Microsurgical Treatment of Cerebral Aneurysms After Previous Endovascular Therapy: Single-Center Series and Systematic Review

Microsurgical Treatment of Previously Coiled Giant Aneurysms: Experience with 6 Cases and Literature Review

OBJECTIVE

Surgical treatment of insufficiently embolized (coiled) or recurrent giant aneurysms has not been well established in the literature. The aim of this study is to bring up the surgical difficulties of these rare aneurysms and to offer solutions.

METHODS

A database was queried for giant aneurysms that had been previously embolized and subsequently required surgical treatment. We only found 29 aneurysms in the literature and here, we report 6 more surgical cases with patient characteristics, radiological studies, applied surgical techniques, and outcomes which were reviewed retrospectively.

RESULTS

Four females and 2 males, with a mean age of 45.6 years took part in the study. The most common aneurysm location was the middle cerebral artery. While 5 aneurysms were successfully clipped, 1 was excised and the neck was closed with micro sutures. The coils were compulsorily removed in 3 patients. Postoperative digital subtraction angiography confirmed total occlusion of the aneurysms in all cases. Overall morbidity was 16.6%. There was no mortality. No recurrence was observed in the angiographic follow-up (mean 22.6 months, range 7-47 months). The literature review also determined that 97.1% of 35 previously coiled giant aneurysms (including ours) were occluded using various surgical techniques, with 82.8% good outcome.

CONCLUSIONS

Surgical clipping is a safe and effective procedure for the treatment of insufficiently embolized or recurrent giant aneurysms after coiling. If possible, the coils should not be removed. However, if safe clipping is not possible due to the coils, the removal of the coils should not be avoided.

Are Guidelines Important? Results of a Prospective Quality Improvement Lumbar Fusion Project

BACKGROUND

United States (U.S.) healthcare is a volume-based inefficient delivery system. Value requires the consideration of quality, which is lacking in most healthcare disciplines.

OBJECTIVE

To assess whether patients who met specific evidence-based medicine (EBM)-based criteria preoperatively for lumbar fusion would achieve higher rates of achieving the minimal clinical important difference (MCID) than those who did not meet the EBM indications.

METHODS

All elective lumbar fusion cases, March 2018 to August 2019, were prospectively evaluated and categorized based on EBM guidelines for surgical indications. The MCID was defined as a reduction of ≥5 points in Oswestry Disability Index (ODI). Multiple logistic regression identified multivariable-adjusted odds ratio of EBM concordance.

RESULTS

A total of 325 lumbar fusion patients were entered with 6-mo follow-up data available for 309 patients (95%). The median preoperative ODI score was 24.4 with median 6-mo improvement of 7.0 points (P < .0001). Based on ODI scores, 79.6% (246/309) improved, 3.8% (12/309) had no change, and 16% (51/309) worsened. A total of 191 patients had ODI improvement reaching the MCID. 93.2% (288/309) cases were EBM concordant, while 6.7% (21/309) were not.In multivariate analysis, EBM concordance (P = .0338), lower preoperative ODI (P < .001), lower ASA (American Society of Anesthesiologists) (P = .0056), and primary surgeries (P = .0004) were significantly associated with improved functional outcome. EBM concordance conferred a 3.04 (95% CI 1.10-8.40) times greater odds of achieving MCID in ODI at 6 mo (P = .0322), adjusting for other factors.

CONCLUSION

This analysis provides validation of EBM guideline criteria to establish optimal patient outcomes. The EBM concordant patients had a greater than 3 times improved outcome compared to those not meeting EBM fusion criteria.