Predictors of Intraoperative Aneurysm Rupture, Aneurysm Remnant, and Brain Ischemia following Microsurgical Clipping of Intracranial Aneurysms: Single-Center, Retrospective Cohort Study

The safety and efficiency of SMART coil for brain aneurysm: A systematic review and meta-analysis

BACKGROUND

The SMART coil system is a relatively new generation of embolic coils consisting of a bare platinum coil, a detachment pusher, and a detachment handle. This study investigated the safety and efficiency of the SMART coil system in treating cerebral aneurysms.

METHOD

PubMed/Medline, Embase, Web of Science, and Scopus were searched until October, 1st 2023. Non-English language, non-human studies, and non-original studies were excluded.

RESULTS

A total of 7 studies were included. The results of our study reflected complete aneurysm occlusion (mRRC1) rate of 45% (95% CI, 0.35-0.56), neck remnant aneurysm (mRRC2) rate of 36% (95% CI, 0.30-0.42), and residual aneurysm (mRRC3) rate of 22% (95% CI, 0.12-0.38) during post-procedural assessment. Moreover, considering longest follow-up, our study showed complete aneurysm occlusion (mRRC1) rate of 66% (95% CI, 0.43-0.84), neck remnant aneurysm (mRRC2) rate of 27% (95% CI, 0.13-0.49), and residual aneurysm (mRRC3) rate of 9% (95% CI, 0.04-0.20). In addition, recanalization and retreatment rates were reported 10% (95% CI, 0.06-0.17) and 9% (95% CI, 0.06-0.12), respectively. The rates of adverse and serious adverse events were 9% (95% CI, 0.07-0.10) and 6% (95% CI, 0.01-0.22), respectively. Three studies reported a stroke rate which was 2% (95% CI, 0.00-0.13), and five studies reported a mortality rate which was 6% (95% CI, 0.03-0.11).

CONCLUSION

The findings suggested that the SMART coil can be a safe and efficient treatment in patients with intracranial aneurysms compared to other available treatment methods.

Impact of preaneurysmal M1 length in unruptured middle cerebral artery aneurysm: mid-term outcome and single-center experience

OBJECTIVE

This study was design to investigate the surgical and functional outcome based on the preaneurysmal M1 length for unruptured MCA aneurysm.

METHODS

Among 250 consecutive patients with unruptured aneurysms operated in our institution between 2015 and 2017, 72 were MCA aneurysms. Risk factors for IR (i.e., intraoperative rupture) were investigated including age, sex, preaneurysmal M1 length, maximal MCA aneurysm diameter, neck size, aneurysm shape, sphenoid ridge proximation sign. Outcome was measured at discharge, 1 yr and last follow-up. Outcome was compared according to the preaneurysmal M1 length.

RESULTS

Among 68 patients included, five patients (7.3%) suffered IR. Mean maximal diameter of MCA aneurysm (7.9 mm ± 3.4 vs. 4.5 ± 1.8; p = 0.01) was significantly associated with IR risk. Mean M1 length seemed to be shorter in the IR group although not statistically significant (16.2 mm ± 5.1 vs. 11.5 mm ± 4.8; p = 0.053). Mid-term outcome was favorable for all patients at last follow-up but was worsen in case of short preaneurysmal M1 segment (10.7 mm ± 4.8 vs. 16.4 mm ± 5.3, p = 0.02). Complete aneurysm occlusion was achieved for sixty-nine patients (95.5%) with 6.9% of early postoperative complications.

CONCLUSIONS

The microsurgical treatment of unruptured MCA aneurysm was associated with favorable mid-term outcome in all patients and high rates of complete occlusion. Aneurysm size was significantly associated with the intraoperative rupture risk for unruptured MCA aneurysm and patients with a short preaneurysmal M1 segment seemed to have a greater risk of intraoperative rupture although not statistically significant. Short preaneurysmal M1 patients had worsen mid-term outcome.

Clinical Characteristics and Outcome of Patients With Intraoperative Aneurysm Rupture: A Retrospective Cohort Study From Nepal

BACKGROUND AND OBJECTIVES

Intraoperative aneurysm rupture (IAR) is a significant complication during microsurgical clipping of cerebral aneurysms. The timing of rupture during surgery, morphology of the aneurysm, and strategies to mitigate risk are the key factors that influence the outcome.

METHODS

Consecutive patients with the diagnosis of ruptured cerebral aneurysms were retrospectively reviewed at a single University Hospital in Kathmandu, Nepal. Variables analyzed included age, sex, presenting symptoms, Hunt and Hess grades, the location of aneurysms, the timing of surgery, and intraoperative rupture status. Outcomes were assessed at 6 months after surgery.

RESULTS

A total of 199 patients with 231 ruptured cerebral aneurysms from July 2014 to December 2022 were reviewed. Surgery was performed within 3 days in 60 (30.1%) patients. Twenty aneurysms ruptured intraoperatively in 20 patients (10% per patient and 8.6% per aneurysm). Patients with IAR were significantly younger (mean age 52 years) than those without IAR (mean age 58 years) (P < .001, 95% CI: 3.72-8.28). There was no difference in IAR rate in early vs late surgery. Anterior communicating artery complex aneurysms were noted as the most common. However, posterior inferior cerebellar and posterior cerebral artery aneurysms had the highest IAR rate, albeit with the smallest total number. Rupture during dissection was noted in 10 (50%) and during clipping in 9 (45%) procedures. Strategies for handling IAR included direct definitive clip application in 9, temporary clip-aided permanent clipping in 8, and trapping of the parent vessel in 1 patient. Although postoperative complications were significantly higher in the IAR group (P < .000129), the neurological outcomes using the modified Rankin scale in 6 months were similar (P = .877).

CONCLUSION

The demographic and clinical characteristics and rates of IAR in our patient population are similar to those in the contemporary literature. In patients with IAR, the outcome is not worse than those without IAR.

The mechanism and therapy of aortic aneurysms

Aortic aneurysm is a chronic aortic disease affected by many factors. Although it is generally asymptomatic, it poses a significant threat to human life due to a high risk of rupture. Because of its strong concealment, it is difficult to diagnose the disease in the early stage. At present, there are no effective drugs for the treatment of aneurysms. Surgical intervention and endovascular treatment are the only therapies. Although current studies have discovered that inflammatory responses as well as the production and activation of various proteases promote aortic aneurysm, the specific mechanisms remain unclear. Researchers are further exploring the pathogenesis of aneurysms to find new targets for diagnosis and treatment. To better understand aortic aneurysm, this review elaborates on the discovery history of aortic aneurysm, main classification and clinical manifestations, related molecular mechanisms, clinical cohort studies and animal models, with the ultimate goal of providing insights into the treatment of this devastating disease. The underlying problem with aneurysm disease is weakening of the aortic wall, leading to progressive dilation. If not treated in time, the aortic aneurysm eventually ruptures. An aortic aneurysm is a local enlargement of an artery caused by a weakening of the aortic wall. The disease is usually asymptomatic but leads to high mortality due to the risk of artery rupture.

The risk factors of postoperative infarction after surgical clipping of unruptured anterior communicating artery aneurysms: anatomical consideration and infarction territory

PURPOSE

An anterior communicating artery is a common location for both ruptured and unruptured intracranial aneurysms, and microsurgery is sometimes necessary for their successful treatment. However, postoperative infarction should be considered during clipping due to the complex surrounding structures of anterior communicating artery aneurysms. This study aimed to evaluate the risk factors of postoperative infarction after surgical clipping of unruptured anterior communicating artery aneurysms and its clinical outcomes.

METHODS

The data of patients who underwent microsurgical clipping of an unruptured anterior communicating artery aneurysm in our hospital between January 2008 and December 2020 were retrospectively analyzed. The patients' demographic data, anatomical features of the anterior communicating artery complex and aneurysm, surgical technique, characteristics of postoperative infarction, and its clinical course were evaluated.

RESULTS

Notably, among 848 patients, 66 (7.8%) and 34 (4%) patients had radiologic and symptomatic infarctions, respectively. Univariate and multivariate logistic regression analyses showed that hypertension (odds ratio (OR), 1.99; [Formula: see text]), previous stroke (OR, 3.89; [Formula: see text]), posterior projection (OR, 5.58; [Formula: see text]), aneurysm size (OR, 1.17; optimal cut-off value, 6.14 mm; [Formula: see text]), and skull base-to-aneurysm distance (OR, 1.15; optimal cut-off value, 11.09 mm; [Formula: see text]) were associated with postoperative infarction. In the pterional approach, a closed A2 plane was an additional risk factor (OR, 1.88; [Formula: see text]). Infarction of the subcallosal and hypothalamic branches was significantly associated with symptomatic infarction ([Formula: see text]).

CONCLUSION

Hypertension, previous stroke, posteriorly projecting aneurysms, aneurysm size, and highly positioned aneurysms are independent risk factors for postoperative infarction during surgical clipping of an unruptured anterior communicating artery aneurysm. Additionally, a closed A2 plane is an additional risk factor of postoperative infarction in patients undergoing clipping via the pterional approach.