1/48 clipped versus 1/58 coiled participants had died, and 1/48 clipped versus 1/58 coiled participants had become disabled (modified Rankin Scale > 2). All the evidence is of very low quality. AUTHORS' CONCLUSIONS There is currently insufficient good-quality evidence to support either conservative treatment or interventional treatments (microsurgical clipping or endovascular coiling) for individuals with unruptured intracranial aneurysms. Further randomized trials are required to establish if surgery is a better option than conservative management, and if so, which surgical approach is preferred for which patients. Future studies should include consideration of important characteristics such as participant age, gender, aneurysm size, aneurysm location (anterior circulation and posterior circulation), grade of ischemia (major stroke), and duration of hospitalizations.
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Affiliation(s)
| | - Edina Mk da Silva
- Emergency Medicine and Evidence Based Medicine, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Jose Cc Baptista-Silva
- Evidence Based Medicine, Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Vladimir Vasconcelos
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
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25
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Lim J, Choi G, Joo KI, Cha HJ, Kim J. Embolization of Vascular Malformations via In Situ Photocrosslinking of Mechanically Reinforced Alginate Microfibers using an Optical-Fiber-Integrated Microfluidic Device. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2021; 33:e2006759. [PMID: 33543521 DOI: 10.1002/adma.202006759] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/12/2020] [Indexed: 06/12/2023]
Abstract
Embolization, which is a minimally invasive endovascular treatment, is a safe and effective procedure for treating vascular malformations (e.g., aneurysms). Hydrogel microfibers obtained via spatiotemporally controllable in situ photocrosslinking exhibit great potential for embolizing aneurysms. However, this process is challenging because of the absence of biocompatible and morphologically stable hydrogels and the difficulty in continuously spinning the microfibers via in situ photocrosslinking in extreme endovascular environments such as those involving a tortuous geometry and high absorbance. A double-crosslinked alginate-based hydrogel with tantalum nanopowder (DAT) that exploits the synergistic effect of covalent crosslinking by visible-light irradiation and ionic crosslinking using Ca2+ , which is present in the blood, is developed in this study. Furthermore, an effective strategy to design and produce an optical-fiber-integrated microfluidic device (OFI-MD) that can continuously spin hydrogel microfibers via in situ photocrosslinking in extreme endovascular environments is proposed. As an embolic material, DAT exhibits promising characteristics such as radiopacity, nondissociation, nonswelling, and constant mechanical strength in blood, in addition to excellent cyto- and hemo-compatibilities. Using OFI-MD to spin DAT microfibers continuously can help fill aneurysms safely, uniformly, and completely within the endovascular simulator without generating microscopic fragments, which demonstrates its potential as an effective embolization strategy.
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Affiliation(s)
- Jongkyeong Lim
- Department of Mechanical Engineering, Pohang University of Science and Technology (POSTECH), 77 Cheongam-Ro, Nam-Gu, Pohang, Gyeongbuk, 37673, Republic of Korea
| | - Geunho Choi
- Department of Chemical Engineering, Pohang University of Science and Technology (POSTECH), 77 Cheongam-Ro, Nam-Gu, Pohang, Gyeongbuk, 37673, Republic of Korea
| | - Kye Il Joo
- Department of Chemical Engineering, Pohang University of Science and Technology (POSTECH), 77 Cheongam-Ro, Nam-Gu, Pohang, Gyeongbuk, 37673, Republic of Korea
| | - Hyung Joon Cha
- Department of Chemical Engineering, Pohang University of Science and Technology (POSTECH), 77 Cheongam-Ro, Nam-Gu, Pohang, Gyeongbuk, 37673, Republic of Korea
| | - Joonwon Kim
- Department of Mechanical Engineering, Pohang University of Science and Technology (POSTECH), 77 Cheongam-Ro, Nam-Gu, Pohang, Gyeongbuk, 37673, Republic of Korea
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Rotim K, Kalousek V, Splavski B, Tomasović S, Rotim A. HYBRID MICROSURGICAL AND ENDOVASCULAR APPROACH IN THE TREATMENT OF MULTIPLE CEREBRAL ANEURYSMS: AN ILLUSTRATIVE CASE SERIES IN CORRELATION WITH LITERATURE DATA. Acta Clin Croat 2021; 60:33-40. [PMID: 34588719 PMCID: PMC8305362 DOI: 10.20471/acc.2021.60.01.05] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 02/26/2021] [Indexed: 11/24/2022] Open
Abstract
Contemporary cerebral aneurysm treatment has advanced due to the expansion of microsurgical and endovascular techniques having different advantages and restraints. However, some aneurysms cannot be effectively treated by a single method alone due to their specific anatomy, location, complexity, and/or multiplicity. Subsequently, multiple aneurysms sometimes necessitate a hybrid strategy integrating both methods. The study aims were to discuss indications, possibilities, and challenges of a hybrid strategy in the decision making and treatment of multiple intracranial aneurysms. A single-institution illustrative case series of multiple intracranial aneurysm patients treated by a hybrid approach was analyzed and management outcome discussed and correlated with literature data. Following the treatment, both patients from our case series recovered well, having complete and stable aneurysmal occlusion with no relapse and no postoperative procedure-related complications or long-lasting neurological symptoms. In conclusion, a hybrid approach is advised as a treatment option for multiple cerebral aneurysms when a single modality is insufficient to bring satisfactory results. It may be a suitable and safe addition to an assortment of treatments pledging clinical improvement and enabling positive management outcome in patients with ruptured and non-ruptured multiple cerebral aneurysms.
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Affiliation(s)
| | - Vladimir Kalousek
- 1Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia; 3University of Applied Health Sciences, Zagreb, Croatia; 4Department of Radiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 5Josip Juraj Strossmayer University of Osijek, Faculty of Dental Medicine and Health, Osijek, Croatia; 6Department of Neurology, Sveti Duh University Hospital, Zagreb, Croatia
| | - Bruno Splavski
- 1Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia; 3University of Applied Health Sciences, Zagreb, Croatia; 4Department of Radiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 5Josip Juraj Strossmayer University of Osijek, Faculty of Dental Medicine and Health, Osijek, Croatia; 6Department of Neurology, Sveti Duh University Hospital, Zagreb, Croatia
| | - Sanja Tomasović
- 1Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia; 3University of Applied Health Sciences, Zagreb, Croatia; 4Department of Radiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 5Josip Juraj Strossmayer University of Osijek, Faculty of Dental Medicine and Health, Osijek, Croatia; 6Department of Neurology, Sveti Duh University Hospital, Zagreb, Croatia
| | - Ante Rotim
- 1Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia; 3University of Applied Health Sciences, Zagreb, Croatia; 4Department of Radiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 5Josip Juraj Strossmayer University of Osijek, Faculty of Dental Medicine and Health, Osijek, Croatia; 6Department of Neurology, Sveti Duh University Hospital, Zagreb, Croatia
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Dellaretti M, do Nascimento LM, de Oliveira Lima AD, de Almeida JC, Quadros RS. Efficacy and safety of surgical treatment for middle cerebral artery aneurysms: A retrospective case series. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.101018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Darsaut TE, Keough MB, Sagga A, Chan VKY, Diouf A, Boisseau W, Magro E, Kotowski M, Roy D, Weill A, Iancu D, Bojanowski MW, Chaalala C, Bilocq A, Estrade L, Lejeune JP, Bricout N, Scholtes F, Martin D, Otto B, Findlay JM, Chow MM, O'Kelly CJ, Ashforth RA, Rempel JL, Lesiuk H, Sinclair J, Altschul DJ, Arikan F, Guilbert F, Chagnon M, Farzin B, Gevry G, Raymond J. Surgical or Endovascular Management of Middle Cerebral Artery Aneurysms: A Randomized Comparison. World Neurosurg 2021; 149:e521-e534. [PMID: 33556601 DOI: 10.1016/j.wneu.2021.01.142] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 01/07/2023]
Abstract
OBJECTIVE There are few randomized data comparing clipping and coiling for middle cerebral artery (MCA) aneurysms. We analyzed results from patients with MCA aneurysms enrolled in the CURES (Collaborative UnRuptured Endovascular vs. Surgery) and ISAT-2 (International Subarachnoid Aneurysm Trial II) randomized trials. METHODS Both trials are investigator-led parallel-group 1:1 randomized studies. CURES includes patients with 3-mm to 25-mm unruptured intracranial aneurysms (UIAs), and ISAT-2 includes patients with ruptured aneurysms (RA) for whom uncertainty remains after ISAT. The primary outcome measure of CURES is treatment failure: 1) failure to treat the aneurysm, 2) intracranial hemorrhage during follow-up, or 3) residual aneurysm at 1 year. The primary outcome of ISAT-2 is death or dependency (modified Rankin Scale score >2) at 1 year. One-year angiographic outcomes are systematically recorded. RESULTS There were 100 unruptured and 71 ruptured MCA aneurysms. In CURES, 90 patients with UIA have been treated and 10 await treatment. Surgical and endovascular management of unruptured MCA aneurysms led to treatment failure in 3/42 (7%; 95% confidence interval [CI], 0.02-0.19) for clipping and 13/48 (27%; 95% CI, 0.17-0.41) for coiling (P = 0.025). All 71 patients with RA have been treated. In ISAT-2, patients with ruptured MCA aneurysms managed surgically had died or were dependent (modified Rankin Scale score >2) in 7/38 (18%; 95% CI, 0.09-0.33) cases, and 8/33 (24%; 95% CI, 0.13-0.41) for endovascular. One-year imaging results were available in 80 patients with UIA and 62 with RA. Complete aneurysm occlusion was found in 30/40 (75%; 95% CI, 0.60-0.86) patients with UIA allocated clipping, and 14/40 (35%; 95% CI, 0.22-0.50) patients with UIA allocated coiling. Complete aneurysm occlusion was found in 24/34 (71%; 95% CI, 0.54-0.83) patients with RA allocated clipping, and 15/28 (54%; 95% CI, 0.36-0.70) patients with RA allocated coiling. CONCLUSIONS Randomized data from 2 trials show that better efficacy may be obtained with surgical management of patients with MCA aneurysms.
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Affiliation(s)
- Tim E Darsaut
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Michael B Keough
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Abdelaziz Sagga
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Vivien K Y Chan
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Ange Diouf
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - William Boisseau
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Elsa Magro
- Service of Neurosurgery, CHU Cavale Blanche, InsermUMR 1101 LaTIM, Brest, France
| | - Marc Kotowski
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Daniel Roy
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Alain Weill
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Daniela Iancu
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Michel W Bojanowski
- Service of Neurosurgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Chiraz Chaalala
- Service of Neurosurgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Alain Bilocq
- Centre Hospitalier Régional de Trois-Rivières Service of Neurosurgery, Trois-Rivières, Quebec, Canada
| | - Laurent Estrade
- Department of Interventional Neuroradiology, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Jean-Paul Lejeune
- Department of Neurosurgery, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Nicolas Bricout
- Department of Interventional Neuroradiology, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Felix Scholtes
- Department of Neurosurgery, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - Didier Martin
- Department of Neurosurgery, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - Bernard Otto
- Division of Medical Imaging, Department of Medical Physics, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - J Max Findlay
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Michael M Chow
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Cian J O'Kelly
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Robert A Ashforth
- Department of Radiology and Diagnostic Imaging, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Jeremy L Rempel
- Department of Radiology and Diagnostic Imaging, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Howard Lesiuk
- Section of Neurosurgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - John Sinclair
- Section of Neurosurgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - David J Altschul
- Department of Neurological Surgery and Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Fuat Arikan
- Department of Neurosurgery and Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Francois Guilbert
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Miguel Chagnon
- Department of Mathematics and Statistics, Université de Montréal, Montréal, Quebec, Canada
| | - Behzad Farzin
- Interventional Neuroradiology Laboratory, Research Centre, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Guylaine Gevry
- Interventional Neuroradiology Laboratory, Research Centre, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Jean Raymond
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada; Interventional Neuroradiology Laboratory, Research Centre, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
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Clinical features of ischemic complications after unruptured middle cerebral artery aneurysm clipping: patients and radiologically related factors. Neurosurg Rev 2021; 44:2819-2829. [PMID: 33462782 DOI: 10.1007/s10143-021-01475-8] [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: 10/11/2020] [Revised: 12/17/2020] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
Postoperative ischemic complication results in neurological sequelae and longer hospitalization after unruptured middle cerebral artery (MCA) aneurysm clipping surgery. We evaluated the radiological and patient-related factors associated with ischemic complications after unruptured MCA aneurysm clipping surgery. Patient demographics, radiological findings, and intraoperative factors were compared between patients with and without postoperative ischemic complications. The clinical courses and outcomes of postoperative ischemic complications were compared according to the types of ischemic complication. Forty-two out of 2227 patients (1.9%) developed postoperative ischemic complications after MCA aneurysm clipping. Multivariate analysis revealed that diabetes mellitus (DM) was a patient-related factor. Intraarterial (IA) calcification of the distal internal carotid artery (ICA), preoperative M1 stenosis, and M1 aneurysm were radiological factors that increased the risk of postoperative ischemic complications. DM was significantly associated with divisional branch territory infarction (P = 0.04). The time to first presentation of ischemic complication was significantly longer in divisional branch territory infarction than perforator territory infarction (67.8 ± 75.9 h vs. 22 ± 20.7, P = 0.023). Twelve out of 42 patients with ischemic complications (28.6%) had unfavorable outcome (mRS > 3). Perforator territory infarction was significantly associated with an unfavorable outcome (mRS > 3, P = 0.019). IA calcification of the distal ICA, M1 stenosis and aneurysms, and DM were significantly associated with postoperative ischemic complications after unruptured MCA aneurysm clipping. Patients with DM should be closely monitored postoperatively to detect delayed occurrence of divisional branch infarction. Trial registration number: 2019-1002, Date of registration: January 1, 2005, "retrospectively registered".
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Liu J, Peng C, Zhu G, Sheng C, Song S, Cheng Z, Zhu J. Comparison of surgical clipping and endovascular coiling in the treatment of oculomotor nerve palsy caused by posterior communicating artery aneurysm. Medicine (Baltimore) 2020; 99:e22969. [PMID: 33217799 PMCID: PMC7676548 DOI: 10.1097/md.0000000000022969] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Oculomotor nerve palsy (ONP) caused by posterior communicating aneurysm (PcomAA) is mainly treated by surgical clipping or endovascular coiling. However, there are still some controversies about which treatment method could provide the more beneficial prognosis. This study aimed to compare ONP recovery rate between surgical clipping and endovascular coiling in patients diagnosed as PcomAA combined with ONP, and explore the potential risk factors of ONP recovery.The clinical data of 152 patients with ONP caused by PcomAA were retrospectively analyzed. Diameter of aneurysm, different treatment methods (surgical clipping or endovascular coiling), subarachnoid hemorrhage (SAH), degree of preoperative ONP, time from ONP onset to treatment, as well as degree of ONP symptom recovery were collected from medical records. All patients were followed up for at least 1 year.One hundred twelve patients underwent surgical clipping and 40 patients received endovascular coiling. There were no significant differences in age, gender, aneurysm diameter, hypertension, dyslipidemia, time from ONP symptom onset to treatment, SAH, and preoperative ONP degree between the 2 groups (all P > .05). Time to complete or partial recovery was 86.7 ± 35.7 days for patients receiving surgical clipping and 132.6 ± 37.5 days for patients receiving endovascular coiling, respectively (Log rank test, P < .001). The recovery rate was 94.6% in the surgical clipping group and 65.0% in the endovascular coiling group. The difference between the two groups was statistically significant (P < .001). Postoperative ONP recovery in the surgical clipping group was significantly superior to that of patients in the endovascular coiling group (HR, 2.625; 95% CI: 1.423-4.841; P = .002). Time from ONP symptom onset to treatment exerted the obvious effect on the ONP prognosis (HR, 0.572; 95% CI: 0.384-0.852; P = .006). In addition, the ONP recovery in patients with SAH before surgery was also independently associated with ONP prognosis (HR, 1.276; 95% CI, 1.043-1.562; P = .018). There was no treatment-related death in either group, and postoperative complications were within the manageable range.The recovery rate and recovery degree of ONP after surgical clipping was significantly better than that of endovascular coiling in PcomAA patients combined with ONP. The postoperative ONP recovery was associated with preoperative spontaneous SAH and time from ONP onset to treatment.
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Surgical clipping compared to endovascular coiling of ruptured coil able middle cerebral aneurysms: A single-center experience. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2020.100708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Ki HJ, Lee KS, Kim BS, Choi JH, Shin YS. Clinical and morphological risk factors for the recurrence of anterior communicating artery aneurysms after clipping or coiling. Acta Neurochir (Wien) 2020; 162:2245-2250. [PMID: 32556525 DOI: 10.1007/s00701-020-04450-2] [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: 04/19/2020] [Accepted: 06/04/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The aim of this study was to evaluate clinical and morphological factors associated with recurrence in anterior communicating artery (AcomA) aneurysms after clipping or coiling. METHODS We retrospectively reviewed the clinical and radiologic features of consecutive 214 patients with AcomA aneurysms treated between January 2012 and December 2016 in a single tertiary institute. Univariate and multivariate analyses were performed to identify the relationship between clinical and morphological variables and recurrence. RESULTS Of 214 patients, 166 were unruptured aneurysms and 109 were treated with coiling. Overall recurrence rate was 13% (28 out of 214 aneurysms) during mean 36.9 ± 18.4-month follow-up. Multivariate logistic regression analysis showed that size greater than 10 mm (OR = 5.651; 95% CI, 1.317-24.242; p = 0.020), smoking (OR = 3.474; 95% CI, 1.342-8.996; p = 0.010), coiling (OR = 2.98; 95% CI, 1.005-8.832; p = 0.049), and anterior direction of aneurysm (OR = 3.77; 95% CI, 1.12-12.66; p = 0.032) were significantly associated with recurrence of AcomA aneurysms after treatment. CONCLUSIONS The results of this study demonstrated that coiling, large aneurysm, anterior direction, and smoking history may be independent risk factors for the recurrence of AcomA aneurysms. Therefore, careful follow-up should be needed especially in large AcomA aneurysms with anterior direction after coiling.
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Rotim K, Raguž M, Rotim A, Splavski B, Kalousek V. LATE ANEURYSM RELAPSE AFTER MICROSURGICAL TREATMENT OF MIDDLE CEREBRAL ARTERY ANEURYSM: A CASE REPORT AND LITERATURE REVIEW OF TREATMENT OPTIONS. Acta Clin Croat 2020; 59:532-538. [PMID: 34177065 PMCID: PMC8212637 DOI: 10.20471/acc.2020.59.03.19] [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: 11/24/2022] Open
Abstract
Recurrence of intracranial aneurysm after initial microsurgical or endovascular treatment is uncommon. Although the exact etiology remains unknown, recurrent aneurysms may be observed in surgical patients with big and multiple aneurysms, arterial hypertension, non-atherosclerotic cerebrovascular arteriopathies, as well as in those with a familial history of the disease. Such recurrence can occur over a wide period ranging from several months to years after the initial aneurysm treatment. Still, the occurrence delayed by more than 20 years is rather unusual. Herein, we present a case of a 70-year-old female patient who developed late intracranial aneurysm relapse 30 years after successful microsurgical clipping of the middle cerebral artery aneurysm. We also provide a brief review of relevant literature, discussing the etiology and pathophysiology of aneurysm reappearance, as well as different treatment options available. In conclusion, one should always consider the possibility of intracranial aneurysm recurrence regardless of the mode and time of primary surgery. In such a case, a multidisciplinary management approach using flow diverting endovascular techniques is advised in selected patients.
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Affiliation(s)
| | - Marina Raguž
- 1Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia; 3University of Applied Health Sciences, Zagreb, Croatia; 4Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia; 5Josip Juraj Strossmayer University of Osijek, School of Dental Medicine and Health, Osijek, Croatia; 6Department of Radiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Ante Rotim
- 1Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia; 3University of Applied Health Sciences, Zagreb, Croatia; 4Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia; 5Josip Juraj Strossmayer University of Osijek, School of Dental Medicine and Health, Osijek, Croatia; 6Department of Radiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Bruno Splavski
- 1Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia; 3University of Applied Health Sciences, Zagreb, Croatia; 4Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia; 5Josip Juraj Strossmayer University of Osijek, School of Dental Medicine and Health, Osijek, Croatia; 6Department of Radiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Vladimir Kalousek
- 1Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia; 3University of Applied Health Sciences, Zagreb, Croatia; 4Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia; 5Josip Juraj Strossmayer University of Osijek, School of Dental Medicine and Health, Osijek, Croatia; 6Department of Radiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
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Oishi H, Fujii T, Yatomi K, Teranishi K, Suzuki K, Mishima Y, Nakajima S. Stent-assisted coil embolization of unruptured middle cerebral artery aneurysms using LVIS Jr. stents. J Clin Neurosci 2020; 80:87-91. [PMID: 33099374 DOI: 10.1016/j.jocn.2020.07.070] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/24/2020] [Accepted: 07/30/2020] [Indexed: 01/28/2023]
Abstract
Authors reported the anatomical and clinical results of the stent assisted coiling (SAC) of unruptured middle cerebral artery (MCA) aneurysms using Low-profile Visualized Intraluminal Support Junior (LVIS Jr.). Forty-seven MCA aneurysms in 46 patients were the subjects of this study. The mean aneurysm size, neck width were 4.5 ± 1.8 mm, 3.0 ± 1.0 mm, respectively. Immediate anatomical outcomes were class Ⅰ in 31 (65.0%), class Ⅱ in 5 (10.6%) and class III in 11 (23.4%) patients according to Raymond-Roy classification. The latest anatomical outcomes were class Ⅰ in 33 (86.8%), class Ⅱ in 2 (5.3%) and class III in 3 (7.9%) patients. The change of aneurysm obliteration status were unchanged in 27 (71.0%), improved in 9 (23.7%) and worsen in 2 (5.3%). There were no recurrence necessitating additional treatment. Two patients suffered from angiographically evident in-stent thrombosis, but their clinical outcomes remain good. The modified Rankin scale at discharge were 0 in 45 patients, 1 in 1 patient. No patient showed clinical worsening during the clinical follow-up period at outpatient clinic (mean, 27.4 months). SAC of unruptured MCA aneurysms using LVIS Jr. provide safe and durable effect with high complete obliteration rate recurrence rate.
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Affiliation(s)
- Hidenori Oishi
- Department of Neurosurgery, Juntendo University, Faculty of Medicine, Japan.
| | - Takashi Fujii
- Department of Neurosurgery, Juntendo University, Faculty of Medicine, Japan
| | - Kenji Yatomi
- Department of Neurosurgery, Juntendo University, Faculty of Medicine, Japan
| | - Kohsuke Teranishi
- Department of Neurosurgery, Juntendo University, Faculty of Medicine, Japan
| | - Kazumoto Suzuki
- Department of Neurosurgery, Juntendo University, Faculty of Medicine, Japan
| | - Yumiko Mishima
- Department of Neurosurgery, Juntendo University, Faculty of Medicine, Japan
| | - Shintaro Nakajima
- Department of Neurosurgery, Juntendo University, Faculty of Medicine, Japan
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Liang F, Yang Y, Luo L, Liao B, Zhang G, Ou S, Xiao W, Guo N, Qi T. Endovascular treatment of complex middle cerebral artery aneurysms using TuBridge flow diverters. Interv Neuroradiol 2020; 26:539-546. [PMID: 32722987 DOI: 10.1177/1591019920946216] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The safety and efficacy of the TuBridge flow diverter in treating middle cerebral artery aneurysms remains unknown. In this study, we report our preliminary experience treating complex middle cerebral artery aneurysms using the TuBridge flow diverter. METHODS A prospectively maintained database of intracranial aneurysms treated with the TuBridge flow diverter was retrospectively reviewed, and patients with middle cerebral artery aneurysms were included in this study. Demographics, aneurysm features, complications, and clinical and angiographic outcomes were assessed. Evaluation of the angiographic results included occlusion grade of aneurysm (O'Kelly-Marotta grading scale), patency of jailed branch(es), and in-stent stenosis. RESULTS Eight patients with eight middle cerebral artery aneurysms were included in this study. The mean aneurysm size was 11.8 ± 6.8 mm. There were no procedure-related complications and there was no morbidity or mortality at a mean follow-up of 11.3 ± 3.6 months. All patients had follow-up angiograms at a mean of 7.5 ± 4.0 months after surgery. Of the eight patients, there was 1 (12.5%) O'Kelly-Marotta grading scale A, 3 (37.5%) O'Kelly-Marotta grading scale B, 1 (12.5%) O'Kelly-Marotta grading scale C, and 3 (37.5%) O'Kelly-Marotta grading scale D. Of the seven patients with jailed branch, the blood flow of jailed branch was unchanged in 4 (57.1%), decreased in 2 (28.6%), and occluded in 1 (14.3%). In-stent stenosis was mild in 2 (25%) patients and moderate in 1 (12.5%) patient. CONCLUSION Midterm results suggest that endovascular treatment of middle cerebral artery aneurysms using the TuBridge flow diverter is safe and associated with good outcomes. The TuBridge flow diverter may be an option for complex middle cerebral artery aneurysms that are difficult to treat with either clipping or coiling.
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Affiliation(s)
- Feng Liang
- Department of Neurosurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yibing Yang
- Department of Neurosurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Lijuan Luo
- Department of Neurosurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Bingye Liao
- Department of Operation Theater, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Guofeng Zhang
- Department of Neurosurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Siqi Ou
- Department of Neurosurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Weiping Xiao
- Department of Neurosurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ning Guo
- Department of Neurosurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Tiewei Qi
- Department of Neurosurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Microsurgical Clipping Compared with New and Most Advanced Endovascular Techniques in the Treatment of Unruptured Middle Cerebral Artery Aneurysms: A Meta-Analysis in the Modern Era. World Neurosurg 2020; 137:451-464.e1. [DOI: 10.1016/j.wneu.2019.12.118] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 11/19/2022]
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Poupart O, Schmocker A, Conti R, Moser C, Nuss KM, Grützmacher H, Mosimann PJ, Pioletti DP. In vitro Implementation of Photopolymerizable Hydrogels as a Potential Treatment of Intracranial Aneurysms. Front Bioeng Biotechnol 2020; 8:261. [PMID: 32318555 PMCID: PMC7146053 DOI: 10.3389/fbioe.2020.00261] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 03/13/2020] [Indexed: 12/19/2022] Open
Abstract
Intracranial aneurysms are increasingly being treated with endovascular therapy, namely coil embolization. Despite being minimally invasive, partial occlusion and recurrence are more frequent compared to open surgical clipping. Therefore, an alternative treatment is needed, ideally combining minimal invasiveness and long-term efficiency. Herein, we propose such an alternative treatment based on an injectable, radiopaque and photopolymerizable polyethylene glycol dimethacrylate hydrogel. The rheological measurements demonstrated a viscosity of 4.86 ± 1.70 mPa.s, which was significantly lower than contrast agent currently used in endovascular treatment (p = 0.42), allowing the hydrogel to be injected through 430 μm inner diameter microcatheters. Photorheology revealed fast hydrogel solidification in 8 min due to the use of a new visible photoinitiator. The addition of an iodinated contrast agent in the precursor contributed to the visibility of the precursor injection under fluoroscopy. Using a customized light-conducting microcatheter and illumination module, the hydrogel was implanted in an in vitro silicone aneurysm model. Specifically, in situ fast and controllable injection and photopolymerization of the developed hydrogel is shown to be feasible in this work. Finally, the precursor and the polymerized hydrogel exhibit no toxicity for the endothelial cells. Photopolymerizable hydrogels are expected to be promising candidates for future intracranial aneurysm treatments.
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Affiliation(s)
- Oriane Poupart
- Laboratory of Biomechanical Orthopedics, EPFL, Lausanne, Switzerland
| | - Andreas Schmocker
- Laboratory of Applied Photonics Devices, EPFL, Lausanne, Switzerland
- Department of Chemistry and Applied Biosciences, ETH, Zurich, Switzerland
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Riccardo Conti
- Department of Chemistry and Applied Biosciences, ETH, Zurich, Switzerland
| | - Christophe Moser
- Laboratory of Applied Photonics Devices, EPFL, Lausanne, Switzerland
| | - Katja M. Nuss
- Musculoskeletal Research Unit, Department of Molecular Mechanisms of Disease, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | | | - Pascal J. Mosimann
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, Bern, Switzerland
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Huynh TD, Felbaum DR, Jean WC, Ngo HM. Spontaneous Thrombosis of Giant Dissecting Fusiform Middle Cerebral Aneurysm After Double-Barrel Superficial Temporal Artery–Middle Cerebral Artery Bypass: A Case Report of Decision-Making in a Limited Resource Environment. World Neurosurg 2020; 136:161-168. [DOI: 10.1016/j.wneu.2020.01.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 01/06/2020] [Accepted: 01/07/2020] [Indexed: 11/29/2022]
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Rayz VL, Cohen-Gadol AA. Hemodynamics of Cerebral Aneurysms: Connecting Medical Imaging and Biomechanical Analysis. Annu Rev Biomed Eng 2020; 22:231-256. [PMID: 32212833 DOI: 10.1146/annurev-bioeng-092419-061429] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
In the last two decades, numerous studies have conducted patient-specific computations of blood flow dynamics in cerebral aneurysms and reported correlations between various hemodynamic metrics and aneurysmal disease progression or treatment outcomes. Nevertheless, intra-aneurysmal flow analysis has not been adopted in current clinical practice, and hemodynamic factors usually are not considered in clinical decision making. This review presents the state of the art in cerebral aneurysm imaging and image-based modeling, discussing the advantages and limitations of each approach and focusing on the translational value of hemodynamic analysis. Combining imaging and modeling data obtained from different flow modalities can improve the accuracy and fidelity of resulting velocity fields and flow-derived factors that are thought to affect aneurysmal disease progression. It is expected that predictive models utilizing hemodynamic factors in combination with patient medical history and morphological data will outperform current risk scores and treatment guidelines. Possible future directions include novel approaches enabling data assimilation and multimodality analysis of cerebral aneurysm hemodynamics.
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Affiliation(s)
- Vitaliy L Rayz
- Weldon School of Biomedical Engineering and School of Mechanical Engineering, Purdue University, West Lafayette, Indiana 47907, USA;
| | - Aaron A Cohen-Gadol
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA.,Goodman Campbell Brain and Spine, Carmel, Indiana 46032, USA
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Kang XK, Guo SF, Lei Y, Wei W, Liu HX, Huang LL, Jiang QL. Endovascular coiling versus surgical clipping for the treatment of unruptured cerebral aneurysms: Direct comparison of procedure-related complications. Medicine (Baltimore) 2020; 99:e19654. [PMID: 32221092 PMCID: PMC7220217 DOI: 10.1097/md.0000000000019654] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Endovascular coiling and surgical clipping are routinely used to treat unruptured cerebral aneurysms (UCAs). However, the evidence to support the efficacy of these approaches is limited. We aimed to analyze the efficacy of endovascular coiling compared with surgical clipping in patients with UCAs. METHOD A systematic search of 4 databases was conducted to identify comparative articles involving endovascular coiling and surgical clipping in patients with UCAs. We conducted a meta-analysis using the random-effects model when I> 50%. Otherwise, a meta-analysis using the fixed-effects model was performed. RESULTS Our results showed that endovascular coiling was associated with a shorter length of stay (WMD: -4.14, 95% CI: (-5.75, -2.531), P < .001) and a lower incidence of short-term complications compared with surgical clipping (OR: 0.518; 95% CI (0.433, 0.621); P < .001), which seems to be a result of ischemia complications (OR: 0.423; 95% CI (0.317, 0.564); P < .001). However, surgical clipping showed a higher rate of complete occlusion after surgery, in both short-term (OR: 0.179, 95% CI (0.064, 0.499), P = .001) and 1-year follow-ups (OR: 0.307, 95% CI (0.146, 0.646), P = .002), and a lower rate of short-term retreatment (OR: 0.307, 95% CI (0.146, 0.646), P = .002). Meanwhile, there was no significant difference in postoperative death, bleeding, and modified Rankin Scale (mRS) > 2 between the 2 groups. CONCLUSIONS The latest evidence illustrates that surgical clipping resulted in lower retreatment rates and was associated with a higher incidence of complete occlusion, while endovascular coiling was associated with shorter LOS and a lower rate of complications, especially ischemia.
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Affiliation(s)
- Xiao-kui Kang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, Shandong
| | - Sheng-fu Guo
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, Shandong
| | - Yi Lei
- Department of Gynaecology and Obstetrics, Anyi County People's Hospital, Nanchang
| | - Wei Wei
- Department of Neurology, Mianyang Central Hospital, Sichuan
| | | | - Li-li Huang
- Department of Endocrinology, Liaocheng People's Hospital, Liaocheng, Shandong, China
| | - Qun-long Jiang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, Shandong
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Three-dimensional visualization of aneurysm wall calcification by cerebral angiography: Technical case report. J Clin Neurosci 2020; 73:290-293. [PMID: 32067827 DOI: 10.1016/j.jocn.2020.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 02/09/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND We describe on a 57-year-old man with an incidental middle cerebral artery (MCA) aneurysm in whom a preoperative standard three-dimensional rotational angiogram (3D-RA) was used to depict luminal morphology along with 3D density rendering to precisely locate aneurysm wall calcification. METHODS To detect aneurysm calcification, a native 3D rotational angiogram was acquired for calcium density visualization, followed by an intraarterial contrast-enhanced 3D rotational angiogram in the same location. Both data sets were postprocessed obtaining a 3D calcium volume rendering on a 3D-RA. RESULTS Depiction of both the MCA luminal aneurysm morphology as well as calcium-rich components in the aneurysm wall was valuable to determine treatment strategy towards surgery. CONCLUSION Imaging of luminal morphology and calcification within the same angiographic procedure allows for a plain and simple estimation of the degree and distribution of brain aneurysm wall calcification with limited amount of additional radiation dosage.
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Jee TK, Nam TM, Yeon JY, Kim KH, Jeon P, Kim JS, Hong SC. Intracranial Aneurysms in Young Adult Patients: Surgical and Endovascular Treatment Outcomes. World Neurosurg 2020; 136:e214-e222. [PMID: 31899407 DOI: 10.1016/j.wneu.2019.12.124] [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: 09/06/2019] [Revised: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Despite its relative rarity, the potential for loss of productive years makes aneurysmal subarachnoid hemorrhage (SAH) a considerably important entity in young adult patients (20-39 years of age). This study aimed to analyze outcomes of microsurgery (MS) and endovascular treatment (EVT) for saccular intracranial aneurysms (IAs) in young adult patients. METHODS A total of 276 young adult patients with 315 IAs, treated with MS or EVT between January 2001 and December 2015, were studied. Major recurrence and treatment-related complications were the primary outcome measures. Functional outcomes in patients with SAH were also assessed. RESULTS Major recurrence occurred in 21 cases (6.7%). Younger age (adjusted hazard ratio [aHR], 3.77; 95% confidence interval [CI], 1.45-9.83; P = 0.007), ruptured IA (aHR, 6.44; 95% CI, 2.09-19.89; P = 0.001), size (aHR, 1.84; 95% CI, 1.06-3.18; P = 0.030), and EVT (aHR, 7.21; 95% CI, 2.44-21.35; P < 0.001) were independently related to major recurrence. Treatment-related complications occurred in 5 cases (1.6%) and did not differ between the MS and EVT groups (P > 0.999). Unfavorable outcomes (modified Rankin scale score ≥2) were identified in 30 patients (19.6%) with SAH, and only Hunt and Hess grade was independently associated with unfavorable functional outcome. CONCLUSIONS Both MS and EVT are safe for treating IAs in young adult patients. MS showed better durability of treatment and may be preferred over EVT in young patients in view of their longer life expectancy compared with older patients.
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Affiliation(s)
- Tae Keun Jee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Taek Min Nam
- Department of Neurosurgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Je Young Yeon
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Keon Ha Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Pyoung Jeon
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jong-Soo Kim
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seung-Chyul Hong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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43
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Hulsbergen AF, Mirzaei L, van der Boog AT, Smith TR, Muskens IS, Broekman ML, Mekary RA, Moojen WA. Long-Term Durability of Open Surgical versus Endovascular Repair of Intracranial Aneurysms: A Systematic Review and Meta-Analysis. World Neurosurg 2019; 132:e820-e833. [DOI: 10.1016/j.wneu.2019.08.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 07/31/2019] [Accepted: 08/01/2019] [Indexed: 11/28/2022]
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Lv Z, Zhu Y, Wang W, Wu Q, Li W, Li Q, Xu L. Comparison of Two Endovascular Interventions with Low-Profile Visualized Intraluminal Support or Pipeline Embolization Device in Middle Cerebral Arterial Aneurysms Patients. J INVEST SURG 2019; 34:590-594. [PMID: 31769307 DOI: 10.1080/08941939.2019.1670883] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Zhonghua Lv
- Department of Neurosurgery, The Second Hospital Changxing Branch Affiliated to Zhejiang University, Hangzhou Shi, Zhejiang Sheng, China
| | - Yong Zhu
- Department of Neurosurgery, The Second Hospital Changxing Branch Affiliated to Zhejiang University, Hangzhou Shi, Zhejiang Sheng, China
| | - Wei Wang
- Department of Neurosurgery, The Second Hospital Changxing Branch Affiliated to Zhejiang University, Hangzhou Shi, Zhejiang Sheng, China
| | - Qiangjun Wu
- Department of Neurosurgery, Lishui Central Hospital, Lishui Shi, Zhejiang Sheng, China
| | - Wen Li
- Department of Neurosurgery, The First Hospital Affiliated to Soochow University, Suzhou Shi, Jiangsu Sheng, China
| | - Qiang Li
- Department of Neurosurgery, Shanghai Changhai Hospital, Yangpu Qu, Shanghai Shi, China
| | - Liang Xu
- Department of Neurosurgery, The Second Hospital Affiliated to Zhejiang University, Hangzhou Shi, Zhejiang Sheng, China
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45
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Ravina K, Rennert RC, Kim PE, Strickland BA, Chun A, Russin JJ. Orphaned Middle Cerebral Artery Side-to-Side In Situ Bypass as a Favorable Alternative Approach for Complex Middle Cerebral Artery Aneurysm Treatment: A Case Series. World Neurosurg 2019; 130:e971-e987. [DOI: 10.1016/j.wneu.2019.07.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 07/03/2019] [Accepted: 07/04/2019] [Indexed: 10/26/2022]
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46
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Toyooka T, Wada K, Otani N, Tomiyama A, Takeuchi S, Tomura S, Nishida S, Ueno H, Nakao Y, Yamamoto T, Mori K. Potential Risks and Limited Indications of the Supraorbital Keyhole Approach for Clipping Internal Carotid Artery Aneurysms. World Neurosurg X 2019; 2:100025. [PMID: 31218296 PMCID: PMC6580886 DOI: 10.1016/j.wnsx.2019.100025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 02/15/2019] [Indexed: 11/17/2022] Open
Abstract
Background Internal carotid artery (ICA) aneurysm may be a good target for supraorbital keyhole clipping. We discuss the surgical indications and risks of keyhole clipping for ICA aneurysms based on long-term clinical and radiologic results. Methods This was a retrospective analysis of 51 patients (aged 35–75 years, mean 62 years) with ICA aneurysms (mean 5.8 ± 1.8 mm) who underwent clipping via the supraorbital keyhole approach between 2005 and 2017. Neurologic and cognitive functions were examined by several methods, including the modified Rankin Scale and Mini-Mental Status Examination. The state of clipping was assessed 1 year and then every few years after the operation. Results Complete clipping was confirmed in 45 patients (88.2%), dog-ear remnants behind the clip persisted in 4 patients, and wrapping was performed in 2 patients. Mean duration of postoperative hospitalization was 3.4 ± 6.9 days. The mean clinical follow-up period was 6.6 ± 3.2 years. The overall mortality was 0, and overall morbidity (modified Rankin Scale score ≥2 or Mini-Mental Status Examination <24) was 3.9%. Completely clipped aneurysms did not show any recurrence during the mean follow-up period of 6.3 ± 3.1 years, but the 2 (3.9%) aneurysms with neck remnants showed regrowth. Conclusions The risk of neck remnant behind the clip blade is a drawback of supraorbital keyhole clipping. The surgical indication requires preoperative simulation and careful checking of the clip blade state is essential.
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Key Words
- 3D, 3-Dimensional
- AcomA, Anterior communicating artery
- AntChoA, Anterior choroidal artery
- BDI, Beck Depression Inventory
- CT, Computed tomography
- CTA, Computed tomography angiography
- Clipping
- DSA, Digital subtraction angiography
- DWI, Diffusion-weighted imaging
- HAM-D, Hamilton Depression Scale
- HDS-R, Revised Hasegawa Dementia Scale
- ICA, Internal carotid artery
- ISUIA, International Study of Unruptured Intracranial Aneurysms
- Internal carotid artery
- Keyhole surgery
- MCA, Middle cerebral artery
- MMSE, Mini-Mental Status Examination
- MRI, Magnetic resonance imaging
- NIHSS, National Institutes of Health Stroke Scale
- PcomA, Posterior communicating artery
- UCA, Unruptured cerebral aneurysm
- Unruptured cerebral aneurysm
- mRS, Modified Rankin Scale
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Affiliation(s)
- Terushige Toyooka
- Department of Neurosurgery, Tokyo General Hospital, Tokyo, Japan.,Department of Neurosurgery, National Defense Medical College, Saitama, Japan
| | - Kojiro Wada
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan
| | - Naoki Otani
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan
| | - Arata Tomiyama
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan
| | - Satoru Takeuchi
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan
| | - Satoshi Tomura
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan
| | - Sho Nishida
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan
| | - Hideaki Ueno
- Department of Neurosurgery, Juntendo University, Shizuoka Hospital, Shizuoka, Japan
| | - Yasuaki Nakao
- Department of Neurosurgery, Juntendo University, Shizuoka Hospital, Shizuoka, Japan
| | - Takuji Yamamoto
- Department of Neurosurgery, Juntendo University, Shizuoka Hospital, Shizuoka, Japan
| | - Kentaro Mori
- Department of Neurosurgery, Tokyo General Hospital, Tokyo, Japan.,Department of Neurosurgery, National Defense Medical College, Saitama, Japan
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Goertz L, Brinker G, Hamisch C, Kabbasch C, Borggrefe J, Hof M, Timmer M, Stavrinou P, Goldbrunner R, Krischek B. Elective Treatment of Additional and Recurrent Aneurysms in Patients with a Previous Subarachnoid Hemorrhage: A Single-Center Analysis of Complications and Clinical Outcome. World Neurosurg 2019; 125:e1196-e1202. [DOI: 10.1016/j.wneu.2019.01.279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 01/28/2019] [Accepted: 01/30/2019] [Indexed: 10/27/2022]
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Pontes FGDB, Vasconcelos V, Baptista-Silva JCC, da Silva EMK. Treatments for unruptured intracranial aneurysms. Hippokratia 2019. [DOI: 10.1002/14651858.cd013312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Felipe Gomes de Barros Pontes
- University Hospital Prof. Alberto Antunes (Federal University of Alagoas); Department of Surgery; Maceio Alagoas Brazil 57036-730
| | - Vladimir Vasconcelos
- Universidade Federal de São Paulo; Department of Surgery, Division of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo Brazil 04038-001
| | - Jose CC Baptista-Silva
- Universidade Federal de São Paulo; Evidence Based Medicine, Cochrane Brazil; Rua Borges Lagoa, 564, cj 124 São Paulo São Paulo Brazil 04038-000
| | - Edina MK da Silva
- Universidade Federal de São Paulo; Emergency Medicine and Evidence Based Medicine; Rua Borges Lagoa 564 cj 64 Vl. Clementino São Paulo São Paulo Brazil 04038-000
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Endovascular treatment of small (< 5 mm) unruptured middle cerebral artery aneurysms. Pol J Radiol 2019; 84:e198-e204. [PMID: 31481991 PMCID: PMC6717937 DOI: 10.5114/pjr.2019.84829] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 02/18/2019] [Indexed: 01/09/2023] Open
Abstract
Purpose We report our experience with endovascular treatment of these lesions, with special consideration of angiographic and clinical outcomes and periprocedural complications. Material and methods The analysis included treatment results of 19 patients with 20 aneurysms. The aneurysm size ranged from 1.9 to 4.7 mm (mean 3.8, SD 0.7). Clinical examinations with the use of modified Rankin Score and angiographic outcomes were evaluated initially postembolisation and at a minimum follow-up of six months. Results Initial post-treatment complete and near-complete aneurysm occlusion was achieved in 19 (95%) cases and incomplete occlusion in one (5%) case. Imaging follow-up, performed in 17 (89.4%) patients, showed no change in the degree of occlusion in 16 (94.1%) patients and coil compaction in one (5.9%). There were no retreatment procedures. The procedure-related mortality rate was 5% (1/20) and was associated with intraprocedural aneurysm rupture. There was a case of a clinically silent coil prolapse into the parent artery. The clinical follow-up evaluation achieved in 17 (89.4%) patients showed no change in clinical status in all followed patients. Conclusions Endovascular treatment of small unruptured middle cerebral artery aneurysms is feasible and effective. The procedure-related complications are not negligible, especially in terms of the benign natural course of these lesions.
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50
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Mori K, Wada K, Otani N, Tomiyama A, Toyooka T, Takeuchi S, Yamamoto T, Nakao Y, Arai H. Keyhole strategy aiming at minimizing hospital stay for surgical clipping of unruptured middle cerebral artery aneurysms. J Neurosurg 2019:1-8. [DOI: 10.3171/2017.10.jns171973] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 10/19/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVEAneurysms of the middle cerebral artery (MCA) are still most often treated by clipping through standard craniotomy, but a longer hospital stay is one of the main drawbacks of this treatment. The authors developed a pterional keyhole clipping strategy for unruptured MCA aneurysms with the intention of minimizing hospital stay. In this paper, they report on their experience with this approach and analyze the long-term neurological and radiological outcomes.METHODSA total of 160 relatively small unruptured MCA aneurysms (mean 6.4 mm) were clipped through the pterional keyhole approach (19–30 mm, mean 24.6 mm) in 149 patients (aged 34–79 years, mean 62 years). Neurological and cognitive function were examined by several scales, including the modified Rankin Scale (mRS) and Mini–Mental State Examination (MMSE). Patients’ level of depression was assessed using the Beck Depression Inventory and Hamilton Depression Scale. The state of clipping was assessed at 1 year and then every few years after the operation.RESULTSThe mean duration of postoperative hospitalization was 2.3 ± 3.4 days; in 31.3% of the cases, the patients were discharged on the day after the operation (overnight hospital stay) and in 93.2% within 3 days. Of the patients younger than 60 years, 40.4% required only an overnight stay. Complete aneurysm neck clipping was confirmed in 157 cases (98.1%). None of the completely clipped aneurysms showed any recurrence during the mean follow-up period of 5.0 years. The mean length of clinical follow-up was 5.4 years. After 2 (1.3%) of the surgical procedures, the patients showed persistent neurological deficits, defined as mRS score 1, but the overall operative morbidity based on the International Study of Unruptured Intracranial Aneurysms (ISUIA) definition (mRS score ≥ 2 or MMSE score < 24) was 0% at the last examination. Depression scores were significantly improved after surgery, and in 85.6% of the cases the patients were satisfied with their cosmetic results.CONCLUSIONSPterional keyhole clipping is less invasive than clipping via standard craniotomy, minimizes hospital stay, and achieves durable treatment for relatively small unruptured MCA aneurysms.
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Affiliation(s)
- Kentaro Mori
- 1Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama
| | - Kojiro Wada
- 1Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama
| | - Naoki Otani
- 1Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama
| | - Arata Tomiyama
- 1Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama
| | - Terushige Toyooka
- 1Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama
| | - Satoru Takeuchi
- 1Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama
| | - Takuji Yamamoto
- 2Department of Neurosurgery, Juntendo University, Shizuoka Hospital, Izunokuni, Shizuoka; and
| | - Yasuaki Nakao
- 2Department of Neurosurgery, Juntendo University, Shizuoka Hospital, Izunokuni, Shizuoka; and
| | - Hajime Arai
- 3Department of Neurosurgery, Juntendo University, Tokyo, Japan
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