Comparative Effectiveness of Unruptured Cerebral Aneurysm Therapies

Preventive clipping versus coiling in unruptured intracranial aneurysms: A comprehensive meta-analysis and systematic review to explore safety and efficacy

BACKGROUND

Surgical clipping and endovascular coiling are both effective in preventing aneurysmal subarachnoid hemorrhage, but the choice between these interventions remains controversial, leading to treatment disparities across medical centers.

METHODS

A systematic review and meta-analysis were conducted, including relevant two-arm clinical trials up to September 2023, sourced from Scopus, PubMed, Web of Science, and the Cochrane Library. Our primary outcomes were complete occlusion rates during mid-term and long-term follow-ups. Standard mean differences and risk ratios were used to analyze variations in outcomes. Python meta-analysis with sensitivity testing and regional subgroup analysis was used to resolve heterogeneity.

RESULTS

The analysis included 139,485 participants. Clipping demonstrated significantly higher complete occlusion rates in midterm follow-up (RR = 0.83, 95% CI [0.75, 0.91], p = 0.0001) but was associated with a higher risk of procedural complications such as bleeding and ischemic stroke. Coiling showed a higher risk of retreatment (RR = 3.46, 95% CI [1.21, 9.86], p = 0.02), yet it had lower procedural complications (RR = 0.54, 95% CI [0.38, 0.78], p < 0.0009), shorter hospital stays (MD 4.36, 95% CI [2.96, 5.77], p = 0.0001), and better post-procedural outcomes as indicated by lower modified Rankin Scale scores (RR = 0.73, 95% CI [0.55, 0.97], p = 0.03). Long-term occlusion rates were comparable between the two methods.

CONCLUSION

While clipping achieves higher mid-term occlusion rates, coiling is associated with fewer complication rates, shorter hospital stays, and potentially better long-term outcomes. Treatment decisions should be individualized, considering patient-specific characteristics and procedural feasibility.

Risk Factors and Predictive Model for Ischemic Complications in Endovascular Treatment of Intracranial Aneurysms: Insights From a Large Patient Cohort

Objectives

There remains a conspicuous absence of systematic analysis concerning the risk factors for the development of ischemic complications in the interventional treatment of IAs. Our study aimed to identify the risk factors for ischemic complications after the interventional treatment of IAs and to make an individualized prediction of the occurrence of ischemic complications, providing important reference guidance for clinicians.

Methods

This study encompassed a sample of 473 patients diagnosed with intracranial aneurysms (IA) and treated at our center between February 2022 and April 2024. Ischemic complications were identified via clinical symptomatology and corroborated with diagnostic subtraction angiography (DSA), computed tomography (CT), or magnetic resonance imaging (MRI). We used a machine learning (ML) approach to screen potential variables for ischemic complications and identify correlations between them, and subsequently constructed a logistic regression model to quantify these correlations.

Results

Patients were categorized based on the occurrence or absence of ischemic complications. A total of five potential factors were screened using LASSO regression, XGBoost, and Randomforest algorithms: hypertension, history of alcohol consumption, multiple IAs, rupture status, and antiplatelet agent. Multivariate analysis further disclosed that hypertension, history of alcohol consumption, ruptured aneurysms, and antiplatelet agent were independent risk factors for postoperative ischemic complications. The predictive model, derived from the multivariate regression analysis results, demonstrated robust reliability.

Conclusions

Hypertension, history of alcohol consumption, ruptured aneurysms, and antiplatelet agent as independent risk factors for ischemic complications following the interventional treatment of IAs. Accordingly, we constructed the first risk prediction model regarding ischemic complications of all IAs based on these factors, aiming to enhance prognostic judgment and treatment strategy planning.

Advancements in Brain Aneurysm Management: Integrating Neuroanatomy, Physiopathology, and Neurosurgical Techniques

Brain aneurysms, characterized by abnormal bulging in blood vessels, pose significant risks if ruptured, necessitating precise neuroanatomical knowledge and advanced neurosurgical techniques for effective management. This article delves into the intricate neuroanatomy relevant to brain aneurysms, including the vascular structures and critical regions involved. It provides a comprehensive overview of the pathophysiology of aneurysm formation and progression. The discussion extends to modern neurosurgical approaches for treating brain aneurysms, such as microsurgical clipping, endovascular coiling, and flow diversion techniques. Emphasis is placed on preoperative planning, intraoperative navigation, and postoperative care, highlighting the importance of a multidisciplinary approach. By integrating neuroanatomical insights with cutting-edge surgical practices, this article aims to enhance the understanding and treatment outcomes of brain aneurysms.

Coil embolization of the middle cerebral artery bifurcation aneurysms: Feasibility and durability

OBJECTIVE

To evaluate the feasibility and durability of coil embolization for MCAB aneurysms by analyzing clinical and radiological results.

METHODS

From January of 2008 to June of 2018, we treated a total of 1785 aneurysms using coil embolization. The aneurysms were treated by both coiling and stent-assisted coiling. Among these cases, 223 MCAB aneurysms were analyzed retrospectively. Clinical and radiological assessments were conducted at admission, after treatment, at discharge, and at last clinical follow-up.

RESULTS

Coil embolization was performed on 223 MCAB aneurysms in 217 patients. Peri-procedural ischemic, hemorrhagic, and other complications within 30 days after coil embolization occurred at rates of 8.0 %, 8.0 %, and 2.0 %, respectively, in the ruptured group and at 2.9 %, 1.2 %, and 0 %, respectively, in the unruptured group. The overall morbidity and mortality rates associated with complications were 2.3 % and 2.0 %. The cumulative major recurrence rates were 5.1 % at 12 months, 7.1 % at 18 months, and 11.9 % at three years after coil embolization. The mean follow-up period was 33.27 ± 25.48 months. Independent risk factors for major recurrence after coil embolization for MCAB aneurysms were a ruptured aneurysm, initial incomplete occlusion, the aneurysm size, and the neck size.

CONCLUSION

Coil embolization is a good alternative treatment option for MCAB aneurysms compared to surgical clipping. Considering the risk factors for major recurrence, the follow-up angiography should continue up to three years after coil embolization.

Risk Factor Analysis of Complications and Mortality Following Coil Procedures in Patients with Intracranial Unruptured Aneurysms Using a Nationwide Health Insurance Database

(1) Background: Unruptured intracranial aneurysm (UIA) occurs in 1-2% of the population and is being increasingly detected. Patients with UIA are treated with close observation, endovascular coiling or surgical clipping. The proportion of endovascular coiling has been rising. However, complications such as cerebral infarction (CI), intracranial hemorrhage (ICRH), and death remain crucial issues after coil treatment. (2) Methods: We analyzed the incidence and risk factors of complications after the use of coil in patients with UIA based on the patients' characteristics. We utilized the Health Insurance Review and Assessment (HIRA) database. Patients treated with coils for UIA between 1 January 2015 and 1 December 2021 were retrospectively analyzed. (3) Results: Of the total 35,140 patients, 1062 developed ICRH, of whom 87 died, with a mortality rate of 8.2%. Meanwhile, 749 patients developed CI, of whom 29 died, with a mortality rate of 3.9%. The overall mortality rate was 1.8%. In a univariate analysis of the risk factors, older age, males, a higher Charlson Comorbidity Index (CCI) score, and diabetes increase the risk of CI. Meanwhile, males with higher CCI scores and hemiplegia or paraplegia show increased ICRH risk. Older age, males and metastatic solid tumors relate to increased mortality risk. (4) Conclusions: This study is significant in that the complications based on the patient's underlying medical condition were analyzed.

Global Outcomes for Microsurgical Clipping of Unruptured Intracranial Aneurysms: A Benchmark Analysis of 2245 Cases

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.

The Management of Intracranial Aneurysms: Current Trends and Future Directions

Intracranial aneurysms represent a major global health burden. Rupture of an intracranial aneurysm is a catastrophic event. Without access to treatment, the fatality rate is 50% in the first 30 days. Over the last three decades, treatment approaches for intracranial aneurysms have changed dramatically. There have been improvements in the medical management of aneurysmal subarachnoid haemorrhage, and there has been an evolution of treatment strategies. Endovascular therapy is now the mainstay of the treatment of ruptured intracranial aneurysms based on robust randomised controlled trial data. There is now an expansion of treatment indications for unruptured intracranial aneurysms to prevent rupture with both microsurgical clipping and endovascular treatment. Both microsurgical and endovascular treatment modalities have evolved, in particular with the introduction of innovative endovascular treatment options including flow diversion and intra-saccular flow disruption. These novel therapies allow clinicians to treat more complex and previously untreatable aneurysms. We aim to review the evolution of treatment strategies for intracranial aneurysms over time, and discuss emerging technologies that could further improve treatment safety and functional outcomes for patients with an intracranial aneurysm.

Frailty is a Predictor of Increased Readmissions and Increased Postoperative Complications After Elective Treatment of Unruptured Aneurysms

INTRODUCTION

Frailty is a state of decreased physiologic reserve associated with adverse treatment outcomes across surgical specialties. We sought to determine whether frailty affected patient outcomes after elective treatment (open microsurgical clipping or endovascular therapy [EVT]) of unruptured cerebral aneurysms (UCAs).

METHODS

The National Readmissions Database was queried from 2010 to 2014 to identify patients who had a known UCA and underwent elective clipping or EVT. Frailty was assessed using the Johns Hopkins Adjusted Clinical Groups frailty indicator tool. Multivariable exact logistic regression analyses were conducted to assess the associations between frailty and the primary outcome variables of 30- and 90-day readmissions, complications, length of stay (LOS), and patient disposition.

RESULTS

Of 18,483 patients who underwent elective treatment for UCAs, 358 (1.9%) met the criteria for frailty. After adjusting for patient- and hospital-based factors, frailty (30-day: odds ratio [OR], 1.55; 95% confidence interval [CI], 1.11-2.17; P = 0.01; 90-day: OR, 1.47; 95% CI, 1.05-2.06; P = 0.02) and clipping versus EVT (30-day: OR, 2.12; 95% CI, 1.85-2.43; P < 0.000; 90-day: OR, 1.80; 95% CI, 1.59-2.03; P < 0.0001) were associated with increased readmission rates. Furthermore, frailty was associated with an increased rate of complications (surgical: OR, 2.91; 95% CI, 2.27-3.72; P < 0.0001; neurological: OR, 3.04; 95% CI, 2.43-3.81; P < 0.0001; major: OR, 2.75; 95% CI, 1.96-3.84; P < 0.0001), increased LOSs (incidence rate ratio, 3.08; 95% CI, 2.59-3.66; P < 0.0001), and an increased rate of nonroutine disposition (OR, 3.94; 95% CI, 2.91-5.34; P < 0.0001).

CONCLUSIONS

Frailty was associated with an increased likelihood of 30- and 90-day readmissions after elective treatment of UCAs. Frailty was notably associated with several postoperative complications, longer LOSs, and nonroutine disposition in the treatment of UCAs.

Prognostic factors affecting the ruptured intracranial aneurysms: A 9-year multicenter study in Fujian, China

BACKGROUND

A multicenter retrospective study was conducted to explore the factors affecting short-term prognosis and long-term outcomes of intracranial aneurysms (IA) rupture. Further, the prognosis prediction model was constructed based on survival analysis, contributing to the development of prevention strategies for aneurysmal subarachnoid hemorrhage.

METHODS

Data of 1280 patients with IA rupture were gathered between 2014 and 2022 in Fujian, China. Logistic regression was implemented to study the short-term prognostic factors of IA rupture. Survival analysis of 911 patients among them was performed to explore the long-term outcome status by Cox risk assessment. Nomogram prognosis models were constructed using R software.

RESULTS

The findings displayed that blood type O (OR = 1.79; P = 0.019), high systolic pressure (OR = 1.01; P < 0.001), Glasgow Coma score (GCS) 9-12 (OR = 2.73; P = 0.022), GCS < 9 (OR = 3.222; P = 0.006), diabetes (OR = 2.044; P = 0.040), and high white blood cell count (OR = 1.059, P = 0.040) were core influencing factors for poor short-term prognosis. Survival analysis revealed that age > 60 years (HR = 2.87; P = 0.001), hypertension (HR = 1.95; P = 0.001), conservative (HR = 6.89; P < 0.001) and endovascular treatment (HR = 2.20; P = 0.001), multiple ruptured IAs (HR = 2.37; P = 0.01), Fisher 3 (HR = 1.68; P = 0.09), Fisher 4 (HR = 2.75; P = 0.001), and Hunt-Hess 3 (HR = 0.55; P = 0.05) were the major risk factors for terrible long-term outcomes.

CONCLUSIONS

People over 60 years with characteristics of type O blood, high systolic pressure, diabetes, high white blood cell count, and onset GCS < 12 will have more complications and a worse short-term prognosis. Those aged > 60 years with hypertension, conservative and endovascular treatment, multiple ruptured IAs, Fisher ≥ 3 and Hunt-Hess 3 have a greater risk of poor long-term prognosis.

Duration between aneurysm rupture and treatment and its association with outcome in aneurysmal subarachnoid haemorrhage

Timely treatment of aneurysmal subarachnoid haemorrhage (aSAH) is key to prevent further rupture and poor outcome. We evaluated complications and outcome adjusting for time from haemorrhage to treatment. Retrospective analysis of aSAH patients admitted between 2006 and 2020. Data was collected using standardized case report forms. We compared risk factors using multivariable logistic regression. We included 853 patients, 698 (81.8%) were treated within 24 h. Patients with higher Hunt and Hess grades were admitted and treated significantly faster than those with lower grades (overall p-value < 0.001). Fifteen patients (1.8%) rebled before intervention. In the multivariable logistic analysis adjusting for timing, Barrow Neurological Institute score and intracerebral haemorrhage were significantly associated with rebleeding (overall p-value 0.006; OR 3.12, 95%CI 1.09-8.92, p = 0.03, respectively) but timing was not. Treatment > 24 h was associated with higher mortality and cerebral infarction in only the subgroup of lower grades aSAH (OR 3.13, 1.02-9.58 95%CI, p-value = 0.05; OR 7.69, 2.44-25.00, p-value < 0.001, respectively). Therefore treatment > 24 h after rupture is associated with higher mortality and cerebral infarction rates in lower grades aSAH. Delay in treatment primarily affects lower grade aSAH patients. Patients with lower grade aSAH ought to be treated with the same urgency as higher-grade aSAH.

Evolution of open surgery for unruptured intracranial aneurysms over a fifteen year period-increased difficulty and morbidity

OBJECTIVE

The approach to intervention for unruptured intracranial aneurysms (UIAs) remains controversial. Utilization of endovascular techniques for aneurysm repair increased dramatically during the last decade. We sought to analyze recent national trends for electively treated (open and endovascular) UIAs focusing on pre-existing patient disease burden and intervention modality selection.

METHODS

The Nationwide Inpatient Sample (NIS) national database was used to identify patients with primary diagnosis codes of unruptured intracranial aneurysm between 1999 and 2014. Patients were dichotomized by intervention into endovascular or open surgical treatment. Analysis of pre-existing disease severity were calculated using the Elixhauser comorbidity index. Complications of combined peri-procedural stroke or death during admission and hospital length of stay were used as primary endpoints for comparison.

RESULTS

The percent of total UIAs treated electively with open approach decreased from more than 95 % of cases in 1999 to less than 25 % in 2014. Patients undergoing clipping were 3 years younger than those in the endovascular group (p < 0.001). The rate of primary endpoint complications (stroke and death) and length of stay for open cases saw a decrease throughout the study but remained statistically higher when compared to the endovascular group over the study period (p < 0.001). Additionally, non-neurologic complications increased over the time period for open cases. The average preoperative co-morbid disease severity for all groups treated increased over this interval. Conversely, the relative volume of endovascular cases increased but the rate of complications and average group disease remained statistically lower than the surgical clipping group (p < 0.05).

CONCLUSION

The percent of UIAs treated electively with open approach has decreased since 1999 with a concomitant increase in complication rate in particular compared to endovascular cases. However, the health characteristics of patients treated with surgical clipping show an increase in severity of pre-existing co-morbidities. Further research into factors contributing to this finding, including potential socioeconomic differences and changes in surgeon experience are needed.

The impact of high-resolution cone-beam CT findings on decision-making for the treatment of unruptured middle cerebral artery aneurysms

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.

Cerebral ischemia after treatment of posterior communicating artery aneurysms: clipping versus coiling

Objection

This study aimed to compare the incidence of cerebral ischemia and outcomes between surgical clipping and endovascular coiling in patients with posterior communicating artery (PCoA) aneurysms.

Methods

Clinical and imaging data of patients with at least one PCoA aneurysm who underwent surgical clipping or endovascular coiling in our institution from January 2017 to December 2019 were analyzed.

Results

Three hundred sixty-three aneurysms in 353 patients were included for analysis, 257 in the clipping group, and 106 in the coiling group. The groups did not differ in terms of baseline characteristics. The incidence of postoperative cerebral ischemia (23.35% vs. 11.32%, p = 0.029) was higher in the clipping group. The proportion of patients with a modified Rankin Scale score ≥ 2 was significantly higher in the clipping group at discharge (35.80% vs. 15.09%; p < 0.05) but not six months after discharge (15.56% vs. 8.49%; p > 0.05). In the clipping group, the mean age was significantly higher in patients who developed cerebral ischemia than in those who did not. In the coiling group, modified Fisher grade and incidence of fetal PCoA were significantly higher in patients who developed ischemia.

Conclusion

The incidence of postoperative cerebral ischemia was higher after PCoA aneurysm clipping than after coiling. The causes and characteristics of postoperative cerebral ischemia after PCoA clipping and coiling are different; therefore, treatment should be selected accordingly.

Analysis of Clinical Effects of Comprehensive Nursing Based on Enhanced Recovery after Surgery in Patients with Embolization for Intracranial Aneurysms

Objective. This research sets out to elucidate the clinical effect of comprehensive nursing based on the concept of enhanced recovery after surgery (ERAS) in patients with embolization for intracranial aneurysms (IAs). Methods. This study enrolled 119 patients with embolization for IAs in the Zhongnan Hospital of Wuhan University from January 2020 to January 2021 and divided them into two groups according to the perioperative care they received: a control group ( $n=39$ ) treated with routine perioperative nursing and an observation group ( $n=80$ ) treated with ERAS-based comprehensive nursing. Surgical indicators, neurological function (National Institute of Health Stroke Scale (NIHSS) score; Scandinavian Stroke Scale (SSS) score), anxiety and depression (Self-Rating Anxiety Scale (SAS) score; Self-Rating Depression Scale (SDS) score), incidence of adverse events, and patient satisfaction were compared. Results. The observation group had better surgical indicators and lower scores of NIHSS, SSS, SAS, and SDS than the control group, accompanied by a lower incidence of adverse events and higher patient satisfaction. Conclusions. ERAS-based comprehensive nursing can better promote patients’ neurological recovery after embolization for IAs, relieve unhealthy emotions (depression, anxiety, etc.), and reduce the occurrence of adverse reactions, facilitating patient discharge.

Evolution of the patient-first approach: a dual-trained, single-neurosurgeon experience with 2002 consecutive intracranial aneurysm treatments

OBJECTIVE

The paradigm for intracranial aneurysm (IA) treatment is shifting toward a hybrid approach involving open and endovascular techniques. The authors chronicled the evolution of IA treatment by retrospectively examining a large series of IA cases treated by a single dual-trained neurosurgeon, focusing on evolving technology relative to the choice of treatment options, perioperative morbidity, and mortality.

METHODS

The aneurysm database at the authors' institution was searched to identify consecutive patients treated with endovascular or open microsurgical approaches by one neurosurgeon during an 18-year time span. Patients were included regardless of IA rupture status, location or morphology, or treatment modality. Data collected were baseline clinical characteristics, aneurysm size, treatment modality, operative complications, in-hospital mortality, and retreatment rate.

RESULTS

A total of 1858 patients with 2002 IA treatments were included in the study. Three-hundred fifty IAs (17.5%) were ruptured. Open microsurgery was performed in 504 aneurysms (25.2%) and endovascular surgery in 1498 (74.8%). Endovascular IA treatments trended toward a growing use of flow diversion during the last 11 years. In-hospital mortality was 1.7% overall, including 7.0% in ruptured and 0.5% in unruptured cases. The overall complication rate was 3.3%, including 3.4% for microsurgical cases and 3.3% for endovascular cases. The rate of retreatment was 3.6% after clipping and 10.7% for endovascular treatment.

CONCLUSIONS

This study demonstrates complementary use of open and endovascular approaches for IA treatment. By customizing treatment to the patient, comparable rates of procedural complications, mortality, and retreatment were achieved for both endovascular and microsurgical approaches.

The Impact of Interhospital Competition on Treatment Strategy and Outcomes for Unruptured Intracranial Aneurysms

BACKGROUND

Interhospital competition has been shown to affect surgical outcomes and expenditures. However, interhospital competition's impact on neurosurgery is poorly characterized.

OBJECTIVE

To assess how interhospital competition is associated with treatment strategy and outcomes for unruptured intracranial aneurysms (UIAs).

METHODS

We identified all elective UIA admissions in the National Inpatient Sample from 2002 to 2011. Competitive intensity of each hospital market was quantified using the validated Herfindahl-Hirschman Index (HHI), with lower values denoting higher competition. We then obtained nationwide HHI values for 2012 to 2016 from the Health Care Cost Project. Outcomes included treatment modality (clipping, coiling, or nonoperative management), inpatient mortality, disposition, complications, length of stay (LOS), and costs. Multivariate regression assessed the association between HHI and outcomes, controlling for patient demographics, severity metrics, hospital characteristics, and treatment.

RESULTS

We studied 157 979 elective UIA admissions at 1435 hospitals from 2002 to 2011, with an increase in coiling admissions (13.4% to 33.7%) and decrease in clipping admissions (30.9% to 17.6%). Mean hospital HHI was 0.11 (range = 0.001-0.97). Competition decreased for 61.8% of hospitals from 2002 to 2011 and 68.1% of metropolitan localities from 2012 to 2016. Admissions in more competitive hospital markets exhibited increased odds of undergoing surgery (odds ratio [OR] = 1.37, P < .001), with preference toward coiling over clipping (OR = 1.27, P < .001). HHI was not associated with mortality, disposition, or LOS. However, increased interhospital competition was associated with more complications (OR = 1.09, P = .001) and greater hospital costs (β-coefficient = 1.06, P < .001).

CONCLUSION

For UIA patients, admission to hospitals in more competitive geographies was associated with increased rates of surgical intervention, coiling utilization, complications, and hospitalization costs.

Diagnosis and Treatment of Unruptured Intracranial Aneurysms and Aneurysmal Subarachnoid Hemorrhage

Unruptured intracranial aneurysms (UIAs) are commonly acquired vascular lesions that form an outpouching of the arterial wall due to wall thinning. The prevalence of UIAs in the general population is 3.2%. In contrast, an intracranial aneurysm may be manifested after rupture with classic presentation of a thunderclap headache suggesting aneurysmal subarachnoid hemorrhage (SAH). Previous consensus suggests that although small intracranial aneurysms (<7 mm) are less susceptible to rupture, aneurysms larger than 7 mm should be treated on a case-by-case basis with consideration of additional risk factors of aneurysmal growth and rupture. However, this distinction is outdated. The PHASES score, which comprises data pooled from several prospective studies, provides precise estimates by considering not only the aneurysm size but also other variables, such as the aneurysm location. The International Study of Unruptured Intracranial Aneurysms is the largest observational study on the natural history of UIAs, providing the foundation to the current guidelines for the management of UIAs. Although SAH accounts for only 3% of all stroke subtypes, it is associated with considerable burden of morbidity and mortality. The initial management is focused on stabilizing the patient in the intensive care unit with close hemodynamic and serial neurologic monitoring with endovascular or open surgical aneurysm treatment to prevent rebleeding. Since the results of the International Subarachnoid Aneurysm Trial, treatment of aneurysmal SAH has shifted from surgical clipping to endovascular coiling, which demonstrated higher odds of survival free of disability at 1 year after SAH. Nonetheless, aneurysmal SAH remains a public health hazard and is associated with high rates of disability and death.

Flow-diverting device versus coil embolization for unruptured intracranial aneurysm: A meta-analysis

BACKGROUND

Both coil embolization (CE) and flow-diverting device (FDD) placement are widely used for treatment of intracranial aneurysms (IAs). The aim of this meta-analysis is to compare the relative clinical safety and efficacy of FDD and CE for the treatment of unruptured IAs.

METHODS

The PubMed, Embase, and Cochrane Library databases were searched for relevant studies from the date of inception through April 2020. The primary endpoint for this meta-analysis was the 6-month rate of complete occlusion, while secondary endpoints included rates of retreatment, complications, and parental arterial patency.

RESULTS

This meta-analysis includes 8 studies, which included 839 total patients that underwent FDD and 2734 that underwent CE. FDD group exhibited a significantly higher pooled 6-month complete occlusion rate (P = .02). The subgroup analysis demonstrated that FDD treatment was associated with significantly higher pooled 6-month complete occlusion rates in patients with large or giant IAs (P < .00001), whereas no differences in 6-month complete occlusion rates were observed between the FDD and CE groups of patients with non-large/giant IAs (P = .83). The pooled retreatment (P = .16) and complication (P = .15) rates were comparable between 2 groups. The CE group exhibited significantly higher pooled parent artery patency rate (P = .01). The funnel plots did not reveal any evidence of publication bias.

CONCLUSIONS

FDDs can be used to effectively and safely treat large and giant IAs, achieving higher rates of complete occlusion than CE treatment. For non-large/giant IAs, we observed comparable efficacy between FDD and CE treatments.

Major intraoperative aneurysm rupture may increase the risk of cerebral infarction following surgical clipping of unruptured intracranial aneurysms

OBJECTIVE

Intraoperative aneurysm rupture (IAR) could cause a poor outcome. This study aimed to investigate the relationship between IARs and postoperative cerebral infarctions (CIs).

METHOD

We retrospectively reviewed patients with asymptomatic unruptured intracranial aneurysms (UIAs) who received microsurgical clipping in two neurosurgical centers from January 2016 to June 2019. A propensity score matching was done to constitute a cohort. The data were collected regarding the clinical and radiological characteristics. The CI at 1-2 weeks and the functional outcome at two weeks after clipping were recorded. Differences between IAR patients with CIs and without CIs were compared. The relationship between the IARs and postoperative CIs was investigated by using logistic regression analysis.

RESULTS

This study yielded 96 UIAs patients, including 48 patients undergoing IARs and 48 patients not. Twenty patients with CIs at 1-2 weeks after clipping were identified. The rate of CIs in patients undergoing IARs was higher than that in patients not undergoing IARs (OR, 2.88; p = 0.038); moreover, the mRS was also worse in patients undergoing IARs (OR, 1.58; p = 0.015). For patients undergoing IARs, the significance was found in ischemic cerebrovascular disease (OR, 6.40; p = 0.048), Essen stroke risk score (OR, 2.14; p = 0.026), and severity of intraoperative rupture (OR, 5.63; p = 0.023). The multivariate logistic analysis demonstrated the major IARs (OR, 6.09; CI, 1.18-31.53; p = 0.031) as the independent risk factor related to postoperative CI.

CONCLUSION

IARs could increase the risk of postoperative CIs and worsen the functional outcome, and major IAR was the independent risk factor related to the postoperative CIs.

Perioperative Ischemic Stroke in Unruptured Intracranial Aneurysm Surgical or Endovascular Therapy

Background: Ischemic stroke among hospitalized patients who underwent surgical or endovascular therapies for unruptured intracranial aneurysms (IAs) has not been previously examined in nationally representative samples.

Objectives: The purpose of this study is to compare the occurrence and in-hospital outcomes (nonroutine discharge, length of stay) of perioperative ischemic stroke among hospitalized patients diagnosed with unruptured IA across treatment selection [surgical clipping, endovascular coiling, stent- or balloon-assisted coiling (SAC or BAC), combined clipping and coiling].

Methods: A cross-sectional study was conducted using 23,053 hospital discharge records from the 2002-2012 Nationwide Inpatient Sample (NIS). Rates, β coefficients, and odds ratios (ORs) with their 95% confidence intervals (CIs) were calculated accounting for survey design complexity, patient- and hospital-level confounders.

Results: Ischemic stroke rate was 6.9% [surgical clipping (4.3%), endovascular coiling (8.1%), BAC or SAC (1.9%), and combined techniques (4.2%)]. Multivariable logistic regression models suggested that compared to patients undergoing surgical clipping alone, those undergoing SAC or BAC were less likely to be diagnosed with ischemic stroke (adjusted OR=0.34, 95% CI: 0.14, 0.85). Compared to clipping, endovascular techniques resulted in fewer nonroutine dispositions and shorter hospitalizations, whereas combined techniques resulted in longer hospitalizations. Differences in hospitalization outcomes between treatment types were only affected by ischemic stroke when comparing coiling to clipping.

Conclusions: Perioperative ischemic stroke rate among patients with unruptured IA may be less among those undergoing SAC or BAC as compared to those undergoing surgical clipping alone. Improved in-hospital outcomes among coiling versus clipping recipients may depend on ischemic stroke diagnosis.

Clipping versus coiling in unruptured anterior cerebral circulation aneurysms

Background:

Unruptured intracranial aneurysms (UIAs) are not uncommon, especially in Japan. Treatment strategy for UIAs has evolved in the past decades in Western countries with the increased use of endovascular treatment as the primary option, but in Japan, clipping still has the upper hand.

Methods:

This study retrospectively included 200 patients treated by clipping or coiling for UIAs located in the anterior cerebral circulation. Postoperative angiographic and clinical outcomes were evaluated.

Results:

Of 200 UIAs, 147 and 53 were treated by surgery and coiling, respectively. The average follow-up duration was 30.2 ± 18.8 months for clipping and 29.3 ± 17.6 months for coiling. Complete occlusion was greater in the surgery group (78.9%) than the endovascular group (18.8%). Regrowth occurred in 1.4% of the clipping group and 13.2% of the coiling group. Ischemic events were encountered in both groups; asymptomatic ones were higher in the coiling group (24.5%) than in the clipping group (2%), while symptomatic ischemic complications were equal (7.5%) in both groups. The deterioration of modified Rankin scale was detected totally in 13 UIAs (6.5%) with no statistical difference between groups. Postoperative hospital period was longer in clipping (P = 0.01).

Conclusion:

Clipping and coiling were both safe and feasible in the treatment of unruptured aneurysms. The clipping was advantageous in durability, while the rate of morbidity was lower, and hospitalization period was shorter in the coiling group. The clipping and coiling should coexist while complementing each other by understanding the advantages and disadvantages of both.

Endovascular coiling versus surgical clipping for the treatment of unruptured cerebral aneurysms: Direct comparison of procedure-related complications

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.

Propensity Score Matching Analysis for the Patients of Unruptured Cerebral Aneurysm from a Post Hoc Analysis of a Nationwide Database in Japan

BACKGROUND

This study aimed to compare the functional outcome at discharge for unruptured cerebral aneurysms (UCAs) between surgical clipping and endovascular coiling in total, nonelderly (<65 years), and elderly (≥65 years) patients by nonbiased analysis based on a national database in Japan.

METHODS

A total of 15,671 patients with UCA were registered in the Diagnosis Procedure Combination, the nationwide database, from 2010 to 2015 in Japan. The outcome of the Barthel Index (BI) at discharge was investigated, and propensity score-matched analysis was conducted in total, nonelderly, and elderly patient groups.

RESULTS

Propensity score-matched analysis found no significant difference for in-hospital mortality between the 2 treatment methods in the total and both age-groups. The rate of morbidity of BI <90 at discharge was higher after surgical clipping than after endovascular coiling in the total (4.9% vs. 3.9%; P = 0.040; risk difference, -1.0%; 95% confidence interval, -3.6 to 2.3%) and the elderly age-group (8.1% vs. 5.0%; P < 0.001; risk difference, -3.1%; -4.8% to 1.5%), however, no significant association between the 2 treatment methods (2.4% vs. 2.6%; P = 0.67; risk difference, 0.22%; -0.79 to 1.22%) was found in the nonelderly group.

CONCLUSIONS

In elderly patients with UCA, a better outcome at discharge after endovascular coiling was found. However, no significantly different functional outcome at discharge between surgical clipping and endovascular coiling for UCA in nonelderly patients was confirmed by propensity score-matched analysis from a nationwide database in Japan.

Olfactory dysfunction in patients undergoing supraorbital keyhole craniotomy for clipping of unruptured aneurysms

Olfactory performance has rarely been assessed in the perioperative phase of elective aneurysm surgery. Here, we assessed the risk for olfactory deterioration following surgical treatment of unruptured cerebral aneurysm via the supraorbital keyhole craniotomy. A retrospective review of patients with electively treated cerebral aneurysms who underwent perioperative assessment of olfactory function using a sniffin' sticks odor identification test between January 2015 and January 2016 was performed. A subgroup of patients without history of subarachnoid hemorrhage, without prior aneurysm treatment, and confirmed olfactory function underwent supraorbital keyhole craniotomy for aneurysm clipping. Microscopic and endoscopic videos were reviewed for this subgroup. Sixty-four patients who underwent elective aneurysm treatment either via surgical clipping or endovascular aneurysm obliteration were identified. Prior to treatment, 4/64 (6.3%) demonstrated bilateral anosmia. Collectively, 14 patients (21.9%) met subgroup criteria of supraorbital keyhole craniotomy for aneurysm clipping. Here, olfactory performance significantly decreased postoperatively on the side of craniotomy (ipsilateral, P = 0.007), whereas contralateral and bilateral olfactory function remained unaltered (P = 0.301 and P = 0.582, respectively). Consequently, 4/14 patients (28.6%) demonstrated ipsilateral anosmia 3 months after surgery. One patient (1/14, 7.1%) also experienced contralateral anosmia resulting in bilateral anosmia. Intraoperative visualization of the olfactory tract and surgical maneuvers do not facilitate prediction of olfactory outcome. The supraorbital keyhole craniotomy harbors a specific risk for unilateral olfactory deterioration. Lack of perioperative olfactory assessment likely results in underestimation of the risk for olfactory decline. Despite uneventful surgery, prediction of postoperative olfactory function and dysfunction remain challenging. Clin. Anat. 33:316-323, 2020. © 2019 Wiley Periodicals, Inc.

Trends for in-hospital metrics in the treatment of intracranial aneurysms in Minas Gerais, Brazil

Background: Aneurysmal subarachnoid hemorrhage (ASAH) and unruptured aneurysm (URA) are particularly important because of the high mortality rates, and physical and cognitive impairment, which affect the economically active population. The present work aims at describing the scenario regarding in-hospital indicators related to the following therapeutic approaches: vascular microsurgery (VMS) and endovascular therapy (EVT) in the state of Minas Gerais, Brazil, in order to gather information to construct hypotheses and plan actions. Methods: The study has an ecological design and it is also analytical for the time trends of 2008-2014. Trends for VMS and EVT therapies and mortality are estimated using linear regression, followed by the Prais-Winsten procedure. Data were obtained through Hospital Information System (Sistema de Informações Hospitalares - SIH) of Brazilian Public Health System (Sistema Único de Saúde - SUS). Results: In 2014, 601 procedures were performed, and out of these, 373 (62%) were triggered by SAH and 228 (38%) by URA. The frequency of procedures performed in males and in females results in a ratio of 1:2 for SAH procedures and 1:3 for URA procedures. A heterogeneous distribution of therapeutic approaches was seen among the hospital studied, suggesting a technological preference, which determines the therapeutic approach. Conclusion: Technological bias was observed for aneurysm treatment in Minas Gerais's hospitals. EVT is seen to have a growing trend to detriment of VMS (β₁ = 0.024; p = 0.025), with a stable mortality for both therapeutics in both pathologies (SAH and URA). EVT has been associated with a shorter hospital stay, with higher expenses for both ASAH and URA treatment. EVT showed an inverse correlation with in-hospital fatality for ASAH treatment.

Endovascular Treatment of Unruptured MCA Bifurcation Aneurysms Regardless of Aneurysm Morphology: Short- and Long-Term Follow-Up

BACKGROUND AND PURPOSE

The optimal treatment of unruptured middle cerebral aneurysms is still under debate. Although today almost any aneurysm can be treated endovascularly, there is a lack of data comparing endovascular and microsurgical repair of MCA aneurysms. The aim of our analysis is to provide data on the efficacy, clinical outcome, complications and re-treatment rates of endovascular treatment of this subtype of aneurysms.

MATERIALS AND METHODS

Between May 2008 and July 2017, endovascular treatment of 1184 aneurysms in 827 patients was performed in our department. Twenty-four percent of these aneurysms were located at the MCA, and 150 unruptured MCA bifurcation aneurysms treated with coiling, stent-assisted-coiling, or endovascular flow diverter (WEB device) were identified for this retrospective data analysis. Ninety-six percent of all aneurysms, ruptured and unruptured, were treated by an endovascular approach, which yields a low selection bias for aneurysms suitable for endovascular treatment. Follow-up examinations were performed after 12 and 36 months and then every 1-3 years after embolization. Procedures were analyzed for periprocedural complications, outcome, and retreatment rate of the WEB (n = 38) and coiling with (n = 45) or without stent assistance (n = 67).

RESULTS

The procedure-associated good clinical outcome (mRS ≦ 2) was 89.9%, and the mortality rate was 2.7%. Short-term follow-up good clinical outcome/mortality rates were 91.3%/0.7%. At discharge, 137 patients had an mRS of 0-2 (91.3%) and 13 had an mRS of 3-6 (8.7%). The retreatment rate was significantly higher in the WEB group (21.1%) compared with the coiling group with (5.9%) or without (2.2%) stent placement (P < .05).

CONCLUSIONS

Regardless of the architecture of MCA bifurcation aneurysms, the endovascular treatment can be performed with low morbidity/mortality rates. The higher retreatment rate in the WEB group correlates with the learning curve in choosing the right device size.

Long-term outcomes of coil embolization of unruptured intracranial aneurysms

OBJECTIVELong-term follow-up results of the treatment of unruptured intracranial aneurysms (UIAs) by means of coil embolization remain unclear. The aim of this study was to analyze the frequency of rupture, retreatment, stroke, and death in patients with coiled UIAs who were followed for up to 20 years at multiple stroke centers.METHODSThe authors retrospectively analyzed data from cases in which patients underwent coil embolization between 1995 and 2004 at 4 stroke centers. In collecting the late (≥ 1 year) follow-up data, postal questionnaires were used to assess whether patients had experienced rupture or retreatment of a coiled aneurysm or any stroke or had died.RESULTSOverall, 184 patients with 188 UIAs were included. The median follow-up period was 12 years (interquartile range 11-13 years, maximum 20 years). A total of 152 UIAs (81%) were followed for more than 10 years. The incidence of rupture was 2 in 2122 aneurysm-years (annual rupture rate 0.09%). Nine of the 188 patients with coiled UIAs (4.8%) underwent additional treatment. In 5 of these 9 cases, the first retreatment was performed more than 5 years after the initial treatment. Large aneurysms were significantly more likely to require retreatment. Nine strokes occurred over the 2122 aneurysm-years. Seventeen patients died in this cohort.CONCLUSIONSThis study demonstrates a low risk of rupture of coiled UIAs with long-term follow-up periods of up to 20 years. This suggests that coiling of UIAs could prevent rupture for a long period of time. However, large aneurysms might need to be followed for a longer time.

Analysis of the influence of imaging-related uncertainties on cerebral aneurysm deformation quantification using a no-deformation physical flow phantom

Cardiac-cycle related pulsatile aneurysm motion and deformation is assumed to provide valuable information for assessing cerebral aneurysm rupture risk. Accordingly, numerous studies addressed quantification of cerebral aneurysm wall motion and deformation. Most of them utilized in vivo imaging data, but image-based aneurysm deformation quantification is subject to pronounced uncertainties: unknown ground-truth deformation; image resolution in the order of the expected deformation; direct interplay between contrast agent inflow and image intensity. To analyze the impact of the uncertainties on deformation quantification, a multi-imaging modality ground-truth phantom study is performed. A physical flow phantom was designed that allowed simulating pulsatile flow through a variety of modeled cerebral vascular structures. The phantom was imaged using different modalities [MRI, CT, 3D-RA] and mimicking physiologically realistic flow conditions. Resulting image data was analyzed by an established registration-based approach for automated wall motion quantification. The data reveals severe dependency between contrast media inflow-related image intensity changes and the extent of estimated wall deformation. The study illustrates that imaging-related uncertainties affect the accuracy of cerebral aneurysm deformation quantification, suggesting that in vivo imaging studies have to be accompanied by ground-truth phantom experiments to foster data interpretation and to prove plausibility of the applied image analysis algorithms.

Feasibility and Midterm Outcomes of Endovascular Coil Embolization of an Unruptured Middle Cerebral Artery Aneurysm with an Incorporated Branch

BACKGROUND

Endovascular coiling has emerged as an option for the management of unruptured intracranial aneurysms, which was traditionally treated via surgical clipping. Unlike aneurysms elsewhere, aneurysms of the middle cerebral artery (MCA) have several features that are favorable for surgery. However, endovascular treatment can be difficult for MCA aneurysms, especially if they have incorporated branches. We report the results of coil embolization of incorporated MCA aneurysms.

METHODS

From 2012 to 2017, 129 unruptured aneurysms including 10 incorporated MCA aneurysms were treated. The mean neck, height, and width of the aneurysms were 3.74 ± 1.07, 4.26 ± 1.06, and 3.97 ± 1.03, respectively. The mean aspect ratio, neck/sac width, and sac width/neck were 1.19 ± 0.37, 1.09 ± 0.21, and 0.95 ± 0.18, respectively.

RESULTS

Nine cases of incorporated MCA aneurysms were treated using the double microcatheter technique, whereas the triple microcatheter technique was used in 1 case. There were no procedure-related complications. Postcoiling angiograms showed that 4 aneurysms achieved complete occlusion (40%), 5 had a remnant neck (50%), and 1 had a remnant sac (10%). During the follow-up period, (26.0 ± 4.5 months; range, 3-49 months), there were no incidents of recurrence and bleeding. One patient experienced a small cerebral infarction 1 month after the procedure, but it did not lead to any permanent neurologic deficits.

CONCLUSIONS

Branch-incorporated MCA aneurysms can be treated with coil embolization, with few procedural complications and midterm durability with appropriate techniques and devices.

Long-term outcomes of treatment for unruptured intracranial aneurysms in South Korea: clipping versus coiling

Background

The long-term outcomes of endovascular coiling and surgical clipping for the treatment of unruptured intracranial aneurysms are unclear.

Methods

We performed a nationwide retrospective cohort study using claims data from the Korean Health Insurance Review and Assessment Service on patients undergoing surgical clipping or endovascular coiling from 2008 to 2014. Inverse probability treatment weighting for average treatment effect on the treated and the multiple imputation method were used to balance covariates and handle missing values. The primary outcome was all-cause mortality at 7 years.

Results

We identified 26 411 patients of whom 11 777 underwent surgical clipping and 14 634 underwent endovascular coiling. After adjustment with the use of inverse probability treatment weighting for average treatment effect on the treated, all-cause mortality rates at 7 years were 3.8% in the endovascular coiling group and 3.6% in the surgical clipping group (HR 1.05; 95% CI 0.86 to 1.28; P=0.60, log-rank test). The adjusted probabilities of aneurysm rupture at 7 years were 0.9% after endovascular coiling and 0.7% after surgical clipping (HR 0.9; 95% CI 0.61 to 1.34; P=0.63, log-rank test). The probabilities of retreatment at 7 years after adjustment were 4.9% in the endovascular coiling group and 3.2% in the surgical clipping group (HR 1.52; 95% CI 1.28 to 1.81; P<0.001, log-rank test).

Conclusions

All-cause mortality at 7 years was similar between the elective surgical clipping and endovascular coiling groups in patients with unruptured aneurysms who had no history of subarachnoid hemorrhage due to aneurysm rupture.

Unruptured aneurysms in the elderly: perioperative outcomes and cost analysis of endovascular coiling and surgical clipping

OBJECTIVE

Observation and neurosurgical intervention for unruptured intracranial aneurysms (UIAs) in the elderly population is rapidly increasing. Cerebral aneurysm coiling (CACo) is favored over cerebral aneurysm clipping (CAC) in elderly patients, yet some elderly individuals still undergo CAC. The cost-effectiveness of treating UIAs requires further exploration. Understanding the effect of intervention on hospital charges and length of stay (LOS) as well as perioperative mortality and complications can further shed light on its economic impact. The purpose of this study was to analyze the cost and perioperative outcomes of UIAs in elderly patients (≥ 65 years of age) after CACo or CAC intervention.

METHODS

Retrospective cohorts of CACo and CAC admissions were extracted from National (Nationwide) Inpatient Sample data obtained between 2002 and 2013, forming parallel intervention groups to compare the following outcomes between elderly and nonelderly patients: average LOS and mean hospital admission costs, in-hospital mortality, and complications. Covariates included sex, race or ethnicity, and comorbidities.

RESULTS

Elderly patients undergoing CAC experienced an average LOS of 8.0 days, whereas elderly patients undergoing CACo stayed an average of 3.2 days. The mean hospital charges incurred during admission totaled $95,960 in the elderly patients who underwent CAC versus $87,960 in the ones who underwent CACo. Elderly patients in whom CAC was performed had a 2.2% rate of in-hospital mortality, with a 2.6 greater adjusted odds of in-hospital mortality than nonelderly patients treated with CAC. In contrast, elderly patients who underwent CACo had a 1.36 greater adjusted odds of in-hospital mortality than their nonelderly counterparts. Compared to nonelderly patients receiving both interventions, elderly individuals had a significantly higher prevalence of various comorbidities and incidence of complications. Elderly patients who received CAC experienced a 10.3% incidence rate of perioperative stroke, whereas their CACo counterparts experienced this complication at a rate of 3.5%. Elderly patients treated with CAC had greater odds of perioperative acute renal failure, whereas their CACo counterparts had greater odds of perioperative deep venous thrombosis and pulmonary embolism.

CONCLUSIONS

Intervention with CAC and CACo in the elderly is resource intensive and is associated with higher risk than in the nonelderly. Those deciding between intervention and conservative management should consider these risks and costs, especially the 2.2% postoperative mortality rate associated with CAC in the elderly population. Further comparative cost-effectiveness research is needed to weigh these costs and outcomes against those of conservative management.

Indications for the Performance of Intracranial Endovascular Neurointerventional Procedures: A Scientific Statement From the American Heart Association

Intracranial endovascular interventions provide effective and minimally invasive treatment of a broad spectrum of diseases. This area of expertise has continued to gain both wider application and greater depth as new and better techniques are developed and as landmark clinical studies are performed to guide their use. Some of the greatest advances since the last American Heart Association scientific statement on this topic have been made in the treatment of ischemic stroke from large intracranial vessel occlusion, with more effective devices and large randomized clinical trials showing striking therapeutic benefit. The treatment of cerebral aneurysms has also seen substantial evolution, increasing the number of aneurysms that can be treated successfully with minimally invasive therapy. Endovascular therapies for such other diseases as arteriovenous malformations, dural arteriovenous fistulas, idiopathic intracranial hypertension, venous thrombosis, and neoplasms continue to improve. The purpose of the present document is to review current information on the efficacy and safety of procedures used for intracranial endovascular interventional treatment of cerebrovascular diseases and to summarize key aspects of best practice.

Balloon-Assisted Cannulation for Difficult Anterior Cerebral Artery Access

The anterior communicating artery is a common location for intracranial aneurysms. Compared to surgical clipping, endovascular coiling has been shown to improve outcomes for patients with ruptured aneurysms and we have seen a paradigm shift favoring this technique for treating aneurysms. Access to the anterior cerebral artery can be challenging, especially in patients with tortuous anatomy or subarachnoid hemorrhage or in patients presenting with vasospasm. We present a technique for cannulating the anterior cerebral artery using a balloon inflated in the proximal middle cerebral artery as a rebound surface.

Periprocedural safety of Pipeline therapy for unruptured cerebral aneurysms: Analysis of 279 Patients in a multihospital database

The relative safety of unruptured aneurysm treatment with coiling versus flow diversion therapy is unknown. Most data available on flow diversion reflect highly focused patient groups and very experienced operators. We evaluated a national, multihospital patient database to examine periprocedural morbidity and mortality in patients treated with endovascular flow diversion therapy. The Premier Perspective database was used to identify patients hospitalized between May 2011 and March 2013 for unruptured aneurysm who underwent flow diversion therapy with a Pipeline embolization device. The risk of in-hospital mortality and morbidity was determined using ICD 9 codes. A total of 279 unruptured aneurysm patients at 18 medical centers underwent endovascular therapy with a Pipeline device. Adverse outcomes included in-hospital mortality in two cases (0.7%), discharge to long-term care in 22 cases (7.9%), ischemic complications in 14 cases (5.0%), hemorrhagic complications in four cases (1.4%), and postoperative neurological complications in nine cases (3.2%). This study of a large cohort of patient hospitalizations in the United States provides preliminary data on flow diversion in a "real world" scenario and demonstrates that the periprocedural morbidity and mortality is not negligible and must be considered in the context of the natural history of the aneurysms that are being treated.

Computational fluid dynamics (CFD) using porous media modeling predicts recurrence after coiling of cerebral aneurysms

Objective

This study aimed to predict recurrence after coil embolization of unruptured cerebral aneurysms with computational fluid dynamics (CFD) using porous media modeling (porous media CFD).

Method

A total of 37 unruptured cerebral aneurysms treated with coiling were analyzed using follow-up angiograms, simulated CFD prior to coiling (control CFD), and porous media CFD. Coiled aneurysms were classified into stable or recurrence groups according to follow-up angiogram findings. Morphological parameters, coil packing density, and hemodynamic variables were evaluated for their correlations with aneurysmal recurrence. We also calculated residual flow volumes (RFVs), a novel hemodynamic parameter used to quantify the residual aneurysm volume after simulated coiling, which has a mean fluid domain > 1.0 cm/s.

Result

Follow-up angiograms showed 24 aneurysms in the stable group and 13 in the recurrence group. Mann-Whitney U test demonstrated that maximum size, dome volume, neck width, neck area, and coil packing density were significantly different between the two groups (P < 0.05). Among the hemodynamic parameters, aneurysms in the recurrence group had significantly larger inflow and outflow areas in the control CFD and larger RFVs in the porous media CFD. Multivariate logistic regression analyses demonstrated that RFV was the only independently significant factor (odds ratio, 1.06; 95% confidence interval, 1.01–1.11; P = 0.016).

Conclusion

The study findings suggest that RFV collected under porous media modeling predicts the recurrence of coiled aneurysms.

Hemodynamics and coil distribution with changing coil stiffness and length in intracranial aneurysms

Purpose

The purpose of this study was to investigate hemodynamics and coil distribution with changing coil stiffness and length using the finite element method (FEM) and computational fluid dynamics (CFD) analysis.

Methods

Basic side-wall and bifurcation type aneurysm models were used. Six types of coil models were generated by changing the coil stiffness and length, based on commercially available embolic coils. Coil embolization was simulated using FEM. CFD was performed to characterize the hemodynamics in the aneurysms after embolization. Coil distribution and velocity reduction in the aneurysms were evaluated.

Results

The median value of radial coil distribution was shifted from the center to the outer side of the aneurysmal dome by changing coil stiffness: harder coils entered the outer side of the aneurysmal dome more easily. Short coils were more distributed at the neck region, since their small size made it easy for them to enter the tighter area. CFD results also indicated that velocity in the aneurysm was effectively reduced when the coils were more distributed at the neck region and the outer side of the aneurysmal dome because of the disturbance in blood inflow.

Conclusions

It is easier for coils to enter the outer side of the aneurysmal sphere when they are harder. If coils are short, they can enter tighter areas more easily. In addition, high coil density at the outer side of the aneurysmal dome and at the neck region is important to achieve effective velocity reduction.

A new combined parameter predicts re-treatment for coil-embolized aneurysms: a computational fluid dynamics multivariable analysis study

Purpose

Coil embolization is a minimally invasive method used to treat cerebral aneurysms. Although this endovascular treatment has a high success rate, aneurysmal re-treatment due to recanalization remains a major problem of this method. The purpose of this study was to determine a combined parameter that can be useful for predicting aneurysmal re-treatment due to recanalization.

Methods

Patient-specific geometries were used to retrospectively analyze the blood flow for 26 re-treated and 74 non-retreated aneurysms. Post-operatively aneurysms were evaluated at 12-month follow-up. The hemodynamic differences between the re-treatment and non-retreatment aneurysms were analyzed before and after coil embolization using computation fluid dynamics. Basic fluid characteristics, rates of change, morphological factors of aneurysms and patient-specific clinical information were examined. Multivariable analysis and logistic regression analysis were performed to determine a combined parameter—re-treatment predictor (RP).

Results

Among examined hemodynamic, morphological, and clinical parameters, slight reduction of blood flow velocity rate in the aneurysm, slight increase of pressure rate at the aneurysmal neck and neck area, and hypertension were the main factors contributing to re-treatment. Notably, hemodynamic parameters between re-treatment and non-retreatment groups before embolization were similar: however, we observed significant differences between the groups in the post-embolization average velocity and the rate of reduction in this velocity in the aneurysmal dome.

Conclusions

The combined parameter, RP, which takes into consideration hemodynamic, morphological, and clinical parameters, accurately predicts aneurysm re-treatment. Calculation of RP before embolization may be able to predict the aneurysms that will require re-treatment.

Symptomatic and silent cerebral infarction following surgical clipping of unruptured intracranial aneurysms: incidence, risk factors, and clinical outcome

Cerebral infarction (CI) associated with clipping of unruptured intracranial aneurysms (UIAs) has not been completely studied. The role of individual and operative characteristics is not known, and the risk of silent CI has not been well described. To determine the incidence, risk factors, and clinical outcome of postoperative CI, we retrospectively analyzed 388 consecutive patients undergoing clipping of UIAs between January 2012 and December 2015. We reviewed the pre- and postoperative computed tomography (CT) images of each patient. Postoperative CI was defined as a new parenchymal hypodensity in the vascular territory of treated artery. Patient-specific, aneurysm-specific, and operative variables were analyzed as potential risk factors. Functional outcome at discharge was assessed with the modified Rankin Scale (mRS). Postoperative CI was found in 49 (12.6%) patients, 29 of whom manifested neurological deficits. The incidences of symptomatic stroke and silent CI were 7.5 and 5.2%, respectively. Multivariate analysis showed that larger aneurysm size and history of hypertension were significantly associated with CI. Disability (mRS > 2) rate was 42.9% among patients with CI, which was substantially higher than that among patients without (0.9%). In conclusion, the incidence of CI following clipping of UIAs was not low. Larger aneurysm size and history of hypertension were independent risk factors. Postoperative symptomatic stroke correlated with an extremely high risk of disability. Silent CI was seemingly nondisabling, but the possible cognitive consequence is pending.

A Novel Flow Diverter (Tubridge) for the Treatment of Recurrent Aneurysms: A Single-Center Experience

Objective

The Tubridge flow diverter (FD) is a novel device aimed at reconstructing the parent artery and occluding complex aneurysms. Retreatment of recurrent aneurysms using the FD is challenging. We report our initial experience in the repair of aneurysm recurrence with the FD.

Materials and Methods

A database was reviewed prospectively, and 8 patients with 8 recurrent aneurysms (mean size, 16.7 mm) were identified. Four aneurysms had previously ruptured. The previous aneurysm treatment consisted of coiling in 1 aneurysm and single-stent-assisted coiling in 7 aneurysms. The procedural complications and clinical and angiographic outcomes were analyzed.

Results

Six aneurysms were treated by using a single Tubridge FD alone, while the remaining 2 were treated with FD + coiling. The immediate results of the 8 aneurysms were that they all showed incomplete occlusion. Neither major ischemic nor hemorrhagic complications occurred; however, 1 patient experienced a vasospasm. Follow-up angiographies were available for 7 aneurysms; the mean follow-up was 16.9 months (7–36 months). Five aneurysms were completely occluded, whereas 2 had a residual neck. Severe asymptomatic stenosis of 1 parent artery of a vertebral artery dissecting aneurysm was found. All visible branches covered by the FD were patent. All patients were clinically assessed as having attained a favorable outcome (modified Rankin Scale score ≤ 2) at discharge and follow-up.

Conclusion

In selected patients, the Tubridge FD can provide a safe and efficient option for the retreatment of recurrent aneurysms. Nevertheless, attention should be paid to several technical points.

Intracranial Aneurysms of Neuro-Ophthalmologic Relevance

BACKGROUND

Intracranial saccular aneurysms are acquired lesions that often present with neuro-ophthalmologic symptoms and signs. Recent advances in neurosurgical techniques, endovascular treatments, and neurocritical care have improved the optimal management of symptomatic unruptured aneurysms, but whether the chosen treatment has an impact on neuro-ophthalmologic outcomes remains debated.

EVIDENCE ACQUISITION

A review of the literature focused on neuro-ophthalmic manifestations and treatment of intracranial aneurysms with specific relevance to neuro-ophthalmologic outcomes was conducted using Ovid MEDLINE and EMBASE databases. Cavernous sinus aneurysms were not included in this review.

RESULTS

Surgical clipping vs endovascular coiling for aneurysms causing third nerve palsies was compared in 13 retrospective studies representing 447 patients. Complete recovery was achieved in 78% of surgical patients compared with 44% of patients treated with endovascular coiling. However, the complication rate, hospital costs, and days spent in intensive care were reported as higher in surgically treated patients. Retrospective reviews of surgical clipping and endovascular coiling for all ocular motor nerve palsies (third, fourth, or sixth cranial nerves) revealed similar results of complete resolution in 76% and 49%, respectively. Improvement in visual deficits related to aneurysmal compression of the anterior visual pathways was also better among patients treated with clipping than with coiling. The time to treatment from onset of visual symptoms was a predictive factor of visual recovery in several studies. Few reports have specifically assessed the improvement of visual deficits after treatment with flow diverters.

CONCLUSIONS

Decisions regarding the choice of therapy for intracranial aneurysms causing neuro-ophthalmologic signs ideally should be made at high-volume centers with access to both surgical and endovascular treatments. The status of the patient, location of the aneurysm, and experience of the treating physicians are important factors to consider. Although a higher rate of visual recovery was reported with neurosurgical clipping, this must be weighed against the potentially longer intensive care stays and increased early morbidity.

Vision outcomes in patients with paraclinoid aneurysms treated with clipping, coiling, or flow diversion: a systematic review and meta-analysis

OBJECTIVE

Patients with paraclinoid aneurysms commonly present with visual impairment. They have traditionally been treated with clipping or coiling, but flow diversion (FD) has recently been introduced as an alternative treatment modality. Although there is still initial aneurysm thrombosis, FD is hypothesized to reduce mass effect, which may decompress the optic nerve when treating patients with visually symptomatic paraclinoid aneurysms. The authors performed a meta-analysis to compare vision outcomes following clipping, coiling, or FD of paraclinoid aneurysms in patients who presented with visual impairment.

METHODS

A systematic literature review was performed using the PubMed and Web of Science databases. Studies published in English between 1980 and 2016 were included if they reported preoperative and postoperative visual function in at least 5 patients with visually symptomatic paraclinoid aneurysms (cavernous segment through ophthalmic segment) treated with clipping, coiling, or FD. Neuroophthalmological assessment was used when reported, but subjective patient reports or objective visual examination findings were also acceptable.

RESULTS

Thirty-nine studies that included a total of 2458 patients (520 of whom presented with visual symptoms) met the inclusion criteria, including 307 visually symptomatic cases treated with clipping (mean follow-up 26 months), 149 treated with coiling (mean follow-up 17 months), and 64 treated with FD (mean follow-up 11 months). Postoperative vision in these patients was classified as improved, unchanged, or worsened compared with preoperative vision. A pooled analysis showed preoperative visual symptoms in 38% (95% CI 28%–50%) of patients with paraclinoid aneurysms. The authors found that vision improved in 58% (95% CI 48%–68%) of patients after clipping, 49% (95% CI 38%–59%) after coiling, and 71% (95% CI 55%–84%) after FD. Vision worsened in 11% (95% CI 7%–17%) of patients after clipping, 9% (95% CI 2%–18%) after coiling, and 5% (95% CI 0%–20%) after FD. New visual deficits were found in patients with intact baseline vision at a rate of 1% (95% CI 0%–3%) for clipping, 0% (95% CI 0%–2%) for coiling, and 0% (95% CI 0%–2%) for FD.

CONCLUSIONS

To the authors’ knowledge, this is the first meta-analysis to assess vision outcomes after treatment for paraclinoid aneurysms. The authors found that 38% of patients with these aneurysms presented with visual impairment. These data also demonstrated a high rate of visual improvement after FD without a significant difference in the rate of worsened vision or iatrogenic visual impairment compared with clipping and coiling. These findings suggest that FD is an effective option for treatment of visually symptomatic paraclinoid aneurysms.

Medicare expenditures for elderly patients undergoing surgical clipping or endovascular intervention for subarachnoid hemorrhage

OBJECTIVE The impact of treatment method-surgical clipping or endovascular coiling-on the cost of care for patients with aneurysmal subarachnoid hemorrhage (SAH) is debated. Here, the authors investigated the association between treatment method and long-term Medicare expenditures in elderly patients with aneurysmal SAH. METHODS The authors performed a cohort study of 100% of the Medicare fee-for-service claims data for elderly patients who had undergone treatment for ruptured cerebral aneurysms in the period from 2007 to 2012. To control for measured confounding, the authors used propensity score-adjusted multivariable regression analysis with mixed effects to account for clustering at the hospital referral region (HRR) level. An instrumental variable (regional rates of coiling) analysis was used to control for unmeasured confounding by creating pseudo-randomization on the treatment method. RESULTS During the study period, 3210 patients underwent treatment for ruptured cerebral aneurysms and met the inclusion criteria. Of these patients, 1206 (37.6%) had surgical clipping and 2004 (62.4%) had endovascular coiling. The median total Medicare expenditures in the 1st year after admission for SAH were $113,000 (IQR $77,500-$182,000) for surgical clipping and $103,000 (IQR $72,900-$159,000) for endovascular coiling. When the authors adjusted for unmeasured confounders by using an instrumental variable analysis, clipping was associated with increased 1-year Medicare expenditures by $19,577 (95% CI $4492-$34,663). CONCLUSIONS In a cohort of Medicare patients with aneurysmal SAH, after controlling for unmeasured confounding, surgical clipping was associated with increased 1-year expenditures in comparison with endovascular coiling.

Comparison of clipping and coiling in elderly patients with unruptured cerebral aneurysms

OBJECTIVE The comparative effectiveness of the 2 treatment options-surgical clipping and endovascular coiling-for unruptured cerebral aneurysms remains an issue of debate and has not been studied in clinical trials. The authors investigated the association between treatment method for unruptured cerebral aneurysms and outcomes in elderly patients. METHODS The authors performed a cohort study of 100% of Medicare fee-for-service claims data for elderly patients who had treatment for unruptured cerebral aneurysms between 2007 and 2012. To control for measured confounding, the authors used propensity score conditioning and inverse probability weighting with mixed effects to account for clustering at the level of the hospital referral region (HRR). An instrumental variable (regional rates of coiling) analysis was used to control for unmeasured confounding and to create pseudo-randomization on the treatment method. RESULTS During the study period, 8705 patients underwent treatment for unruptured cerebral aneurysms and met the study inclusion criteria. Of these patients, 2585 (29.7%) had surgical clipping and 6120 (70.3%) had endovascular coiling. Instrumental variable analysis demonstrated no difference between coiling and clipping in 1-year postoperative mortality (OR 1.25, 95% CI 0.68-2.31) or 90-day readmission rate (OR 1.04, 95% CI 0.66-1.62). However, clipping was associated with a greater likelihood of discharge to rehabilitation (OR 6.39, 95% CI 3.85-10.59) and 3.6 days longer length of stay (LOS; 95% CI 2.90-4.71). The same associations were present in propensity score-adjusted and inverse probability-weighted models. CONCLUSIONS In a cohort of Medicare patients, there was no difference in mortality and the readmission rate between clipping and coiling of unruptured cerebral aneurysms. Clipping was associated with a higher rate of discharge to a rehabilitation facility and a longer LOS.

Medicare expenditures for elderly patients undergoing surgical clipping or endovascular intervention for unruptured cerebral aneurysms

BACKGROUND

The cost difference between the two treatment options (surgical clipping and endovascular therapy) for unruptured cerebral aneurysms remains an issue of debate. We investigated the association between treatment method for unruptured cerebral aneurysms and Medicare expenditures in elderly patients.

METHODS

We performed a cohort study of 100% Medicare fee-for-service claims data for elderly patients who underwent treatment for unruptured cerebral aneurysms from 2007 to 2012. In order to control for measured confounding we used multivariable regression analysis with mixed effects to account for clustering at the Hospital Referral Region (HRR) level. An instrumental variable (regional rates of endovascular treatment) analysis was used to control for unmeasured confounding by creating pseudo-randomization on the treatment method.

RESULTS

During the study period 8705 patients underwent treatment for unruptured cerebral aneurysms and met the inclusion criteria. Of these, 2585 (29.7%) had surgical clipping and 6120 (70.3%) had endovascular treatment. The median total Medicare expenditures in the first year after the admission for the procedure were $46 800 (IQR $31 000-$74 400) for surgical clipping and $48 100 (IQR $34 500-$73 900) for endovascular therapy. When we adjusted for unmeasured confounders, using an instrumental variable analysis, clipping was associated with increased 7-day Medicare expenditures by $3527 (95% CI $972 to $5736) and increased 1-year Medicare expenditures by $15 984 (95% CI $9017 to $22 951).

CONCLUSIONS

In a cohort of Medicare patients, after controlling for unmeasured confounding, we demonstrated that surgical clipping of unruptured cerebral aneurysms was associated with increased 1-year expenditures compared with endovascular treatment.