Open and endovascular treatment of unruptured carotid-ophthalmic aneurysms: clinical and radiographic outcomes

Treatment of Unruptured Large and Giant Paraclinoid Aneurysms in Japan at the Time of Flow Diverter Introduction: A Nationwide, Multicenter Survey by the Japanese Society on Surgery for Cerebral Stroke

OBJECTIVE

Large or giant paraclinoid aneurysms have been treated with various strategies, including clipping, coiling, and parent artery occlusion (PAO). In addition, flow diverters (FDs) have been introduced for the management of these aneurysms. The aim of this study was to examine the management of unruptured large/giant paraclinoid aneurysms in Japan when FDs were being introduced by a nationwide survey.

METHODS

A total of 576 unruptured large/giant paraclinoid aneurysms treated in Japan between January 2012 and December 2016 were retrospectively studied.

RESULTS

Half of the large paraclinoid aneurysms were treated by coiling (50.3%), whereas giant aneurysms were occluded mainly by PAO (51.4%). A high nearly complete occlusion rate was achieved with clipping (94.1%), coiling (85.9%), PAO (82.4%), and FDs (77.6%). Coiling had higher risks of recurrence (28.3%) and retreatment (20.3%). Major procedure-related complications were observed in 9.7%. Ischemic complications were common in PAO (9.5%), with cranial nerve symptoms common in clipping (10.9%). All treatment modalities achieved good clinical outcomes (93.5%-96.6%). Although not significant, pre-existing visual disturbance improved most frequently by clipping (53.7%), but also worsened most frequently by clipping (24.4%). Consequently, FD achieved a high occlusion rate with minimal complication and retreatment rates.

CONCLUSIONS

All treatment modalities offer high rates of complete occlusion and good clinical outcomes. Coiling has the disadvantage of high rates of recurrence and retreatment. Clipping and PAO have the disadvantage of a high rate of major procedure-related complications; however, PAO can provide comparable treatment outcomes even in cases with refractory giant aneurysms. FDs are the optimal choice for the management for large/giant paraclinoid aneurysms due to its safety and efficacy.

Comparative Efficacy of Endovascular Therapy and Microsurgery in Treating Ophthalmic Artery Aneurysms: A Systematic Review and Meta-Analysis

BACKGROUND

Ophthalmic artery (OphA) aneurysms, occurring at the junction of the internal carotid artery and the OphA orifice, present significant treatment challenges due to their location and complex anatomy. This systematic review and meta-analysis aimed to evaluate endovascular therapy and microsurgery in managing OphA aneurysms.

METHODS

Adhering to Cochrane Handbook guidelines, a comprehensive search was conducted in ClinicalTrials.gov and 4 databases (PubMed, Scopus, Web of Science, and Embase). Study quality was assessed using the National Institutes of Health tool. Statistical analyses were performed with Review Manager and open MetaAnalyst software.

RESULTS

The meta-analysis included 9 articles, covering 902 OphA aneurysms. Cohort studies showed fair quality, while case series demonstrated good quality. No significant difference in clinical outcomes was found between endovascular therapy and surgery. Post-treatment visual outcomes had an odds ratio (OR) of 2.48 (95% confidence interval [CI] [0.35, 17.45], P = 0.36), modified Rankin Scale (mRS) >2 outcomes had an OR of 0.53 (95% CI [0.16, 1.7], P = 0.28), and severe complications had an OR of 0.52 (95% CI [0.20, 1.35], P = 0.18). In the single-arm analysis, direct surgery outcomes for visual, mRS >2, severe complications, intraoperative aneurysm rupture, and postoperative infarction were 0.139, 0.008, 0.05, 0.036, and 0.037, respectively. In the endovascular group, these outcomes were 0.078, 0.028, 0.03, and 0.691, respectively.

CONCLUSIONS

Our comparison of endovascular therapy and surgery for OphA aneurysms showed no significant difference in clinical outcomes. However, visual complications were more common with surgery, while mRS >2 was higher with endovascular therapy. Flow diversion reduced visual deficits compared to clipping and coiling, but further studies are needed.

Stent-assisted coiling of unruptured paraclinoid aneurysms with wide neck or unfavorable dome-to-neck ratio: Results of ventral wall vs dorsal wall with propensity score matching analysis

OBJECTIVE

This study aimed to evaluate the clinical safety and efficacy of stent-assisted coil embolization of unruptured wide-necked paraclinoid aneurysms based on the projection distribution.

METHODS

Between November 2015 and September 2020, 267 unruptured paraclinod aneurysms in 236 patients were identified with a wide neck or unfavorable dome-to-neck ratio and treated with stent-assisted coiling technique. The classification of this segment aneurysms was simplified to the dorsal group (located on the anterior wall) and ventral group (Non-dorsal). Following propensity score matching analysis, the clinical and radiographic data were compared between the two groups.

RESULTS

Among 267 aneurysms, 186 were located on the ventral wall and 81 were on the dorsal wall. Dorsal wall aneurysms had a larger size (p < .001), wider neck (p = .001), and higher dome-to-neck ratio (p = .023) compared with ventral wall aneurysms. Propensity score-matched analysis found that dorsal group had a significantly higher likelihood of unfavorable results in immediate (residual sac, 39.4% vs. 18.2%, p = .007) and follow-up angiography (residual sac, 14.8% vs. 1.9%, p = .037) compared with ventral group, with significant difference in recurrence rates (9.3% vs. 0%, p = .028). The rates of procedure-related complications were not significantly different, but one thromboembolic event occurred in the dorsal group with clinical deterioration.

CONCLUSIONS

Traditional stent-assisted coiling can be given preference in paraclinoid aneurysms located on the ventral wall. The relatively high rate of recurrence in dorsal wall aneurysms with stent assistance may require other treatment options.

Endovascular treatment strategies and a new classification for multiple aneurysms of the ipsilateral ophthalmic segment of the internal carotid artery

OBJECTIVE

Aneurysms occurring in the ophthalmic segment (C6) of the internal carotid artery (ICA) have complex anatomy. This poses a challenge for the use of traditional open surgery, which is gradually being replaced by endovascular treatment (EVT). However, multiple aneurysm (MA) EVT, especially in MAs occurring ipsilaterally, has not been specifically described or discussed. The present study aimed to propose a more concise clinical classification standard for ipsilateral C6 ICA MAs and report on the clinical experience with EVT.

METHODS

The cases of 18 patients with ipsilateral C6 ICA MAs treated with EVT were retrospectively reviewed. The treatment results and procedure-related complications were recorded, and clinical and angiographic follow-ups were performed at least six months after surgery.

RESULTS

A total of 38 ipsilateral C6 ICA aneurysms were treated during the study period and classified into four main types and six total subtypes based on anatomical features. There was a failure to coil through the stent in one aneurysm, while the remaining 37 were successfully treated using various EVT methods. Of these, 36 were completely concluded. One aneurysm had a size reduction, and one had no changes during the angiographic follow-up. All Tubridge flow diverter stents were patent. All patients achieved satisfactory clinical outcomes and were independent at the final follow-up.

CONCLUSION

EVT may be safe and feasible for the treatment of C6 ICA MAs. Traditional stent-assisted coiling methods, the Willis covered stent, and the double-layered low-profile visualized intraluminal support stent all achieved favorable results. The flow diverter stent is also considered a safe and efficient option for selected aneurysms, but the visual deficit risk should be considered. The present study introduces a new EVT classification option based on the anatomical features of an aneurysm.

Stent-assisted coiling of intracranial carotid ophthalmic segment aneurysm segment aneurysms: Long-term follow-up from a single center

Background

To evaluate the efficacy of stent-assisted coiling (SAC) for the treatment of carotid ophthalmic segment aneurysm segment aneurysms (OSAs) of the internal carotid artery (ICA) through detailed long-term follow-up of a large patient cohort.

Methods

We retrospectively analyzed 88 consecutive patients with OSAs between January 2009 and January 2020 ​at our center. Angiographic results were evaluated using the modified Raymond grading system and clinical outcomes were evaluated using the mRS scale. The primary endpoints were major aneurysm recurrence and poor clinical outcomes for at least 18 months of follow-up. The patients were asked to attend clinical follow-up assessments and possibly undergo DSA or MR via telephone.

Results

We enrolled 88 patients with 99 OSAs treated with coiling, of whom 76 were treated with SAC. The coiling procedures were successful in all 88 patients. Overall, complications occurred in 8 patients (9.1%). No procedure-related mortality was observed. 67 (76.1%) experienced immediate aneurysm occlusion at the end of the procedure. Long-term angiographic follow-up (18 months) was available in 45/88 aneurysms (51%) (average 18.7 ​± ​5.2 months). Four patients continued their follow-up for 5 years after initial aneurysm treatment. After a clinical follow-up time of 28.7 months (range, 12-51 months), 85 patients (95.5%) achieved favorable clinical outcomes (mRS scores of 0-2).

Conclusions

This study indicates that SAC treatment is a safe and effective therapeutic alternative for ruptured and unruptured OSAs. The procedural risks are low with relatively long-term effectiveness.

Endovascular treatment of aneurysms of the paraophthalmic segment of the internal carotid artery: Current status

The paraophthalmic segment of the internal carotid artery (ICA) originates from the distal border of the cavernous ICA and terminates at the posterior communicating artery. Aneurysms arising from the paraophthalmic segment represent ~5–10% of intradural aneurysms. Due to the advent of endovascular treatment (EVT) techniques, specifically flow-diverting stents (FDSs), EVT has become a good option for these aneurysms. A literature review on EVT for paraophthalmic segment aneurysms is necessary. In this review, we discuss the anatomy of the paraophthalmic segment, classification of the paraophthalmic segment aneurysms, EVT principle and techniques, and prognosis and complications. EVT techniques for paraophthalmic segment aneurysms include coil embolization, FDSs, covered stents, and Woven EndoBridge devices. Currently, coiling embolization remains the best choice for ruptured paraophthalmic segment aneurysms, especially to avoid long-term antiplatelet therapy for young patients. Due to the excessive use of antiplatelet therapy, unruptured paraophthalmic segment aneurysms that are easy to coil should not be treated with FDS. FDS is appropriate for uncoilable or failed aneurysms. Other devices cannot act as the primary choice but can be useful auxiliary tools. Both coiling embolization and FDS deployment can result in a good prognosis for paraophthalmic segment aneurysms. The overall complication rate is low. Therefore, EVT offers promising treatments for paraophthalmic segment aneurysms. In addition, surgical clipping continues to be a good choice for paraophthalmic segment aneurysms in the endovascular era.

A comparative propensity-adjusted analysis of microsurgical versus endovascular treatment of unruptured ophthalmic artery aneurysms

OBJECTIVE

Ophthalmic artery (OA) aneurysms are surgically challenging lesions that are now mostly treated using endovascular procedures. However, in specialized tertiary care centers with experienced neurosurgeons, controversy remains regarding the optimal treatment of these lesions. This study used propensity adjustment to compare microsurgical and endovascular treatment of unruptured OA aneurysms in experienced tertiary and quaternary settings.

METHODS

The authors retrospectively reviewed the medical records of all patients who underwent microsurgical treatment of an unruptured OA aneurysm at the University of California, San Francisco, from 1997 to 2017 and either microsurgical or endovascular treatment at Barrow Neurological Institute from 2011 to 2019. Patients were categorized into two cohorts for comparison: those who underwent open microsurgical clipping, and those who underwent endovascular flow diversion or coil embolization. Outcomes included neurological or visual outcomes, residual or recurrent aneurysms, retreatment, and severe complications.

RESULTS

A total of 345 procedures were analyzed: 247 open microsurgical clipping procedures (72%) and 98 endovascular procedures (28%). Of the 98 endovascular procedures, 16 (16%) were treated with primary coil embolization and 82 (84%) with flow diversion. After propensity adjustment, microsurgical treatment was associated with higher odds of a visual deficit (OR 8.5, 95% CI 1.1-64.9, p = 0.04) but lower odds of residual aneurysm (OR 0.06, 95% CI 0.01-0.28, p < 0.001) or retreatment (OR 0.12, 95% CI 0.02-0.58, p = 0.008) than endovascular therapy. No difference was found between the two cohorts with regard to worse modified Rankin Scale score, modified Rankin Scale score greater than 2, or severe complications.

CONCLUSIONS

Compared with endovascular therapy, microsurgical clipping of unruptured OA aneurysms is associated with a higher rate of visual deficits but a lower rate of residual and recurrent aneurysms. In centers experienced with both open microsurgical and endovascular treatment of these lesions, the treatment choice should be based on patient preference and aneurysm morphology.

Evaluation of the Fitting Accuracy of CAD/CAM-Manufactured Patient-Specific Implants for the Reconstruction of Cranial Defects-A Retrospective Study

Cranioplasties show overall high complication rates of up to 45.3%. Risk factors potentially associated with the occurrence of postoperative complications are frequently discussed in existing research. The present study examines the positioning of 39 patient-specific implants (PSI) made from polyetheretherketone (PEEK) and retrospectively investigates the relationship between the fitting accuracy and incidence of postoperative complications. To analyze the fitting accuracy of the implants pre- and post-operatively, STL files were created and superimposed in a 3D coordinate system, and the deviations were graphically displayed and evaluated along with the postoperative complications. On average, 95.17% (SD = 9.42) of the measurements between planned and surgically achieved implant position were within the defined tolerance range. In cases with lower accordance, an increased occurrence of complications could not be demonstrated. The overall postoperative complication rate was 64.1%. The fitting of the PEEK-PSI was highly satisfactory. There were predominantly minor deviations of the achieved compared to the planned implant positions; however, estimations were within the defined tolerance range. Despite the overall high accuracy of fitting, a considerable complication rate was found. To optimize the surgical outcome, the focus should instead be directed towards the investigation of other risk factors.

Comparison of Pipeline Embolization and Coil Embolization for the Treatment of Large Unruptured Paraclinoid Aneurysms

The efficacy of flow diversion (FD) in the treatment of paraclinoid aneurysms has been established. The pipeline embolization device (PED) is one of the most commonly used FD devices. Coil embolization is also useful for treating paraclinoid aneurysms. This study aimed to compare the efficacy and safety of PED treatment and coil embolization for large unruptured paraclinoid aneurysms. This was a single-center, retrospective study of large unruptured paraclinoid aneurysms treated endovascularly between 2009 and 2019 (coil embolization between 2009 and 2015, and PED between 2015 and 2019). Cases with a follow-up period of less than 1 year and recurrence after coil embolization were excluded. The treatment outcomes between coil embolization and PED were compared. We investigated 45 patients with 45 large unruptured paraclinoid aneurysms treated by endovascular surgery in our institution. Twenty-four patients were treated with coil embolization and 21 with PED. In the PED group, the device cost was significantly lower (2,770.4 ± 699.5 vs. 1941.2 ± 552.8 [1000 yen], P = 0.03), procedure duration was significantly shorter (155.4 ± 66.7 vs. 95.1 ± 35.4 min, P <0.01), and the numbers of re-treatments were lower than those in the coil embolization group (41.7 vs. 14.3%, P = 0.05). Both PED and coil embolization were effective and safe for large unruptured paraclinoid aneurysms, and their treatment results were similar. The PED is more beneficial because of its lower cost, shorter procedure duration, and fewer retreatments, and is therefore more useful for the treatment of large unruptured paraclinoid aneurysms.

Flow-diverting devices in the treatment of unruptured ophthalmic segment aneurysms at a mean clinical follow-up of 5 years

A shift toward the endovascular treatment of ophthalmic segment aneurysms is noticeable. However, it is not clear if the long-term treatment results improve with the development of endovascular methods. The aim of this study was to present the outcomes of the treatment of unruptured ophthalmic aneurysms using flow diverting devices (FDD) with or without coiling. This retrospective study included 52 patients with 65 UIAs treated in 2009–2016. The mean aneurysm size was 8.8 mm. Eight aneurysms were symptomatic. Therapeutic procedures included: 5 failed attempts, 55 first sessions with FDD deployment (bilateral procedures in 3) and 3 retreatment procedures. To cover 55 ICAs, 25 Silk, 26 Pipeline, 9 Fred and 1 Surpass FDD were used. FDD with coiling was applied in 19(29.2%), mainly for symptomatic and larger aneurysms. Mean radiological and clinical follow-up was 12 and 61 months, respectively. Postprocedural deterioration was noted in 3(5.8%) patients, but in long-term the modified Rankin Scale grades 0–2 were achieved in 98.1% of patients. One patient died from the treated aneurysm rupture (annual risk—0.07%). Raymond–Roy occlusion classification class I or II was achieved in 98.5% in the long term, with similar results in both groups. Complications occurred in 40.4% of patients and the most frequent were: imperfect FDD deployment (15%), failed attempt of FDD deployment (9.6%) and late FDD stenosis (9.6%). Flow-diverting devices, with additional coiling in selected cases, may offer a very high proportion of satisfactory outcomes. However, in our experience the high risk of complications remains.

Balloon-Assisted Coils Embolization for Ophthalmic Segment Aneurysms of the Internal Carotid Artery

Objective: To explore the role of balloon-assisted coils technique for ophthalmic segment aneurysms (OSAS).

Methods: Clinical data of 30 patients with OSAS were reviewed between December 2017 and December 2018. OSAS were defined as arising from the internal carotid artery (ICA), reaching from the distal dural ring to the origin of the posterior communicating artery. OSAS were classified into four types based on the angiographic findings. The balloon-assisted coils technique was used for the embolization of aneurysms. The duration of balloon inflation cycles, as well as difficulty and complications during the embolization procedure, were recorded. The immediate angiographic results were evaluated according to the Raymond scale. Clinical results were evaluated based on the MRS score. Follow-ups were performed at 18 months post-embolization by DSA or MRA at our institution.

Results: Thirty-two aneurysms in 30 patients were detected by digital subtraction angiography (DSA), which included 30 unruptured and two ruptured cases. The patients with ruptured aneurysms were grade II status according to the Hunt-Hess scale. Three cases were type A, nine cases were type B, 17 cases were type C, and three cases were type D. According to aneurysm size, there were 19 cases of small, 11 cases of medium, two cases of large aneurysm. Thirty-two aneurysms were successfully embolized in 30 patients by balloon-assisted coils technique. The ophthalmic artery could be protected by an engorged balloon in the procedure, especially for type A aneurysms. Considering that type D aneurysm arises from the side-wall of the artery and near to tortuous ICA siphon, the balloon catheter was inflated to stabilize the microcatheter allowing for overinflation when necessary. The average duration of balloon dilatation was 4 min, and the average time was 2.5 times. Raymond class was one in 28 aneurysms and two in four aneurysms according to the immediate post-embolization angiographic results. All the patients achieved good clinical effects, except for one patient who presented with brain ischemia resulting in dizziness and contralateral limb weakness for 10 h due to prolonged temporary clamping of the responsible ICA. The follow-up angiography results were satisfactory at 18 months post-embolization.

Conclusion: OSAS endovascular treatment with balloon-assisted coils has different advantages in a different classification. The technique is safe, effective, and relatively inexpensive, especially for small and medium OSAS.

Endovascular Treatment for Lateral Wall Paraclinoid Aneurysms and the Influence of Internal Carotid Artery Angle

Lateral wall paraclinoid aneurysms (LPA) are a rare type of aneurysm located on the lesser curve side of the internal carotid artery (ICA) bend, at the level of the anterior clinoid process. The objective of this study was to assess the influence of flexion of the ICA on the morphology of aneurysms and outcome of endovascular treatment. Between 2003 and 2018, we treated 643 cases of unruptured paraclinoid aneurysms with endovascular therapy in our institution. Of those cases, aneurysms projecting laterally on preoperative angiography were defined as LPA. The degree of bending of the ICA (ICA angle) was measured and statistically analyzed in relation to the aneurysm characteristics and the occlusion status after treatment. In all, 43 aneurysms were identified. ICA angle was positively correlated with the maximum dome size of the aneurysm (P <0.01) and the aspect ratio (P <0.01), and negatively correlated with the volume coil embolization ratio (P <0.01). Complete occlusion (CO) was achieved in 23 cases (53.5%) immediately after treatment, and in 35 cases (81.4%) at follow-up. The mean ICA angle in the incomplete occlusion group was significantly larger than in the CO group (P = 0.01). Larger ICA angle resulted in recurrence, whereas smaller ICA angle was more likely to obtain progressive thrombosis (P = 0.02). Endovascular treatment for LPA was safe and effective. The degree of flexion of the ICA may contribute to the level of hemodynamic stress on the aneurysm, its morphology, and the embolization effect.

Visual complications after coil embolization of internal carotid artery aneurysms at the ophthalmic segment

BACKGROUND

Coil embolization of aneurysms of the ophthalmic segment of the internal carotid artery (ICA-OphA ANs) has potential risks of visual complications. We analyzed this risk and focused on the relationship of the ophthalmic artery (OphA) origin with the aneurysm neck.

METHODS

From January 2003 to April 2018, 179 unruptured ICA-OphA ANs were treated with endovascular surgery in our institution. Two ruptured and four aneurysms with missing data were excluded. Finally, 173 unruptured aneurysms were included in this study. The aneurysms were classified into three groups according to the location of the OphA origin: Separate, Shared, and Dome type. We retrospectively assessed visual complications based on the relationship between types of aneurysm and postoperative angiographic findings for the OphA.

RESULTS

Visual deficits remained permanent in eleven cases (6.4%). In the Dome type, visual complications were significantly more frequent compared to the Separate type. Change in the OphA flow was significantly associated with a higher complication rate of 2.9%, but patients with changed OphA flow had a significant rate of 7.5% (p = 0.020). We found no significant difference in the incidence of visual complications concerning the use of perioperative antithrombotic therapy.

CONCLUSIONS

The location of OphA origin regarding the aneurysmal neck and postoperative OphA flow were significantly correlated with the visual outcome after coil embolization for ICA-OphA ANs. Post-procedural flow in the OphA was an important factor affecting the rate of ischemic retinal complications. Retinal embolic events occurred with preserved flow in the OphA, albeit at a lower rate.

Clinical and angiographic outcomes of stent-assisted coiling of paraclinoid aneurysms: Comparison of LVIS and Neuroform stents

Paraclinoid aneurysms are mainly intradural, and are associated with a potential risk of subarachnoid hemorrhage (SAH). The application of stent-assisted coiling has been widely used in endovascular treatment of intracranial aneurysms. Here we aimed to compare clinical outcomes between low-profile visualized intraluminal support stents (LVIS) and Neuroform (NU) stents. Between January 2013 and December 2017, a total of 101 patients with 118 unruptured paraclinoid aneurysms were embolized by LVIS or NU stents. Procedure-related complications, angiography, and follow-up results were retrospectively analyzed. A total of 45 patients with 54 aneurysms received LVIS stents, and 56 patients with 64 aneurysms received NU stents. Procedure-related complication rate was 6.7% in the LVIS group and 5.4% in the NU group, with no statistical differences between groups (P = 0.511). Compared with the NU group, greater initial complete or near-complete aneurysm obliteration was achieved in the LVIS group (79.6% vs 59.4%, P = 0.0192). DSA angiography follow-up imaging of the 118 aneurysms showed that the LVIS group increased in Raymond-Roy Grade Scale I (RRGS I), however there is no statistical difference (P = 0.32). Compared with NU stents, LVIS stents may achieve greater complete or near-complete occlusion rate immediately post-operation. However, there was no difference in procedural-related complications and follow-up outcomes between LVIS and NU stent groups.

Anatomical assessment of the endoscopic endonasal approach for the treatment of paraclinoid aneurysms

OBJECTIVE

Endoscopic endonasal approaches (EEAs) are increasingly being incorporated into the neurosurgeon's armamentarium for treatment of various pathologies, including paraclinoid aneurysms. However, few anatomical assessments have been performed on the use of EEA for this purpose. The aim of the present study was to provide a comprehensive anatomical assessment of the EEA for the treatment of paraclinoid aneurysms.

METHODS

Five cadaveric heads underwent an endonasal transplanum-transtuberculum approach to expose the paraclinoid area. The feasibility of obtaining proximal and distal internal carotid artery (ICA) control as well as the topographic location of the origin of the ophthalmic artery (OphA) relative to dural landmarks were assessed. Limitations of the EEA in exposing the supraclinoid ICA were also recorded to identify favorable paraclinoid ICA aneurysm projections for EEA.

RESULTS

The extracavernous paraclival and clinoidal ICAs were favorable segments for establishing proximal control. Clipping the extracavernous ICA risked injury to the trigeminal and abducens nerves, whereas clipping the clinoidal segment put the oculomotor nerve at risk. The OphA origin was found within 4 mm of the medial opticocarotid point on a line connecting the midtubercular recess point to the medial vertex of the lateral opticocarotid recess. An average 7.2-mm length of the supraclinoid ICA could be safely clipped for distal control. Assessments showed that small superiorly or medially projecting aneurysms were favorable candidates for clipping via EEA.

CONCLUSIONS

When used for paraclinoid aneurysms, the EEA carries certain risks to adjacent neurovascular structures during proximal control, dural opening, and distal control. While some authors have promoted this approach as feasible, this work demonstrates that it has significant limitations and may only be appropriate in highly selected cases that are not amenable to coiling or clipping. Further clinical experience with this approach helps to delineate its risks and benefits.

An Anatomic Feasibility Study for Revascularization of the Ophthalmic Artery, Part I: Intracanalicular Segment

BACKGROUND

The anatomico-functional complexity of the ophthalmic segment aneurysms is attributable to the presence of critical neurovascular structures in the surgical field. Surgical clipping of the ophthalmic artery (OpA) aneurysms can result in postoperative visual deficit due to the complexity of the aneurysm, vasospasm, or optic nerve manipulation. In this study, we aimed to characterize the feasibility of an intracanalicular OpA (iOpA) revascularization with 2 donor vessels: an intracranial-intracranial (IC-IC) bypass using the anterior temporal artery (ATA) and an extracranial-intracranial (EC-IC) bypass using the superficial temporal artery (STA). We further discuss their potential role in "unclippable" OpA aneurysms.

METHODS

Twenty cadaveric specimens were used to evaluate the operative exposure of the intradural and intracanalicular OpA segments using an extradural-intradural intracanalicular approach. The arterial caliber and length at the anastomotic sites and required donor artery lengths were measured. The feasibility of the bypass using both donors was assessed.

RESULTS

The average length of the intradural and intracanalicular segment of the OpA was 9.5 ± 1.6 mm. The mean caliber of the iOpA was 1.5 ± 0.2 mm. The mean ATA length required for an ATA-OpA anastomosis was 26.7 ± 8.9 mm, with a mean caliber of 1.0 ± 0.1 mm. The mean length of STA required for the bypass was 89.9 ± 9.7 mm, with a mean caliber of 1.92 ± 0.4 mm.

CONCLUSIONS

This study confirms the feasibility of iOpA revascularization using IC-IC and EC-IC bypasses. These techniques could potentially be used for prophylactic or therapeutic neuroprotection from retinal ischemic injury while treating complex OpA aneurysms, infiltrative tumors, or intraoperative arterial injuries.

Microsurgical clipping of ophthalmic artery aneurysms: surgical results and visual outcomes with 208 aneurysms

OBJECTIVEWhile most paraclinoid aneurysms can be clipped with excellent results, new postoperative visual deficits are a concern. New technology, including flow diverters, has increased the popularity of endovascular therapy. However, endovascular treatment of paraclinoid aneurysms is not without procedural risks, is associated with higher rates of incomplete aneurysm occlusion and recurrence, and may not address optic nerve compression symptoms that surgical debulking can. The increasing endovascular management of paraclinoid aneurysms should be justified by comparisons to surgical benchmarks. The authors, therefore, undertook this study to define patient, visual, and aneurysm outcomes in the most common type of paraclinoid aneurysm: ophthalmic artery (OphA) aneurysms.METHODSResults from microsurgical clipping of 208 OphA aneurysms in 198 patients were retrospectively reviewed. Patient demographics, aneurysm morphology (size, calcification, etc.), clinical characteristics, and patient outcomes were recorded and analyzed.RESULTSDespite 20% of these aneurysms being large or giant in size, complete aneurysm occlusion was accomplished in 91% of 208 cases, with OphA patency preserved in 99.5%. The aneurysm recurrence rate was 3.1% and the retreatment rate was 0%. Good outcomes (modified Rankin Scale score 0-2) were observed in 96.2% of patients overall and in all 156 patients with unruptured aneurysms. New visual field defects (hemianopsia or quadrantanopsia) were observed in 8 patients (3.8%), decreased visual acuity in 5 (2.4%), and monocular blindness in 9 (4.3%). Vision improved in 9 (52.9%) of the 17 patients with preoperative visual deficits.CONCLUSIONSThe most important risk associated with clipping OphA aneurysms is a new visual deficit. Meticulous microsurgical technique is necessary during anterior clinoidectomy, aneurysm dissection, and clip application to optimize visual outcomes, and aggressive medical management postoperatively might potentially decrease the incidence of delayed visual deficits. As the results of endovascular therapy and specifically flow diverters become known, they warrant comparison with these surgical benchmarks to determine best practices.

Central Retinal Artery Thromboembolism without Ophthalmic Artery Occlusion During Stent-Assisted Coil Embolization of Ophthalmic Artery Aneurysm

BACKGROUND

Recent reports have described that endovascular treatment of coil embolization of opththalmic artery (OphA) aneurysms has a relative risk of visual disruption caused by thromboembolic infarction of the central retinal artery (CRA), especially the OphA when it originates within the body of the aneurysm. Patent microthrombus in the OphA might also cause retinal infarction that affects visual acuity. We describe stent-assisted coil embolization of an OphA aneurysm complicated with a severe visual disturbance, although normal flow was scrupulously maintained in the OphA during the procedure. The visual disturbance was recovered by early treatment.

CASE DESCRIPTION

A 40-year-old woman who presented with an intracranial aneurysm arising from the right OphA underwent stent-assisted coil embolization under general anesthesia. Although the area around the origin of the OphA was intentionally avoided and anterograde flow in the OphA was monitored by repeated angiography during this procedure, sight in the right eye was lost immediately thereafter. The immediate application of ocular massage and intraarterial fibrinolysis improved vision in the right eye to essentially normal status after discharge.

CONCLUSIONS

Despite good anterograde flow in the OphA during aneurysm embolization, the procedural risk of a visual disturbance due to thromboembolic complications of CRA occlusion cannot be avoided. Anterograde flow in the OphA and retinochoroidal blush should be monitored by repeated angiography during coil embolization to prevent vision loss. Should vision be lost, a rapid response including ocular massage and intraarterial fibrinolysis is required for recovery.

Residual Cerebral Aneurysms After Microsurgical Clipping: A New Scale, an Agreement Study, and a Systematic Review of the Literature

OBJECTIVE

The surgical repair of a cerebral aneurysm does not always lead to complete occlusion. A standardized repeatable method of reporting results of surgical clipping is desirable. Our purpose was to systematically review methods of classifying aneurysm remnants, provide a new scale with precise definitions of categories, and perform an agreement study to assess the variability in adjudicating remnants after aneurysm clipping.

METHODS

A systematic review was performed to identify ways to report angiographic results of surgical clipping between 1963 and 2017. Postclipping angiographic results of 43 patients were also independently evaluated by 10 raters of various experience and backgrounds using a new 4-category scale. Agreement between responses were analyzed using κ statistics.

RESULTS

The systematic review yielded 63 articles with 37 different nomenclatures using 2-6 categories. The reliability of judging the presence of an aneurysm remnant on catheter angiography was studied only twice, with only 2 raters each time, with contradictory results. Interobserver agreement using the new 4-category scale was moderate (κ = 0.52; 95% confidence interval, 0.43-0.62) for all observers, but improved to substantial (κ = 0.62; 95% confidence interval, 0.47-0.76) when results were dichotomized (grade 0/1 vs. 2/3).

CONCLUSIONS

Various classification schemes to evaluate angiographic results after surgical clipping exist in the literature, but they lack standardization. Adjudication using fewer, better defined categories may yield more reliable agreement.

Vision Outcomes of Endovascular Treatment for Unruptured Ophthalmic Artery Aneurysms

OBJECTIVE

The purpose of this study was to report the authors' experience with endovascular treatment (EVT) of ophthalmic artery (OA) aneurysms and to investigate risk factors for visual complications of EVT for unruptured OA aneurysms.

METHODS

Fifty-four patients with unruptured OA aneurysms subjected to EVT were recruited for this study from March 2010 to December 2017. The clinical and angiographic outcomes of all 54 patients were investigated and analyzed retrospectively.

RESULTS

Of the 54 patients included in this study, 5 patients (9.3%) had visual complications, including asymptomatic unintended OA occlusion in 2 patients (3.7%) and symptomatic complications in 3 patients (5.6%); 2 patients (3.7%) had transient visual complications, and 1 (1.9%) had a permanent complication. No subacute or delayed visual complications occurred during the 20.8-month follow-up period. OA incorporation by the aneurysm (odds ratio [OR], 3.471; 95% confidence interval [CI], 1.115-9.184; P = 0.038) and intentional OA occlusion (OR, 1.820; 95% CI, 1.248-6.221; P = 0.044) were independent risk factors for visual complications in a multivariate logistic regression analysis.

CONCLUSIONS

The visual complication rate was 9.3% when performing EVT for unruptured OA aneurysms. OA aneurysms with OA incorporation by the aneurysm might be at higher risk of visual complications when performing EVT. Intentional OA occlusion should be performed with caution, even though a patient may have favorable collaterals during balloon test occlusion.

Risk Factors to Predict Neurologic Complications After Endovascular Treatment of Unruptured Paraclinoid Aneurysms

OBJECTIVE

Unruptured paraclinoid aneurysms are often asymptomatic, and endovascular coiling is the main treatment. However, endovascular treatment of these lesions still leads to neurologic complications. We aimed to identify predictors of neurologic complications in these lesions.

METHODS

We retrospectively analyzed patients with unruptured paraclinoid aneurysms who were treated with endovascular coiling between January 2014 and December 2015. A neurologic complication was defined as any transient or permanent increase in the modified Rankin Scale score after aneurysm embolization. Univariate and mulitivariate logistic regression analyses were performed to assess the risk factors of neurologic complications.

RESULTS

Of the 443 unruptured paraclinoid aneurysms that were included in this study, the incidence of neurologic complications was 5.2%. Neurologic complications were highly correlated with hypertension (odds ratio [OR], 3.147; 95% confidence interval [CI], 1.217-8.138; P = 0.018), cerebral ischemic comorbidities (OR, 3.396; 95% CI, 1.378-8.374; P = 0.008), and aneurysm size (OR, 7.714; 95% CI, 1.784-31.635; P < 0.001), and irregular shape (OR, 3.157; 95% CI, 1.239-8.043; P = 0.016) in the univariate analysis. Cerebral ischemic comorbidities (OR, 2.837, 95% CI, 1.070-7.523; P = 0.036) and aneurysm size as dichotomous variables (OR, 7.557; 95% CI, 2.975-19.198; P < 0.001) were strongly correlated with neurologic complications in the final adjusted multivariate logistic analysis.

CONCLUSIONS

Unruptured paraclinoid aneurysms after endovascular treatments had 5.2% of neurologic complications. Cerebral ischemic comorbidities and aneurysm size were predictors of neurologic complications.

Unruptured Paraclinoid Aneurysm Treatment Effects on Visual Function: Systematic Review and Meta-analysis

OBJECTIVE

Postoperative visual outcomes following repair of unruptured paraclinoid aneurysms (UPAs) are not well defined. We aim to investigate the influence of treatment modality on visual function.

METHODS

A systematic literature analysis using the Ovid Medline and EMBASE databases was performed, encompassing English language studies (published between 1996 and 2016) reporting treatment outcomes for UPAs. Rates of visual morbidity (new, permanent postoperative deficit, worsening preoperative deficit); angiographic (occlusion, recurrence, retreatment) and clinical outcomes (death, disability, post-treatment subarachnoid hemorrhage) were recorded. Random effects meta-analysis was performed.

RESULTS

Twenty-eight studies reported visual outcomes, with data for 1013 endovascular and 691 microsurgical patients. In patients with normal vision undergoing elective repair of UPAs, rates of postoperative visual morbidity were higher following microsurgical (10.8%; 95% confidence interval [CI] 8.5-13.7) than endovascular (2.0%; 95% CI 1.2-3.2) interventions, P < 0.001. In those presenting with preoperative visual impairment, surgery was associated with a modest advantage in visual recovery compared with endovascular therapies (65.2% vs. 48.9%, P < 0.03). There were no differences in visual morbidity following treatment with any of the endovascular modalities. Meta-analysis of comparative studies suggested a trend toward poor visual (ES = 0.42; 95% CI 0.08-2.09) and clinical outcomes (ES = 0.57; 95% CI 0.07-4.44) following microsurgery and a trend toward angiographic recurrence (ES = 2.52; 95% CI 0.80-7.90) and retreatment (ES = 1.62; 95% CI 0.46-5.67) after endovascular interventions.

CONCLUSION

In patients with normal vision undergoing repairs for UPAs, there is a positive correlation between visual outcomes and endovascular treatments. When visual compromise is present, surgery provided modest advantage in visual recovery. However, definitive conclusions were not possible due to data heterogeneity.

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.

Direct Surgery of Previously Coiled Large Internal Carotid Ophthalmic Aneurysm for the Purpose of Optic Nerve Decompression

Background Progressive visual loss after coil embolization of a large internal carotid ophthalmic aneurysm has been widely reported. It is generally accepted that the primary strategy for this complication should be conservative, including steroid therapy; however, it is not well known as to what approach to take when the conservative therapy is not effective.

Case Presentation We report a case of a 55-year-old female presenting with progressive visual loss after the coiling of a ruptured large internal carotid ophthalmic aneurysm. As the conservative therapy had not been effective, we performed neck clipping of the aneurysm with optic canal unroofing, anterior clinoidectomy, and partial removal of the embolized coils for the purpose of optic nerve decompression. After the surgery, the visual symptom was improved markedly.

Conclusions It is suggested that direct surgery for the purpose of optic nerve decompression may be one of the options when conservative therapy is not effective for progressive visual disturbance after coil embolization.

Management of infections associated with neurosurgical implanted devices

INTRODUCTION

Neurosurgical devices are increasingly used. With it, neurosurgical device-related infections gain relevance. As biofilms are involved in implant-associated infections the diagnosis and treatment is challenging and requires specific anti-biofilm concepts and management algorithms. Areas covered: The literature concerning the management of neurosurgical device-associated infections is scarce and heterogeneous treatment concepts are discussed, but no standardized diagnostic and treatment procedures exist. Therefore, we emphasize extrapolating management strategies predominantly from orthopedic device-associated infections, where the concept is better established and clinically validated. This review covers infections associated with craniotomy fixation devices, cranioplasties, external ventricular and lumbar drainages, internal shunts and neurostimulators. Expert commentary: Sonication of the removed implants significantly improves microbiological diagnosis. A combined surgical and antimicrobial management is crucial for successful treatment: appropriate surgical intervention is combined with prolonged anti-biofilm therapy of usually 12 weeks. In selected patients, new treatment algorithms enable cure of neurosurgical device-associated infections without implant removal or with a one-stage implant exchange, considerably improving the quality of patient lives.

Endovascular parent-artery occlusion of large or giant unruptured internal carotid artery aneurysms. A long-term single-center experience

The development of stent-like devices has increased treatment options for complex internal carotid artery (ICA) aneurysms, but the optimal treatment remains unclear. The purpose of this study was to evaluate the safety and efficacy of endovascular parent-artery occlusion (PAO) for ICA aneurysms. We retrospectively reviewed 28 patients with unruptured ICA aneurysms ⩾10mm treated with PAO between April 2002 and March 2015 at our institution. Patients who developed neurologic symptoms or with venous-phase delay >2s during balloon test occlusion were not treated by PAO. Patients with venous-phase delays of 1-2s underwent superficial temporal artery to middle cerebral artery (STA-MCA) bypass prior to PAO. The median patient age was 65 (range, 26-84)years. Nineteen aneurysms (68%) were located in the cavernous segment. The median aneurysm size was 25 (range 11-40)mm. Venous-phase delay of 1-2s was observed in five patients. Perioperative ischemic complications (N=9, 32%), which occurred within 30days after treatment, were significantly associated with venous-phase delays of 1-2s (p<0.01) and history of hypertension (p<0.01). Six-month morbidity was observed in one (3.6%) patient. Complete occlusion at final follow-up and delayed (i.e. ⩾31days after treatment) ischemic events were observed in 100% and 0% of patients, respectively, over a median period of 63 (range, 6-147) months. Despite the high frequency of perioperative ischemic episodes, endovascular PAO with selective use of STA-MCA bypass showed excellent long-term outcomes in patients with unruptured ICA aneurysms ⩾10mm.

Surgical clipping is still a good choice for the treatment of paraclinoid aneurysms

Paraclinoid aneurysms are lesions located adjacent to the clinoid and ophthalmic segments of the internal carotid artery. In recent years, flow diverter stents have been introduced as a better endovascular technique for treatment of these aneurysms.

METHOD

From 2009 to 2014, a total of 43 paraclinoid aneurysms in 43 patients were surgically clipped. We retrospectively reviewed the records of these patients to analyze clinical outcomes.

RESULTS

Twenty-six aneurysms (60.5%) were ophthalmic artery aneurysms, while 17 were superior hypophyseal artery aneurysms (39.5%). The extradural approach to the clinoid process was used to clip these aneurysms. One hundred percent of aneurysms were clipped (complete exclusion in 100% on follow-up angiography). The length of follow-up ranged from 1 to 60 months (mean, 29.82 months).

CONCLUSION

Surgical clipping continues to be a good option for the treatment of paraclinoid aneurysms.

Flow Diversion for Ophthalmic Artery Aneurysms

Endovascular treatments of ophthalmic segment aneurysms are commonly used but visual outcomes remain a concern. We performed a retrospective review of patients with carotid-ophthalmic aneurysms treated with flow diversion from June 2009 to June 2015. The following outcomes were studied through chart review: visual outcomes, complications, postoperative stroke and intraparenchymal hemorrhage, and clinical outcomes. Angiographic outcomes were studied with angiography and MRA at 6 months, 1 year, and 3 years. We evaluated 50 carotid-ophthalmic aneurysms in 48 patients, among whom 44 patients with 46 aneurysms underwent treatment. The mean clinical follow-up was 29 ± 22 months (range, 0-65 months). There were no permanent adverse visual outcomes. There was 1 death because of late intraparenchymal hemorrhage (2.2%). Six-month angiography showed complete occlusion in 24 of 37 patients (64.9%), and 3-year angiography results showed occlusion in 24 of 25 patients (96%). In conclusion, flow diversion is a safe and effective treatment for carotid-ophthalmic aneurysms in carefully selected patients. The risk of adverse visual outcomes is low, and most aneurysms progress to complete occlusion.

Predictors of infection after 754 cranioplasty operations and the value of intraoperative cultures for cryopreserved bone flaps

OBJECTIVE

The authors' aim was to report the largest study on predictors of infection after cranioplasty and to assess the predictive value of intraoperative bone flap cultures before cryopreservation.

METHODS

They retrospectively examined all cranioplasties performed between March 2004 and November 2014. Throughout this study period, the standard protocol during initial craniectomy was to obtain a culture swab of the extracted autologous bone flap (ABF)—prior to its placement in cytostorage—to screen for microbial contamination. Two consecutive protocols were employed for the use and interpretation of the intraoperative swab culture results: A) From March 2004 through June 2013, any culture-positive ABF (+ABF) was discarded and a custom synthetic prosthesis was implanted at the time of cranioplasty. B) From July 2013 through November 2014, any ABF with a skin flora organism was not discarded. Instead, cryopreservation was maintained and the +ABF was reimplanted after a 10-minute soak in bacitracin irrigation as well as a 3-minute soak in betadine.

RESULTS

Over the 10.75-year period, 754 cranioplasty procedures were performed. The median time from craniectomy to cranioplasty was 123 days. Median follow-up after cranioplasty was 237 days for protocol A and 225 days for protocol B. The overall infection rate after cranioplasty was 6.6% (50 cases) occurring at a median postoperative Day 31. Staphylococcus spp. were involved as the causative organisms in 60% of cases.

Culture swabs taken at the time of initial craniectomy were available for 640 ABFs as 114 ABFs were not salvageable. One hundred twenty-six (20%) were culture positive. Eighty-nine +ABFs occurred during protocol A and were discarded in favor of a synthetic prosthesis at the time of cranioplasty, whereas 37 +ABFs occurred under protocol B and were reimplanted at the time of cranioplasty.

Cranioplasty material did not affect the postcranioplasty infection rate. There was no significant difference in the infection rate among sterile ABFs (7%), +ABFs (8%), and synthetic prostheses (5.5%; p = 0.425). All 3 +ABF infections under protocol B were caused by organisms that differed from those in the original intraoperative bone culture from the initial craniectomy. A cranioplasty procedure ≤ 14 days after initial craniectomy was the only significant predictor of postcranioplasty infection (p = 0.007, HR 3.62).

CONCLUSIONS

Cranioplasty procedures should be performed at least 14 days after initial craniectomy to minimize infection risk. Obtaining intraoperative bone cultures at the time of craniectomy in the absence of clinical infection should be discontinued as the culture results were not a useful predictor of postcranioplasty infection and led to the unnecessary use of synthetic prostheses and increased health care costs.

Larger inflow angle and incomplete occlusion predict recanalization of unruptured paraclinoid aneurysms after endovascular treatment

BACKGROUND

Unruptured paraclinoid aneurysms have a high incidence of aneurysm recanalization (AR) after endovascular treatment. We aimed to identify the incidence and predictors of AR in these lesions.

METHODS

We retrospectively analyzed consecutive patients with unruptured paraclinoid aneurysms who underwent endovascular treatment between January 2013 and December 2014. Patients with fusiform aneurysms, dissection aneurysms, traumatic aneurysms, or without digital subtraction angiography (DSA) at follow-up, were excluded. AR was defined as any aneurysm remnant that had increased in size or contrast filling that was observed via DSA at the follow-up. Univariate and multivariate logistic regression analyses were performed to assess the predictors of AR.

RESULTS

We included 145 patients with 150 unruptured paraclinoid aneurysms in the analysis. The incidence of AR was 8.7% (95% confidence interval (CI): 4.7-13.3%) at a mean follow-up of 7.4 months. In the univariate analysis, AR was associated with aneurysm size (odd ratio (OR): 6.098; 95% CI: 1.870-19.886; p = 0.003), location (OR: 3.88; 95% CI: 1.196-12.583; p = 0.024), inflow angle (OR: 6.852; 95% CI: 1.463-32.087; p = 0.015), and Raymond scale (OR: 12.473; 95% CI: 2.7496-56.59; p < 0.001). In the adjusted multivariate analysis, AR was independently predicted by Raymond scale (OR: 9.136; 95% CI: 1.683-49.587; p = 0.001) and inflow angle (OR: 16.159; 95% CI: 3.211-81.308; p = 0.01).

CONCLUSIONS

Unruptured paraclinoid aneurysms had a high incidence of AR after endovascular treatment. An inflow angle of ≥90 degrees and incomplete occlusion were significant predictors of AR.

Central Retinal Artery Occlusion after the Endovascular Treatment of Unruptured Ophthalmic Artery Aneurysm: A Case Report and a Literature Review

Endovascular coil embolization for ophthalmic artery (OphA) aneurysms has a risk of occlusion of the OphA, which can lead to loss of vision. The authors report a patient with unruptured OphA aneurysm which treated with endovascular coiling and were complicated by blindness due to OphA thromboembolic occlusion after the procedure. The OphA successfully recanalized using local intra-arterial fibrinolysis with complete regain of visual acuity. The risk of visual loss due to thromboembolic complications cannot be ignored during endovascular coiling of the OphA aneurysm despite of good retrograde flow during OphA occlusion test using a balloon catheter. Rapid intervention is required for recovering visual disturbance in such a situation.

Efficacy and Versatility of the 3-D Titanium Mesh Implant in the Closure of Large Post-Craniectomy Osseous Defects, and its Therapeutic Role in Reversing the Syndrome of the Trephined: Clinical Study of a Case Series and Review of Literature

INTRODUCTION

An ideal cranioplasty material is one which adequately restores calvarial continuity, contour and esthetics, provides adequate cerebral protection, is biocompatible and corrosion resistant, lightweight yet strong, easy to manipulate and possesses long term stability. The 3-D Titanium mesh implant fulfills most of these criteria, and offers certain added advantages, as exemplified in this case series. Four patients with post craniectomy osseous defects of varying sizes and at different locations of the calvarium were studied. In addition to the obvious cosmetic deformity, the patients also exhibited various subjective and objective features of neurosensory and motor deficits characteristic of the motor trephine syndrome (MTS), that often develops secondary to large cranial defects.

OBJECTIVE

There have been no documented reports so far on the effect of Titanium mesh cranioplasty on features of the MTS in patients with large cranial defects. It was the objective of this study to see if any specific therapeutic goals such as reversal of the neurological deterioration and sensorimotor deficits associated with the syndrome could be achieved by performing Titanium mesh cranioplasty to reconstruct the missing part of the cranial shield in these patients. Any added benefits of using 3-D Titanium mesh as a cranioplasty material were also recorded.

MATERIALS AND METHODS

The cranial defects in all four patients were reconstructed using different dimensions of Titanium mesh implants. Two of the cases were early cranioplasties (performed within 3 months of craniectomy) and two were late cranioplasties (performed after 3 months of craniectomy), one of them even being a previous autologous bone flap cranioplasty failure. The patients were followed up for a period ranging from 3 to 4 years and observed carefully for cosmetic, functional and neurological improvements following the cranioplasty.

RESULTS

There was achieved gratifying cosmetic correction of the cranial deformities, and remarkable functional recovery from the sensorimotor deficits, reversal of the neurological deterioration as well as resolution of most of the symptoms of MTS in all the four patients, following the Titanium mesh cranioplasty. Many added benefits were noted, such as quick post operative recovery, absence of any early or late complications and a ready means to aspirate any epidural collections, if they developed post operatively, through the mesh structure of the implant.

CONCLUSION

Apart from the cosmetic, functional and protective roles, Titanium mesh cranioplasty demonstrated a definite therapeutic role in all the cases presented, making it preferable to even replacement with natural bone (either re-implanted excised autologous bone flaps, or cortico-cancellous bone autografts). It is an extremely safe and reliable alternative to autografts, and is even preferable to them, especially when the size of the cranial defect is large.

Preoperative external tissue expansion for complex cranial reconstructions

OBJECTIVE Reconstruction of large solitary cranial defects after multiple craniotomies is challenging because scalp contraction generally requires more than simple subcutaneous undermining to ensure effective and cosmetically appealing closure. In plastic and reconstructive surgery, soft tissue expansion is considered the gold standard for reconstructing scalp defects; however, these techniques are not well known nor are they routinely practiced among neurosurgeons. The authors here describe a simple external tissue expansion technique that is associated with low morbidity and results in high cosmetic satisfaction among patients. METHODS The authors reviewed the medical records of patients with large cranial defects (> 5 cm) following multiple complicated craniotomies who had undergone reconstructive cranioplasty with preoperative tissue expansion using the DermaClose RC device. In addition to gathering data on patient age, sex, primary pathology, number of craniotomies and/or craniectomies, history of radiation therapy, and duration of external scalp tissue expansion, the authors screened patient charts for cerebrospinal fluid (CSF) leak, meningitis, intracranial abscess formation, dermatitis, and patient satisfaction rates. RESULTS The 6 identified patients (5 female, 1 male) had an age range from 36 to 70 years. All patients had complicating factors such as recalcitrant scalp infections after multiple craniotomies or cranial radiation, which led to secondary scalp tissue scarring and retraction. All patients were deemed to be potential candidates for rotational flaps with or without skin grafts. All patients underwent the same preoperative tissue expansion followed by standard cranial bone reconstruction. None of the patients developed CSF leak, meningitis, intracranial abscess, dermatitis, or permanent cosmetic defects. None of the patients required a reoperation. Mean follow-up was 117 days. CONCLUSIONS Preoperative scalp tissue expansion with the DermaClose RC device allows for simple and reliable completion of complicated cranial reconstruction with low morbidity rates and high cosmetic satisfaction among patients.

Clinical and Radiological Outcomes After Treatment of Unruptured Paraophthalmic Internal Carotid Artery Aneurysms: a Comparative and Pooled Analysis of Single-Center Experiences

OBJECTIVE

Unruptured paraophthalmic aneurysms present unique challenges, and the ideal management remains unknown.

METHODS

We performed a pooled analysis of single-center experiences to compare the risks and effectiveness involving patients with unruptured paraophthalmic aneurysms treated with clipping, coiling alone, stent-assisted coiling, and flow-diversion. The MEDLINE database was searched and thirty-three series (including our institutional experience) were included.

RESULTS

Clipping caused more intracranial hemorrhage (ICH) and neurologic complications (NCs) than coiling alone (ICH: odds ratio [OR] = 3.058, P = 0.013; NC: OR = 5.809, P < 0.001), stent-assisted coiling (ICH: P = 0.018; NC: OR = 7.367, P < 0.001), and flow-diversion (ICH: P = 0.006; NC: OR = 16.954, P < 0.001). Clipping also caused more unfavorable visual outcomes than both coiling alone (OR = 3.037, P = 0.001) and stent-assisted coiling (OR = 6.055, P = 0.005). Clipping resulted in a lower reoperation rate than coiling alone in large/giant aneurysm group, which approached statistical significance (OR = 0.133, P = 0.057). Clipping, stent-assisted coiling, and flow-diversion all showed higher occlusion rates compared with coiling alone (OR [clipping vs. coiling alone] = 2.852, P ≤ 0.001; OR [coiling alone vs. stent-assisted coiling] = 0.302, P = 0.003; OR [coiling alone vs. flow-diversion] = 0.400, P = 0.013). Flow-diversion showed comparative complication rate, clinical outcomes, and angiographic result compared with stent-assisted coiling. No significant differences were found among all 4 treatment modalities on mortality and poor outcome.

CONCLUSIONS

Endovascular therapies have benefits over surgical clipping in terms of fewer intracranial hemorrhage complications, fewer NCs, and lower unfavorable visual outcome rate. Flow diversion showed comparative safety and effectiveness to stent-assisted coiling, and they both achieved better radiologic results than coiling alone. Further validation by randomized cohort studies is still needed to provide robust evidence.

Endovascular Treatment of Unruptured Paraclinoid Aneurysms: Single-Center Experience with 400 Cases and Literature Review

BACKGROUND AND PURPOSE

Paraclinoid aneurysms have been increasingly treated endovascularly. The natural history of these aneurysms has gradually been elucidated. The purpose of this study was to assess the safety and efficacy of endovascular treatment for these aneurysms.

MATERIALS AND METHODS

We performed a retrospective review of 377 patients with 400 paraclinoid aneurysms treated between January 2006 and December 2012. Their clinical records, endovascular reports, and radiologic and clinical outcomes were analyzed. Because aneurysms ≥7 mm are at higher risk of rupture, we classified aneurysms as small (<7 mm) or large (≥7 mm).

RESULTS

Overall, 115 of the 400 aneurysms (28.8%) were large (≥7 mm). Thromboembolic complications were found significantly more often with large aneurysms than with small ones (7.4% vs 1.0%, P = .001). Hemorrhagic complications were found only with small aneurysms (0.7%). The 6-month morbidity rates were similar for small (1.0%) and large (0.8%) aneurysms. Immediate angiographic outcomes were similar (P = .37), whereas recurrences and retreatment occurred more frequently with large aneurysms (P = .001 and P = .007, respectively). Multivariate analysis showed that aneurysm size was the only independent predictor for recurrence (P = .005). Most recurrences (81%) were detected by scheduled angiography at 6 months.

CONCLUSIONS

Aneurysm size influenced the type of complication (thromboembolic or hemorrhagic) and the recurrence rate. Given the approximately 1% annual rupture rate for aneurysms ≥7 mm, analysis of our data supports the rationale of using prophylactic endovascular treatment for unruptured paraclinoid aneurysms ≥7 mm.

Flow-diversion for ophthalmic segment aneurysms

BACKGROUND

The use of flow-diversion to treat ophthalmic segment aneurysms (OSA) has not been well evaluated.

OBJECTIVE

To assess the visual outcomes, the obliteration rate, and the need for retreatment of OSA treated by the pipeline embolization device (PED).

METHODS

Patients who underwent treatment with PED for OSA from 2009 to 2014 were selected and retrospectively reviewed. Patient's age, sex, mode of presentation, and aneurysm size were recorded. The complication rates, the need for retreatment (due to recurrence of the aneurysm or worsening symptoms), the aneurysm occlusion rates, the evolution of visual symptoms, and the evolution of headache/retro-orbital pain were registered.

RESULTS

Forty-one patients harboring 44 OSA treated by flow-diversion were identified. Females constituted 87.80% (37/41) of the cohort. The mean age was 59.16 ± 12.54 years. At final angiographic follow-up, 77.27% (34/44) had complete occlusion, 6.81% (3/44) had near-complete occlusion, and 15.90% (7/44) had incomplete occlusion. Of the 22 symptomatic OSA, complete resolution or significant improvement was noted in 72.72% (16/22), while worsening of symptoms occurred in 4.54% (1/22). Five patients out of 22 (22.72%; 5/22) had no significant changes in their symptoms. The complication rate was 2.27% (1/44). The mortality rate was 0%.

CONCLUSION

The low complication rate, the high obliteration rate, and the high rate of improvement in the visual symptoms make flow-diversion an appealing option for the treatment of OSA.

Endovascular treatment of unruptured ophthalmic artery aneurysms: clinical usefulness of the balloon occlusion test in predicting vision outcomes after coil embolization

BACKGROUND

Endovascular coil embolization for ophthalmic artery (OphA) aneurysms has the latent risk of occlusion of the OphA during the procedure, which can lead to loss of vision. We report clinical and angiographic results of endovascular treatment of OphA aneurysms together with the efficacy of the balloon occlusion test (BOT).

METHODS

From August 2005 to December 2013, 31 consecutive patients with 33 OphA aneurysms were treated in our institution. The patients were classified into two groups according to the location of the OphA within the aneurysmal sac. The BOT was performed in 28 patients using a hypercompliant balloon before endovascular coiling. Collateral circulation between the external carotid artery and the OphA was examined and visual function tests were performed before and after treatment. Patient demographics, angiographic and clinical outcomes were reviewed.

RESULTS

Among the 28 patients who underwent the BOT, intact collateral circulation was demonstrated in 26 (92.9%) patients and complete occlusion of the OphA was obtained in three patients after coiling. Retrograde filling of the OphA with choroidoretinal blush was observed on post-procedural angiography and no specific visual symptoms were reported during the follow-up period. Complete embolization was achieved in 30 lesions (96.8%) and only five patients (16.1%) had minor recanalization.

CONCLUSIONS

Endovascular treatment of OphA aneurysms can be performed safely and effectively in conjunction with BOT. The BOT may give useful information to predict visual outcome in patients whose OphA is likely to be threatened by the coiling procedure and to determine the optimal treatment strategy.

Complications of cranioplasty after decompressive craniectomy for traumatic brain injury

INTRODUCTION

Decompressive craniectomy (DC)--a potentially life-saving intervention following traumatic brain injury (TBI) with medically refractory brain swelling--once performed, surviving patients, more often than not, undergo a second procedure with cranioplasty (CP) in the future. This study analyzes complications following CP after DC, as the beneficial effects of the DC can't be extrapolated in long run over a population unless one adds into it the complications associated with the CP in the survivors of TBI.

MATERIALS AND METHODS

An observational study was performed retrospectively, with the review of case records. Demographic, clinical, and outcome data were collected, and complications were studied for any predictive parameters. A multivariate analysis was performed to identify factors that influenced these complications.

RESULTS

Data were collected for a total of 74 patients who underwent CP with a median age of 32, and a mean follow-up time of 2 years and 8 months. The mortality rate was 1.35% and overall complication rate 31%. The most significant factor determining complications were operating time more than 90 min Odds ratio (OR) 4.77 (1.61-14.20); timing of CP less than 3 months after craniectomy, OR 2.86 (1.48-8.11); age more than 20 years, OR 2.59 (1.20-6.53); and female gender, OR 1.91 (1.13-4.17).

CONCLUSIONS

Although considered as a straight-forward procedure, the risks associated with this elective procedure should be kept in mind by the surgeon so that the patients and families can be apprised judiciously. It should be ascertained that patient and/or family consents for the procedure after being appropriately informed about the benefits and risks associated with the procedure.

Complications following cranioplasty: incidence and predictors in 348 cases

OBJECT

The factors that contribute to periprocedural complications following cranioplasty, including patient-specific and surgery-specific factors, need to be thoroughly assessed. The aim of this study was to evaluate risk factors that predispose patients to an increased risk of cranioplasty complications and death.

METHODS

The authors conducted a retrospective review of all patients at their institution who underwent cranioplasty following craniectomy for stroke, subarachnoid hemorrhage, epidural hematoma, subdural hematoma, and trauma between January 2000 and December 2011. The following predictors were tested: age, sex, race, diabetic status, hypertensive status, tobacco use, reason for craniectomy, urgency status of the craniectomy, graft material, and location of cranioplasty. The cranioplasty complications included reoperation for hematoma, hydrocephalus postcranioplasty, postcranioplasty seizures, and cranioplasty graft infection. A multivariate logistic regression analysis was performed. Confidence intervals were calculated as the 95% CI.

RESULTS

Three hundred forty-eight patients were included in the study. The overall complication rate was 31.32% (109 of 348). The mortality rate was 3.16%. Predictors of overall complications in multivariate analysis were hypertension (OR 1.92, CI 1.22-3.02), increasing age (OR 1.02, CI 1.00-1.04), and hemorrhagic stroke (OR 3.84, CI 1.93-7.63). Predictors of mortality in multivariate analysis were diabetes mellitus (OR 7.56, CI 1.56-36.58), seizures (OR 7.25, CI 1.238-42.79), bifrontal cranioplasty (OR 5.40, CI 1.20-24.27), and repeated surgery for hematoma evacuation (OR 13.00, CI 1.51-112.02). Multivariate analysis was also applied to identify the variables that affect the development of seizures, the need for reoperation for hematoma evacuation, the development of hydrocephalus, and the development of infections.

CONCLUSIONS

The authors' goal was to provide the neurosurgeon with predictors of morbidity and mortality that could be incorporated in the clinical decision-making algorithm. Control of a patient's risk factors and early recognition of complications may help practitioners avoid the exhaustive list of complications.

History of synthetic materials in alloplastic cranioplasty

When faced with calvarial defects, surgeons have long searched for repair materials. General criteria include ease of use, low cost, availability, cosmetic shape, and osteointegrative potential. While autologous bone is widely used and favored in contemporary reconstructive procedures, synthetic alternatives have been used throughout history and are necessary in current practice for select cases when autograft reconstruction is not an option (such as cases with severe bony comminution, bone graft resorption, infection, and limited donor site options). For centuries, surgeons have experimented with metals, ceramics, plastics, and later, resorbable polymers. This paper provides a tour of the materials that have been used and experimented with throughout the history of alloplastic cranioplasty.

Management strategy of surgical and endovascular treatment of unruptured paraclinoid aneurysms based on the location of aneurysms

OBJECTIVE

Advances in endovascular treatment (EVT) have greatly improved the treatment outcomes of paraclinoid aneurysms. However, EVT had the shortcoming of durability and thromboembolic complications. As well, surgical treatment of paraclinoid aneurysms is still challenging due to the complexity of adjacent structures. The objective of this study is to report our experience with a combined surgical and endovascular treatment of unruptured paraclinoid aneurysms based on the location of aneurysms.

METHODS

A retrospective review was conducted of 185 cases of unruptured paraclinoid aneurysms that underwent surgical or endovascular treatment between September 2008 and August 2012. Thirty-one aneurysms (16.8%) were treated by microsurgery and 154 (83.2%) were treated by EVT. Fifty aneurysms (27.0%) were classified to the dorsal group and 135 (73%) were classified to the non-dorsal group.

RESULTS

Twenty of 50 dorsal group aneurysms (40%) were treated by microsurgery while 124 of 135 non-dorsal group aneurysms (91.9%) underwent an EVT. The rate of complete occlusion was 96.8% in surgical series and 60.4% in EVT (P < 0.001). Recanalization occurred in 9 aneurysms (5.8%) of EVT and 1 aneurysm (3.2%) of surgical series (P = 0.360). In non-dorsal group, transient complications (10 aneurysms (5.4%), P = 0.018) and morbidity at last visiting (6 aneurysms (3.2%), P = 0.021) were more present in surgically treated cases rather than in EVT cases. Diplopia and visual field defect occurred in the non-dorsal group only; in 2 of 11 surgical cases (18.2%) and in 1 of 124 EVT series (0.8%) (P = 0.017). The overall rate of excellent or good clinical outcomes (Glasgow outcome scale 5 or 4) was 98.9%.

CONCLUSION

EVT is a safe and effective treatment for the non-dorsal group. Based on angiographic and clinical aspects, microsurgical clipping has prior efficacy with better outcomes in the dorsal group under proper individualized selection.

Vision outcomes and major complications after endovascular coil embolization of ophthalmic segment aneurysms

BACKGROUND AND PURPOSE

As aneurysms arising from the ophthalmic segment of the internal carotid artery increase in size, they can compress the optic nerve, prompting patients to present with visual disturbances. The purpose of this article is to describe the clinical and angiographic results with an emphasis on visual outcomes following the endovascular treatment of ophthalmic segment ICA aneurysms.

MATERIALS AND METHODS

The records of 1254 patients who presented for endovascular treatment of a cerebral aneurysm were retrospectively reviewed to identify 65 consecutive patients who underwent coil embolization of an ophthalmic segment ICA aneurysm. The clinical records, treatment reports, and imaging were reviewed with a focus on visual outcomes.

RESULTS

Twenty-two of the 65 patients (34%) who presented for treatment of an ophthalmic aneurysm reported a visual disturbance at presentation. Fifteen of the 22 patients (68%) experienced an improvement in their symptoms after treatment. Overall, patients with visual symptoms were significantly more likely to benefit from treatment than to have a decline in vision (P = .03). The overall morbidity was 4%, and mortality was 0%. The retreatment rate was high at 30%, though this was disproportionately weighted by an 86% retreatment rate in patients with ruptured aneurysms.

CONCLUSIONS

Patients with visual symptoms attributable to ophthalmic segment ICA aneurysms undergoing endovascular coil embolization were statistically more likely to experience an improvement in their vision than to have worsening or unchanged vision. Coiling was associated with a low morbidity rate, though an elevated retreatment rate.

Clinical outcome of paraclinoid internal carotid artery aneurysms after microsurgical neck clipping in comparison with endovascular embolization

OBJECTIVE

Because of the complex anatomical association among vascular, dural, and bony structures, paraclinoid internal carotid artery (ICA) aneurysms remain a major challenge for vascular neurosurgeons. We studied the clinical outcomes of 61 paraclinoid ICA aneurysms after microsurgical clipping in comparison with endovascular coiling.

MATERIALS AND METHODS

Between January 2008 and December 2012, we treated 61 paraclinoid ICA aneurysms created by surgical clipping or endovascular coiling. Preoperative neurologic status and postoperative outcome were evaluated using the Glasgow coma scale (GCS) and the modified Rankin scale (mRS). Postoperative hydrocephalus and vasospasm were reviewed using the patients' medical charts.

RESULTS

Most patients were in good clinical condition before the operations and had good treatment outcomes. Clinical vasospasm was observed after the operation in five patients, and hydrocephalus occurred in six patients. No statistically significant difference regarding aneurysm size, sex, GCS score, H-H grade, and mRS was observed between the surgical clipping group and the endovascular coiling group. In addition, the treatment results and complications did not show statistically significant difference in either group.

CONCLUSION

Surgical occlusion of paraclinoid ICA aneurysms is difficult; however, no significant differences were observed in the treatment results or complications when compared with coil embolization. In particular, use of an adequate surgical technique may lead to better outcomes than those for coil embolization in the treatment of large and/or wide-neck paraclinoid ICA aneurysms.

Angiographic and clinical result of endovascular treatment in paraclinoid aneurysms

Purpose

The purpose of this study was to analyze the results of an immediate and mid-term angiographic and clinical follow-up of endovascular treatment for paraclinoid aneurysms.

Materials and Methods

From January 2002 to December 2012, a total of 113 consecutive patients (mean age: 56.2 years) with 116 paraclinoid saccular aneurysms (ruptured or unruptured) were treated with endovascular coiling procedures. Clinical and angiographic outcomes were retrospectively evaluated.

Results

Ninety-three patients (82.3%) were female. The mean size of the aneurysm was 5.5 mm, and 101 aneurysms (87.1%) had a wide neck. Immediate catheter angiography showed complete occlusion in 40 aneurysms (34.5%), remnant sac in 51 (43.9%), and remnant neck in 25 (21.6%). Follow-up angiographic studies were performed on 80 aneurysms (69%) at a mean period of 20.4 months. Compared with immediate angiographic results, follow-up angiograms showed no change in 38 aneurysms, improvement in 37 (Fig. 2), and recanalization in 5. There were 6 procedure-related complications (5.2%), with permanent morbidity in one patient.

Conclusion

Out study suggests that properly selected patients with paraclinoid aneurysms can be successfully treated by endovascular means.

Endovascular treatment of ophthalmic artery aneurysms: assessing balloon test occlusion and preservation of vision in coil embolization

BACKGROUND AND PURPOSE

ICA-ophthalmic artery aneurysms have unique configurations corresponding to relative risks of ophthalmologic morbidities. Presented herein are clinical and radiologic outcomes of coil embolization in ophthalmic artery aneurysms.

MATERIALS AND METHODS

From January 2003 to September 2013, endovascular coiling was performed in 43 consecutive patients with ophthalmic artery aneurysms, each classified by the degree to which the ophthalmic artery was incorporated by the aneurysm and the contiguity between the ophthalmic artery entry and parent ICA. Clinical and radiologic outcomes of this approach were investigated, including the technical aspects of treatment and the efficacy of balloon test occlusion.

RESULTS

Among 14 patients (32.6%, all ophthalmic artery types) undergoing balloon test occlusion before endovascular coiling, patent collaterals between the external carotid artery and ophthalmic artery were demonstrated in 12 (85.7%) and complete compromise of the ophthalmic artery (without affecting vision) occurred in 4 patients during coiling. Steam-shaped S-configured (67.9%) or straight microcatheters (17.8%) facilitated aneurysm selection in most of the superiorly directed ophthalmic artery aneurysms (n = 28), and steam-shaped pigtail microcatheters (85.7%) were useful in medially directed aneurysms (n = 14). Balloon protection (n = 22) was generally used to facilitate coiling, or a stent (n = 9) was alternatively deployed. Satisfactory aneurysmal occlusion was achieved through coil embolization in 37 lesions (86.1%). During follow-up of 35 patients (mean interval, 12.9 ± 9.4 months), only 1 instance (2.9%) of major recanalization was observed.

CONCLUSIONS

If one tailors technical strategies, ophthalmic artery aneurysms are amenable to safe and effective endovascular coil embolization, which tends to be stable in follow-up. Balloon test occlusion may be helpful in devising treatment strategies to preserve vision when coiling ophthalmic artery aneurysms (especially those incorporating an ophthalmic artery origin) is done.