Could late rebleeding overturn the superiority of cranial aneurysm coil embolization over clip ligation seen in the International Subarachnoid Aneurysm Trial?

Role of clipping in aneurysmal subarachnoid hemorrhage: a post hoc analysis of the Earlydrain trial

The choice between clipping and coiling of ruptured cerebral aneurysms in subarachnoid hemorrhage (SAH) remains controversial. The recently published Earlydrain trial provides the opportunity to analyze the latest clip-to-coil ratio in German-speaking countries and to evaluate vasospasm incidence and explorative outcome measures in both treatment modalities. We performed a post hoc analysis of the Earlydrain trial, a multicenter randomized controlled trial investigating the use of an additional lumbar drain in aneurysmal SAH. The decision whether to clip or to coil the ruptured aneurysm was left to the discretion of the participating centers, providing a real-world insight into current aneurysm treatment strategies. Earlydrain was performed in 19 centers in Germany, Switzerland, and Canada, recruiting 287 patients with aneurysmal SAH of all severity grades. Of these, 140 patients (49%) received clipping and 147 patients (51%) coiling. Age and clinical severity based on Hunt-Hess/WFNS grades and radiological criteria were similar. Clipping was more frequently used for anterior circulation aneurysms (55%), whereas posterior circulation aneurysms were mostly coiled (86%, p < 0.001). In high-volume recruiting centers, 56% of patients were treated with clipping, compared to 38% in other centers. A per-year analysis showed a stable and balanced clipping/coiling ratio over time. Regarding vasospasm, 60% of clipped versus 43% of coiled patients showed elevated transcranial Doppler criteria (p = 0.007), reflected in angiographic vasospasm rates (51% vs. 38%, p = 0.03). In contrast to the Earlydrain main results establishing the superiority of an additional lumbar drain, explorative outcomes after clipping and coiling measured by secondary infarctions, mortality, modified Rankin Score, Glasgow Outcome Scale Extended, or Barthel-Index showed no significant differences after discharge and at six months. In clinical practice, aneurysm clipping is still a frequently used method in aneurysmal SAH. Apart from a higher rate of vasospasm in the clipping group, an exploratory outcome analysis showed no difference between the two treatment methods. Further development of periprocedural treatment modalities for clipped ruptured aneurysms to reduce vasospasm is warranted.

An overview of decision-making in cerebrovascular treatment strategies: Part II - Ruptured aneurysms

Introduction

Decision-making for the treatment of ruptured aneurysms is an intricate process, which involves several factors. There has been a rapid advancement in endovascular, but also in the surgical treating field of ruptured intracranial aneurysms, with a growing body of evidence for either treatment technique.

Research question

As there is a wide variety of treatment possibilities, it can be hard to understand the intricacies which lie behind the decision-making process for a given aneurysm.

Materials and methods

An overview of the most relevant literature in decision-making on ruptured intracranial aneurysms is given.

Results

Different decision-altering factors were identified, which can be divided into information from the general evidence, to influential factors such as the patient's age, initial presenting status, and aneurysmal factors such as size, morphology and aneurysmal location.

Discussion and conclusion

This review provides an evidence-based overview of the most pertinent literature on these different aspects of decision-making in ruptured aneurysm cases and provides some recommendations after each of these segments. As always, all different aspects of the patient and aneurysmal factors should be taken into consideration before coming to a conclusion, as to obtain the best possible result for an individual patient.

Emergent Management of Spontaneous Subarachnoid Hemorrhage

OBJECTIVE

Spontaneous subarachnoid hemorrhage (SAH) carries high morbidity and mortality rates, and the emergent management of this disease can make a large impact on patient outcome. The purpose of this article is to provide a pragmatic overview of the emergent management of SAH.

LATEST DEVELOPMENTS

Recent trials have influenced practice around the use of antifibrinolytics, the timing of aneurysm securement, the recognition of cerebral edema and focus on avoiding a lower limit of perfusion, and the detection and prevention of delayed cerebral ischemia. Much of the acute management of SAH can be protocolized, as demonstrated by two updated guidelines published by the American Heart Association/American Stroke Association and the Neurocritical Care Society in 2023. However, the gaps in evidence lead to clinical equipoise in some aspects of critical care management.

ESSENTIAL POINTS

In acute management, there is an urgency to differentiate the etiology of SAH and take key emergent actions including blood pressure management and coagulopathy reversal. The critical care management of SAH is similar to that of other acute brain injuries, with the addition of detecting and treating delayed cerebral ischemia. Strategies for the detection and treatment of delayed cerebral ischemia are limited by disordered consciousness and may be augmented by monitoring and imaging technology.

Clipping and coiling of intracranial aneurysms in the elderly patients: clinical features and treatment outcomes

Objective

In recent years, more and more cases of intracranial aneurysms (IAs) have been found in elderly patients, and neurosurgical interventions have increased, but there is still no consensus on the best treatment strategy for elderly patients. In elderly patients, endovascular coiling (EC) is more popular than surgical clipping (SC) due to its advantages of less trauma and faster recovery. However, SC has made great progress in recent years, significantly improving the prognosis of elderly patients. Therefore, it is necessary to further explore the effects of different treatment modalities on clinical prognosis, hospital stay, and hospital cost of elderly IA patients, and select the most appropriate treatment modalities.

Methods

The authors retrospectively analyzed 767 patients with intracranial aneurysms admitted to the facility between August 2017 and December 2022. Prognostic risk factors and multivariate logistic regression were analyzed for elderly patients treated with EC or SC. The area under the receiver operating characteristic (ROC) curve was used to calculate the predictive power of each independent predictor between the treatment groups.

Results

Our study included 767 patients with aneurysms, of whom 348 (45.4%) were elderly, 176 (22.9%) underwent endovascular coiling, and 172 (22.4%) underwent microsurgical clipping. A comparison of elderly patients treated with EC and SC showed a higher prevalence of hypertension in the EC group (P = 0.011) and a higher Hunt-Hess score on admission in the SC group (P = 0.010). Patients in the EC group had shorter hospital stays but higher costs (P = 0.000 and P = 0.000, respectively). Patients treated with SC had a higher incidence of postoperative cerebral infarction and poor prognosis (P = 0.002 and P = 0.008, respectively). Through multi-factor logistic analysis, it was found that age (OR 1.209, 95% CI 1.047-1.397, P = 0.010), length of stay (LOS) (OR 1.160, 95 CI% 1.041-1.289, P = 0.007), and complications (OR 31.873, 95 CI% 11.677-320.701, P = 0.000) was an independent risk factor for poor prognosis in elderly patients with EC. In elderly patients treated with SC, age (OR 1.105, 95% CI 1.010-1.209, P = 0.029) was an independent risk factor for poor prognosis.

Conclusion

EC and SC interventions in elderly adults carry higher risks compared to non-older adults, and people should consider these risks and costs when making a decision between intervention and conservative treatment. In elderly patients who received EC or SC treatments, EC showed an advantage in improving outcomes in elderly patients although it increased the economic cost of the patient's hospitalization.

2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association

AIM

The "2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage" replaces the 2012 "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage." The 2023 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with aneurysmal subarachnoid hemorrhage.

METHODS

A comprehensive search for literature published since the 2012 guideline, derived from research principally involving human subjects, published in English, and indexed in MEDLINE, PubMed, Cochrane Library, and other selected databases relevant to this guideline, was conducted between March 2022 and June 2022. In addition, the guideline writing group reviewed documents on related subject matter previously published by the American Heart Association. Newer studies published between July 2022 and November 2022 that affected recommendation content, Class of Recommendation, or Level of Evidence were included if appropriate. Structure: Aneurysmal subarachnoid hemorrhage is a significant global public health threat and a severely morbid and often deadly condition. The 2023 aneurysmal subarachnoid hemorrhage guideline provides recommendations based on current evidence for the treatment of these patients. The recommendations present an evidence-based approach to preventing, diagnosing, and managing patients with aneurysmal subarachnoid hemorrhage, with the intent to improve quality of care and align with patients' and their families' and caregivers' interests. Many recommendations from the previous aneurysmal subarachnoid hemorrhage guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Management of Ruptured Intracranial Aneurysms in the Post-International Subarachnoid Aneurysm Trial Era: A Single-Centre Prospective Series

BACKGROUND

Aneurysmal subarachnoid haemorrhage (aSAH) is associated with significant morbidity and mortality. The International Subarachnoid Aneurysm Trial (ISAT) reported reduced morbidity in patients treated with endovascular coiling versus surgical clipping. However, recent studies suggest that there is no significant difference in clinical outcomes. This study examines the outcomes of either technique for treating aSAH during the 15 years post-ISAT at a Canadian quaternary centre.

METHODS

We reviewed prospectively collected data of patients admitted with aSAH from January 2002 to December 2017. Glasgow Outcome Scale (GOS) was compared at discharge, 6 months and 12 months' follow-up using univariate and multivariable ordinal logistic regression. Post-operative complications were assessed using binary logistic regression.

RESULTS

Two-hundred and eighty-seven patients were treated with coiling and 95 patients with clipping. The mean age of clipped patients was significantly younger, and hypertension was significantly commoner in coiled patients. A greater proportion of coiled aneurysms were located in the posterior circulation. No difference in the odds of having a favourable GOS was seen between patients who were clipped versus coiled at any of follow-up time points on univariate or multivariable analysis. In both treatment groups, patient recovery to independence (GOS 4-5) was seen from discharge to 6 months, but not from 6 to 12 months' follow-up, without difference between clipping and coiling.

CONCLUSION

These real-world findings suggest clipping remains an effective and important treatment option for patients with aSAH who do not meet ISAT inclusion criteria. The results can assist in clinical decision-making processes and understanding of the natural recovery progression of aSAH.

Comparison between outcomes of endovascular and surgical treatments of ruptured anterior communicating artery aneurysms

INTRODUCTION

The natural history and optimal treatment of previously ruptured anterior communicating artery (ACOM) aneurysms that recur is unknown. This study looks at rates of complications and recurrences of ruptured ACOM aneurysms treated endovascularly and surgically.

MATERIALS AND METHODS

A retrospective observational study of all patients presenting to a single tertiary neurosurgical centre with the first presentation of subarachnoid haemorrhage (SAH) secondary to a ruptured ACOM aneurysm. Data was collected from November 2012 to September 2018 and included baseline demographics, aneurysm characteristics, management, complications, follow-up imaging, and clinical outcomes.

RESULTS

137 patients were included in the study. 113 aneurysms were coiled and 19 were clipped. Management decisions were taken by the multidisciplinary team based on aneurysm morphology or the presence of a haematoma exerting mass effect. There were 187.5 patient-years of follow-up, with a median of 3 years (range 0-73 months). Rates of vasospasm, infarction, CSF diversion, rebleed, length of stay, and functional outcome were not significantly different in the two cohorts. There was a statistically significant increase in the risk of ACOM recurrence in the coiled group when compared to the clipped group at one year (p = .0433). 15 patients required further treatment at a median time of 16 months. In a subgroup group analysis of coiled aneurysms, there was no statistical differences in rates of rebleeding or the functional outcome in those that had aneurysm recurrence and those that did not.

CONCLUSIONS

This study suggests patients with aneurysms treated by endovascular coiling have an increased risk of recurrence versus those treated with clipping. However, the risk of rebleed was not statistically significant. The prevention and impact of recurrence and residual aneurysms remains incompletely understood. Hence, treatment decisions should be taken by patients after they have been given carefully considered recommendations from the multi-disciplinary team.

The "Brain Stress Timing" phenomenon and other misinterpretations of randomized clinical trial on aneurysmal subarachnoid hemorrhage

Clipping and coiling are currently the two alternatives in treatment of ruptured cerebral aneurysms. In spite of some meritorious analysis, further discussion is helpful to understand the actual state of art. Retreatment and rebleeding rates clearly favors clipping, although short-term functional outcome seems to be beneficial for clipping, while this different is not such if we perform the comparison at a longer follow up. Long-term follow ups and cost analysis are mandatory to have a clear view of the current picture in treatment of subarachnoid hemorrhage. Treatment strategy should be made by a multi-disciplinary team in accredited centers with proficient experience in both techniques.

Therapeutic strategies for residual or recurrent intracranial aneurysms after microsurgical clipping

OBJECTIVES

Therapeutic strategies for residual or recurrent aneurysm (RRA) after microsurgical clipping have not been well established. The purpose of this study was to report our retreatment experiences with previously clipped aneurysms and to demonstrate retreatment strategies for these RRAs.

PATIENTS AND METHODS

From 1996-2016, we treated 68 RRAs after previous clipping. Among them, 34 patients underwent microsurgical retreatment, and the other 34 underwent endovascular retreatment. Radiographic images and clinical data were reviewed retrospectively to determine the treatment efficacy, clinical outcomes, and important factors for selecting the proper treatment modality.

RESULTS

The most common aneurysm location was the middle cerebral artery (50%) in the microsurgery group and the internal carotid artery (47.1%) in the endovascular surgery group (p =  0.001). In the microsurgery group, 16 (47.1%) patients had additional clipping without removal of previous clips, 17 (50.0%) had clipping with removal of previous clips, and 1 (2.9%) had bypass surgery with trapping. In the endovascular surgery group, 28 (82.4%) patients had simple coiling, 5 (14.7%) had stent-assisted coiling, and 1 (2.9%) had a flow diverter. Procedure-related complications during retreatment occurred in 4 (5.9%) patients. Complete obliteration was achieved in 51 (75.0%) patients (microsurgery group, 82.4% and endovascular surgery group, 67.6%; p =  0.002).

CONCLUSIONS

In properly selected cases, treatment of RRAs could be safely performed either by microsurgery or endovascular surgery and result in a good clinical outcome with acceptable morbidity. The decision to choose the treatment modality for RRAs after clipping is not easy but should be considered to lower the risk of retreatment.

Korean Clinical Practice Guidelines for Aneurysmal Subarachnoid Hemorrhage

Despite advancements in treating ruptured cerebral aneurysms, an aneurysmal subarachnoid hemorrhage (aSAH) is still a grave cerebrovascular disease associated with a high rate of morbidity and mortality. Based on the literature published to date, worldwide academic and governmental committees have developed clinical practice guidelines (CPGs) to propose standards for disease management in order to achieve the best treatment outcomes for aSAHs. In 2013, the Korean Society of Cerebrovascular Surgeons issued a Korean version of the CPGs for aSAHs. The group researched all articles and major foreign CPGs published in English until December 2015 using several search engines. Based on these articles, levels of evidence and grades of recommendations were determined by our society as well as by other related Quality Control Committees from neurointervention, neurology and rehabilitation medicine. The Korean version of the CPGs for aSAHs includes risk factors, diagnosis, initial management, medical and surgical management to prevent rebleeding, management of delayed cerebral ischemia and vasospasm, treatment of hydrocephalus, treatment of medical complications and early rehabilitation. The CPGs are not the absolute standard but are the present reference as the evidence is still incomplete, each environment of clinical practice is different, and there is a high probability of variation in the current recommendations. The CPGs will be useful in the fields of clinical practice and research.

Treatment of Intracranial Aneurysms: Clipping Versus Coiling

Intracranial aneurysms (IAs) have an estimated incidence of up to 10 % and can lead to serious morbidity and mortality. Because of this, the natural history of IAs has been studied extensively, with rupture rates ranging from 0.5 to 7 %, depending on aneurysm characteristics. The spectrum of presentation of IAs ranges from incidental detection to devastating subarachnoid hemorrhage. Although the gold standard imaging technique is intra-arterial digital subtraction angiography, other modalities such as computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are being increasingly used for screening and treatment planning. Management of these patients depends upon a number of factors including aneurysmal, patient, institutional, and operator factors. The ultimate goal of treating patients with IAs is complete and permanent occlusion of the aneurysm sac in order to eliminate future hemorrhagic risk, while preserving or restoring the patient's neurological function. The most common treatment approaches include microsurgical clipping and endovascular coiling, and multiple studies have compared these two techniques. To date, three large prospective, randomized studies have been done: a study from Finland, International Subarachnoid Aneurysm Trial (ISAT), and the Barrow Ruptured Aneurysm Trial (BRAT). Despite differences in methodology, the results were similar: in patients undergoing coiling, although rates of rebleeding and retreatment are higher, the overall rate of poor outcomes at 12 months was significantly lower. As minimally invasive procedures and devices continue to be refined, endovascular strategies are likely to increase in popularity. However, as long-term outcome studies become available, it is increasingly apparent that they are complementary treatment strategies, with patient selection of critical importance.

Aneurysmal Neck Clipping as the Primary Treatment Option for Both Ruptured and Unruptured Middle Cerebral Artery Aneurysms

Objective

Although middle cerebral artery (MCA) aneurysms are less amenable to coil embolization, an increasing number of studies support favorable endovascular treatment for them. The purpose of this study is to compare the outcomes of two different treatments (surgery versus coiling) and evaluate the benefits of surgical clipping for MCA aneurysms.

Methods

Here we retrospectively analyzed the outcomes of 178 ruptured and unruptured MCA aneurysms treated in patients between September 2008 and April 2012. Parameters assessing treatment outcomes include degree of aneurysm occlusion, presence of regrowth, clinical status, and complications.

Results

Among 178 MCA aneurysms, 153 were treated surgically. After a mean follow-up of 12 months, the surgery group showed a clinically significant complete occlusion rate (98%) compared with the coiling group (56%) (p<0.001). Follow-up radiologic evaluation showed a higher regrowth rate (four of 16 cases) in the coiling group than in the surgery group (one of 49 cases) (p=0.003). There was no statistically significant difference in favorable clinical outcome rate between the two groups. The procedure-related permanent morbidity and mortality rates were 2% (three of 153 cases) in the surgery group and 0% (0 of 25 cases) in the coiling group.

Conclusion

Compared to endovascular treatment, surgical neck clipping for both ruptured and unruptured MCA aneurysms results in a significantly higher complete obliteration rate and less regrowth. Therefore, even in this endovascular era, we still recommend surgical clipping as the primary treatment option for MCA aneurysms rather than coil embolization.

Very large and giant microsurgical bifurcation aneurysms in rabbits: Proof of feasibility and comparability using computational fluid dynamics and biomechanical testing

BACKGROUND

Giant aneurysms are challenging lesions with unacceptable high rates of aneurysm recanalization and rerupture following embolization. Reliable in vivo models are urgently needed to test the performance of new more efficient endovascular devices.

MATERIALS AND METHODS

Aneurysms were created in 11 New Zealand white rabbits (4.5-5.5kg): A long venous pouch (length 25-30mm) mimicking the aneurysm sac was derived from the external jugular vein and sutured into a microsurgically created bifurcation between both common carotid arteries. After 4 weeks the rabbits underwent 3T Magnetic resonance angiography (3T-MRA). Exemplary computational fluid dynamics (CFD) simulations were performed to compare the flow conditions of giant rabbit and human aneurysms. We used species-related boundary conditions, in particular, we measured blood viscosity values. Biaxial mechanical tests were performed for the mechanical characterization and comparison.

COMPARISON WITH EXISITING METHOD(S)

None.

RESULTS

No peri- or postoperative mortality was observed. 3T-MRA showed aneurysm patency in 10 out of 11 aneurysms (90.9%). Aneurysm lengths ranged from 21.5-25.6mm and aneurysm necks from 7.3-9.8mm. CFD showed complex flow profiles with multiple vortices in both, rabbit and human aneurysms. Lower blood viscosity values of the rabbit (3.92mPas vs. human 5.34mPas) resulted in considerable lower wall shear stress rates (rabbit 0.38Pa vs. human 1.66Pa). Mechanical tests showed lower stiffness of rabbit aneurysms compared to unruptured human aneurysms.

CONCLUSIONS

The proposed model showed favorable aneurysm patency rates, low morbidity and good hemodynamic comparability with complex flow patterns. Biomechanical testing suggests that experimental aneurysms might be even more fragile compared to human aneurysms.

Documentation of Improved Outcomes for Intracranial Aneurysm Management Over a 15-Year Interval

BACKGROUND AND PURPOSE

Despite rapid advancements in intracranial aneurysm management, there is no evidence as of yet that this has translated into improvement in overall prognosis.

METHODS

We compared 2 periods of aneurysm management, 1998 to 2003 (n=1023 aneurysms) and 2007 to 2013 (n=1499 aneurysms), at a single, high-volume neurovascular center. Our outcome of interest was low or moderate disability (Glasgow Outcome Scale score of 4 or 5) at 6 months or more post treatment.

RESULTS

There were significant improvements in outcome for surgical, endovascular, and overall treatment of unruptured (adjusted odds ratio [OR], 2.33; P=0.0091; adjusted OR, 4.40; P=0.0271; and adjusted OR, 2.58; P=0.0008, respectively) and ruptured (adjusted OR, 3.18; P=0.0004; adjusted OR, 3.54; P=0.0001; and adjusted OR, 3.11; P<0.0001, respectively) aneurysms from the first to the second time period. In 2007 to 2013, the proportion of cases with low or moderate disability at 6 months post subarachnoid hemorrhage was 75.6% for surgical clipping and 76.6% for endovascular therapy.

CONCLUSIONS

We report significantly improved outcomes over time for overall aneurysm management and for multiple patient subgroups, associated with increased usage of endovascular therapy.

Endovascular treatment of intracranial aneurysms

Intracranial aneurysms are abnormal dilations of the intracranial vessels, in which all the layers of the vascular wall are affected by degenerative changes that lead to distension of the vessel. Intracranial aneurysms can be classified based on their anatomic location, size, and morphology. Subarachnoid hemorrhage is the most devastating clinical presentation. The goal of preventing hemorrhage or rehemorrhage can only be achieved by excluding the aneurysm from the cerebral circulation. Endovascular or surgical clipping can achieve this goal. Multiple surgical and endovascular approaches have been described for treatment of intracranial aneurysm. Surgical approaches for anterior-circulation intracranial aneurysms include: pterional, orbitozygomatic, and lateral supraorbital craniotomies. Modern microsurgical techniques involve skull base dissection to achieve adequate exposure with minimal brain retraction. Endovascular techniques can be divided into: parent artery reconstruction with coil deposition (primary coil, balloon-assisted coiling, stent-assisted coiling, and other new techniques such as neck reconstruction devices and intraluminal occlusion devices); reconstruction with flow diversion; and deconstructive techniques with involving parent artery sacrifice with or without bypass.

International differences in the management of intracranial aneurysms: implications for the education of the next generation of neurosurgeons

BACKGROUND

The publication of the International Subarachnoid Aneurysm Trial rapidly changed the management of patients with subarachnoid hemorrhage. The present and perceived future trends of aneurysm management have significant implications for patients and how we educate future cerebrovascular specialists.

OBJECTIVE

To determine present perceived competencies of final-year neurosurgical residents who have just finished their residencies and to relate those to what practitioners from a variety of continents expect of these persons. The goal is to provide a basis for further discussion regarding the design of further educational programs in neurosurgery.

METHODS

A 55-item questionnaire with 33 questions related to competencies and expectations of competency from final-year residents who have just finished residency was completed by 229 neurosurgeons and neuro-radiologists (81 % response rate) of mixed seniority from 45 countries. We used bivariate and descriptive analyses to determine future trends and geographic differences in cerebral aneurysm management as well as the educational implications on the future.

RESULTS

More North Americans than those from the rest of the world are of the opinion that graduating residents are presently competent to perform basic cerebrovascular procedures like evacuation of a hematoma and clipping a simple 7-mm middle cerebral artery aneurysm. Extremely few graduating neurosurgical residents anywhere are presently capable of performing endovascular techniques for even the most basic of aneurysms. Most of those surveyed also believe that endovascular and open surgical management of aneurysms should be a part of residency training for all residents (70.4 and 88.7 %, respectively).

CONCLUSIONS

Our findings have implications for the design of neurosurgical curricula for residents as well as for certification examinations and procedures. Specialty and educational organizations and those responsible for the education of future clinicians who will care for patients with cerebrovascular problems should adjust educational objectives and implement curricula and learning experiences that will ensure that cerebrovascular specialists are capable of providing the best care possible to the patient with an aneurysm, whether that be open surgery or endovascular management. These findings mean that organizations around the world will need to make these adjustments to the education of future specialists.

Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage (SAH) is a worldwide health burden with high fatality and permanent disability rates. The overall prognosis depends on the volume of the initial bleed, rebleeding, and degree of delayed cerebral ischemia (DCI). Cardiac manifestations and neurogenic pulmonary edema indicate the severity of SAH. The International Subarachnoid Aneurysm Trial (ISAT) reported a favorable neurological outcome with the endovascular coiling procedure compared with surgical clipping at the end of 1 year. The ISAT trial recruits were primarily neurologically good grade patients with smaller anterior circulation aneurysms, and therefore the results cannot be reliably extrapolated to larger aneurysms, posterior circulation aneurysms, patients presenting with complex aneurysm morphology, and poor neurological grades. The role of hypothermia is not proven to be neuroprotective according to a large randomized controlled trial, Intraoperative Hypothermia for Aneurysms Surgery Trial (IHAST II), which recruited patients with good neurological grades. Patients in this trial were subjected to slow cooling and inadequate cooling time and were rewarmed rapidly. This methodology would have reduced the beneficial effects of hypothermia. Adenosine is found to be beneficial for transient induced hypotension in 2 retrospective analyses, without increasing the risk for cardiac and neurological morbidity. The neurological benefit of pharmacological neuroprotection and neuromonitoring is not proven in patients undergoing clipping of aneurysms. DCI is an important cause of morbidity and mortality following SAH, and the pathophysiology is likely multifactorial and not yet understood. At present, oral nimodipine has an established role in the management of DCI, along with maintenance of euvolemia and induced hypertension. Following SAH, hypernatremia, although less common than hyponatremia, is a predictor of poor neurological outcome.

Endoscopic Endonasal Clipping of Intracranial Aneurysms: Surgical Technique and Results

OBJECTIVE

Microsurgical clipping of intracranial aneurysms requires meticulous technique and is usually performed through open approaches. Endoscopic endonasal clipping of intracranial aneurysms may use the same techniques through an alternative corridor. The aim of this article is to report a series of patients who underwent an endoscopic endonasal approach (EEA) for microsurgical clipping of intracranial aneurysms.

METHODS

We conducted a retrospective chart review. Surgical outcome and complications were noted. The conceptual application and the technical nuances of these procedures are discussed.

RESULTS

Ten patients underwent EEA for clipping of 11 intracranial aneurysms arising from the paraclinoidal internal carotid artery (n = 9) and vertebrobasilar system (n = 2). The internal carotid artery aneurysms projected medially, whereas the vertebrobasilar artery aneurysms were directly ventral to the brainstem with low-lying basilar apices. One patient required craniotomy for distal control given the size and thrombosed nature of the aneurysm. Proximal and distal vascular control with direct visualization of the aneurysm was obtained in all patients. In all cases, aneurysms were completely occluded. Among complications, 3 patients had postoperative cerebrospinal fluid leakage and 2 other patients had meningitis. Two patients suffered lacunar strokes. One recovered completely and the other remains with mild disabling symptoms.

CONCLUSIONS

EEAs can provide direct access for microsurgical clipping of rare and carefully selected intracranial aneurysms. The basic principles of cerebrovascular surgery have to be followed throughout the procedure. These surgeries require a skull base team with a neurosurgeon well versed in both endoscopic endonasal and cerebrovascular surgery, working in concert with an otolaryngologist experienced in skull base endoscopy and reconstruction.

Guidelines for the Management of Patients With Unruptured Intracranial Aneurysms: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this updated statement is to provide comprehensive and evidence-based recommendations for management of patients with unruptured intracranial aneurysms.

METHODS

Writing group members used systematic literature reviews from January 1977 up to June 2014. They also reviewed contemporary published evidence-based guidelines, personal files, and published expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulated recommendations using standard American Heart Association criteria. The guideline underwent extensive peer review, including review by the Stroke Council Leadership and Stroke Scientific Statement Oversight Committees, before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.

RESULTS

Evidence-based guidelines are presented for the care of patients presenting with unruptured intracranial aneurysms. The guidelines address presentation, natural history, epidemiology, risk factors, screening, diagnosis, imaging and outcomes from surgical and endovascular treatment.

Molecular basis and genetic predisposition to intracranial aneurysm

Intracranial aneurysms, also called cerebral aneurysms, are dilatations in the arteries that supply blood to the brain. Rupture of an intracranial aneurysm leads to a subarachnoid hemorrhage, which is fatal in about 50% of the cases. Intracranial aneurysms can be repaired surgically or endovascularly, or by combining these two treatment modalities. They are relatively common with an estimated prevalence of unruptured aneurysms of 2%-6% in the adult population, and are considered a complex disease with both genetic and environmental risk factors. Known risk factors include smoking, hypertension, increasing age, and positive family history for intracranial aneurysms. Identifying the molecular mechanisms underlying the pathogenesis of intracranial aneurysms is complex. Genome-wide approaches such as DNA linkage and genetic association studies, as well as microarray-based mRNA expression studies, provide unbiased approaches to identify genetic risk factors and dissecting the molecular pathobiology of intracranial aneurysms. The ultimate goal of these studies is to use the information in clinical practice to predict an individual's risk for developing an aneurysm or monitor its growth or rupture risk. Another important goal is to design new therapies based on the information on mechanisms of disease processes to prevent the development or halt the progression of intracranial aneurysms.

Aneurysmal subarachnoid haemorrhage from a neuroimaging perspective

Neuroimaging is a key element in the management of patients suffering from subarachnoid haemorrhage (SAH). In this article, we review the current literature to provide a summary of the existing neuroimaging methods available in clinical practice. Noncontrast computed tomography is highly sensitive in detecting subarachnoid blood, especially within 6 hours of haemorrhage. However, lumbar puncture should follow a negative noncontrast computed tomography scan in patients with symptoms suspicious of SAH. Computed tomography angiography is slowly replacing digital subtraction angiography as the first-line technique for the diagnosis and treatment planning of cerebral aneurysms, but digital subtraction angiography is still required in patients with diffuse SAH and negative initial computed tomography angiography. Delayed cerebral ischaemia is a common and serious complication after SAH. The modern concept of delayed cerebral ischaemia monitoring is shifting from modalities that measure vessel diameter to techniques focusing on brain perfusion. Lastly, evolving modalities applied to assess cerebral physiological, functional and cognitive sequelae after SAH, such as functional magnetic resonance imaging or positron emission tomography, are discussed. These new techniques may have the advantage over structural modalities due to their ability to assess brain physiology and function in real time. However, their use remains mainly experimental and the literature supporting their practice is still scarce.

Endovascular treatment of ruptured intracranial aneurysms in patients 70 years of age and older

Background:

An increasing number of elderly patients present with intracranial aneurysms. In addition to female gender, an older age is associated with a higher risk of developing a subarachnoid hemorrhage (SAH), and these patients often fare poorly in terms of long-term outcome. It is often thought that elderly patients would especially benefit from endovascular aneurysm treatment. We assessed the clinical outcomes in elderly patients with ruptured intracranial aneurysms (RIAs) who were treated by endovascular procedures.

Methods:

We performed a retrospective review of a prospective database of elderly patients treated with coil embolization for RIAs. The clinical outcomes were assessed using the modified Glasgow Outcome Scale. The rates of procedural complications and adverse events were also recorded.

Results:

During a period of 5 years, 162 patients with 183 intracranial aneurysms were treated in our hospital by means of an endovascular approach. Among them, 51 patients (31.5%) with a ruptured aneurysm were aged 70 years or older. These patients aged 70-91 years (mean age, 74 years) were treated by coil embolization for RIAs. Among them, seven had a Hunt and Hess (HH) grade of I or II, 42 had an HH grade of III or IV, and 2 had an HH grade of V. Endovascular treatment resulted in 32 complete occlusions (62.7%), 15 neck remnants (22%), and 4 body fillings (7.9%). Procedural complications occurred in five patients (9.8%). The outcomes were good or excellent in 17 patients (33.3%). Three patients (5.8%) who died had an HH grade of IV or V. Rebleeding occurred during follow-up in one patient (1.9%).

Conclusions:

Coil embolization of intracranial aneurysms is safe and effective in the elderly. However, the morbidity and mortality rates are higher in patients with high HH grades. This finding suggests that the timing of treatment should be based on the patient's initial clinical status.

Variability in Outcome After Elective Cerebral Aneurysm Repair in High-Volume Academic Medical Centers

Background and Purpose—

Unruptured intracranial aneurysm repair is the most commonly performed procedure for the prevention of hemorrhagic stroke. Despite efforts to regionalize care in high-volume centers, overall results have improved little. This study aims to determine the effectiveness in improving outcomes of previous efforts to regionalize unruptured intracranial aneurysm repair to high-volume centers and to recommend future steps toward that goal.

Methods—

Using data obtained via the New York Statewide Planning and Research Cooperative System, this study included all patients admitted to any of the 10 highest volume centers in New York state between 2005 and 2010 with a principal diagnosis of unruptured intracranial aneurysm who were treated either by microsurgical or endovascular repair. Mixed-effects logistic regression was used to determine the degree to which hospital-level and patient-level variables contributed to observed variation in good outcome, defined as discharge to home, between hospitals.

Results—

Of 3499 patients treated during the study period, 2692 (76.9%) were treated at the 10 highest volume centers, with 2198 (81.6%) experiencing a good outcome. Good outcomes varied widely between centers, with 44.6% to 91.1% of clipped patients and 75.4% to 92.1% of coiled patients discharged home. Mixed-effects logistic regression revealed that procedural volume accounts for 85.8% of the between-hospital variation in outcome.

Conclusions—

There is notable interhospital heterogeneity in outcomes among even the largest volume unruptured intracranial aneurysm referral centers. Although further regionalization may be needed, mandatory participation in prospective, adjudicated registries will be necessary to reliably identify factors associated with superior outcomes.

Generalized versus patient-specific inflow boundary conditions in computational fluid dynamics simulations of cerebral aneurysmal hemodynamics

BACKGROUND AND PURPOSE

Attempts have been made to associate intracranial aneurysmal hemodynamics with aneurysm growth and rupture status. Hemodynamics in aneurysms is traditionally determined with computational fluid dynamics by using generalized inflow boundary conditions in a parent artery. Recently, patient-specific inflow boundary conditions are being implemented more frequently. Our purpose was to compare intracranial aneurysm hemodynamics based on generalized versus patient-specific inflow boundary conditions.

MATERIALS AND METHODS

For 36 patients, geometric models of aneurysms were determined by using 3D rotational angiography. 2D phase-contrast MR imaging velocity measurements of the parent artery were performed. Computational fluid dynamics simulations were performed twice: once by using patient-specific phase-contrast MR imaging velocity profiles and once by using generalized Womersley profiles as inflow boundary conditions. Resulting mean and maximum wall shear stress and oscillatory shear index values were analyzed, and hemodynamic characteristics were qualitatively compared.

RESULTS

Quantitative analysis showed statistically significant differences for mean and maximum wall shear stress values between both inflow boundary conditions (P < .001). Qualitative assessment of hemodynamic characteristics showed differences in 21 cases: high wall shear stress location (n = 8), deflection location (n = 3), lobulation wall shear stress (n = 12), and/or vortex and inflow jet stability (n = 9). The latter showed more instability for the generalized inflow boundary conditions in 7 of 9 patients.

CONCLUSIONS

Using generalized and patient-specific inflow boundary conditions for computational fluid dynamics results in different wall shear stress magnitudes and hemodynamic characteristics. Generalized inflow boundary conditions result in more vortices and inflow jet instabilities. This study emphasizes the necessity of patient-specific inflow boundary conditions for calculation of hemodynamics in cerebral aneurysms by using computational fluid dynamics techniques.

A safety, length of stay, and cost analysis of minimally invasive microsurgery for anterior circulation aneurysms

OBJECTIVES

The aim of our study was to evaluate minimally invasive techniques for the treatment of anterior circulation aneurysms versus standard surgery, and to calculate the impact of these techniques on health resources, length of stay, and treatment costs.

METHODS

A consecutive series of 24 patients with ruptured and 30 with unruptured anterior circulation aneurysms treated with minimally invasive microsurgery (MIM) by the same surgeon was compared with a matched series of standard microsurgeries (SM) conducted for 23 ruptured and 22 unruptured aneurysms. Complication rates, aneurysm obliteration, modified Rankin Scale (mRS) outcomes, length of stay, and treatment costs were assessed.

RESULTS

Surgical complications, aneurysm obliteration rates and mRS outcomes were comparable between MIM and SM groups in ruptured and unruptured aneurysm cohorts. MIM resulted in shorter operative times both in unruptured (102.7 ± 4.35 vs 194.7 ± 10.26 min, p < 0.0001) and ruptured aneurysms (124.3 ± 827 vs 209 ± 13.84 min, p < 0.0001). Length of stay was reduced in patients with MIM for unruptured aneurysms (1.55 ± 24 vs 4.28 ± 0.71 days, p < 0.000,1) but not in those with ruptured aneurysms. MIM reduced treatment costs of unruptured aneurysm patients, mainly through reduced utilization of inpatient resources (non-acute bed costs in CAD: 371.2 ± 80.99 vs 1440 ± 224.1, p < 0.0001), whereas costs were comparable in patients with ruptured aneurysms.

CONCLUSION

Minimally invasive surgery is a safe and effective approach for the treatment of ruptured and unruptured aneurysms of the anterior circulation. In patients with unruptured aneurysms, reduced invasiveness and shorter operative times decreased length of stay, which reflects improved patient postoperative recovery. Overall, this translated into bed resource economy and cost reduction.

Recurrent and incompletely treated aneurysms

Endovascular treatment of intracranial aneurysms has become an established technique that can provide stable permanent occlusion in over 85 % of the cases. Even those aneurysms considered untreatable by endovascular means can now often be managed by the use of adjunctive measures, e.g., balloon protection devices, intracranial stents, and semipermeable stents, i.e., "flow diverters." In those cases, in which relevant aneurysm recurrences are documented upon angiographic follow-up, both endovascular and surgical techniques can be employed. In rare cases, combined treatment strategies including parent artery occlusion under bypass protection can be performed. At our center, the majority of relevant aneurysm recurrences after initial coil embolization are managed by a second endovascular procedure. In some cases, e.g., aneurysm recurrences not feasible for endovascular re-treatment, documented aneurysmal growth, bleeding from a previously embolized aneurysm, and acute hemorrhagic or ischemic complications during endovascular procedures, surgical management may be necessary. This report briefly outlines the most frequent treatment scenarios.

How we do it: acute management of subarachnoid hemorrhage

OBJECTIVES

Acute subarachnoid hemorrhage (SAH) is a neurological emergency with significant potential for long-term morbidity and mortality. We review our management of acute SAH and some of the evidence base supporting our practices.

METHODS

We reviewed our standardized and multi-disciplinary approach to the management of SAH.

RESULTS

Management of SAH treatment can be divided into acute, aneurysmal, waiting, and post-waiting phases. Acute issues upon presentation include hemodynamic and respiratory stability, prevention of rebleeding, and treatment of hydrocephalus. The aneurysm must then be secured through endovascular or microsurgical methods. Observation for signs and symptoms of vasospasm must be closely undertaken. Prevention of subsequent medical complications must also be undertaken. Weaning from cerebrospinal fluid diversion and possible shunting is the final step.

DISCUSSION

Standardized multi-modality management of rebleeding, hydrocephalus, aneurysmal obliteration, vasospasm, cerebral salt wasting, and other medical complications during these phases, is critical.

Current management of middle cerebral artery aneurysms: surgical results with a "clip first" policy

BACKGROUND

One response to randomized trials like the International Subarachnoid Aneurysm Trial has been to adopt a "coil first" policy, whereby all aneurysms be considered for coiling, reserving surgery for unfavorable aneurysms or failed attempts. Surgical results with middle cerebral artery (MCA) aneurysms have been excellent, raising debate about the respective roles of surgical and endovascular therapy.

OBJECTIVE

To review our experience with MCA aneurysms managed with microsurgery as the treatment of first choice.

METHODS

Five hundred forty-three patients with 631 MCA aneurysms were managed with a "clip first" policy, with 115 patients (21.2%) referred from the Neurointerventional Radiology service and none referred from the Neurosurgical service for endovascular management.

RESULTS

Two hundred eighty-two patients (51.9%) had ruptured aneurysms and 261 (48.1%) had unruptured aneurysms. MCA aneurysms were treated with clipping (88.6%), thrombectomy/clip reconstruction (6.2%), and bypass/aneurysm occlusion (3.3%). Complete aneurysm obliteration was achieved with 620 MCA aneurysms (98.3%); 89.7% of patients were improved or unchanged after therapy, with a mortality rate of 5.3% and a permanent morbidity rate of 4.6%. Good outcomes were observed in 92.0% of patients with unruptured and 70.2% with ruptured aneurysms. Worse outcomes were associated with rupture (P = .04), poor grade (P = .001), giant size (P = .03), and hemicraniectomy (P < .001).

CONCLUSION

At present, surgery should remain the treatment of choice for MCA aneurysms. Surgical morbidity was low, and poor outcomes were due to an inclusive policy that aggressively managed poor-grade patients and complex aneurysms. This experience sets a benchmark that endovascular results should match before considering endovascular therapy an alternative for MCA aneurysms.

Understanding the role of hemodynamics in the initiation, progression, rupture, and treatment outcome of cerebral aneurysm from medical image-based computational studies

About a decade ago, the first image-based computational hemodynamic studies of cerebral aneurysms were presented. Their potential for clinical applications was the result of a right combination of medical image processing, vascular reconstruction, and grid generation techniques used to reconstruct personalized domains for computational fluid and solid dynamics solvers and data analysis and visualization techniques. A considerable number of studies have captivated the attention of clinicians, neurosurgeons, and neuroradiologists, who realized the ability of those tools to help in understanding the role played by hemodynamics in the natural history and management of intracranial aneurysms. This paper intends to summarize the most relevant results in the field reported during the last years.

International Subarachnoid Aneurysm Trial - ISAT part II: study protocol for a randomized controlled trial

BACKGROUND

The International Subarachnoid Aneurysm Trial (ISAT) demonstrated improved one-year clinical outcomes for patients with ruptured intracranial aneurysms treated with endovascular coiling compared to surgical clipping. Patients included in ISAT were mostly good grade subarachnoid hemorrhage (SAH) patients with small anterior circulation aneurysms. The purported superiority of coiling is commonly extrapolated to patients not studied in the original trial or to those treated using new devices not available at the time. Conversely, many patients are treated by clipping despite ISAT, because they are thought either to be better candidates for surgery, or to offer more durable protection from aneurysm recurrences. These practices have never been formally validated. Thus, for many ruptured aneurysm patients the question of which treatment modality leads to a superior clinical outcome remains unclear. METHODS/TRIAL DESIGN: ISAT II is a pragmatic, multicenter, randomized trial comparing clinical outcomes for non-ISAT patients with subarachnoid hemorrhage allocated to coiling or clipping. Inclusion criteria are broad. The primary end-point is the incidence of poor clinical outcome (defined as mRS >2) at one year, just as in ISAT. Secondary end-points include measures of treatment safety for a number of pre-specified subgroups, with efficacy end-points including the presence of a major recurrence at one year; 1,896 patients (862 each arm plus 10% losses) are required to demonstrate a significant difference between coiling and clipping, hypothesizing 23% and 30% poor clinical outcome rates, for coiling and clipping, respectively. The trial should involve at least 50 international centers, and will take approximately 12 years to complete. Analysis will be by intention-to-treat.

The Barrow Ruptured Aneurysm Trial: 3-year results

OBJECT

The authors report the 3-year results of the Barrow Ruptured Aneurysm Trial (BRAT). The objective of this ongoing randomized trial is to compare the safety and efficacy of microsurgical clip occlusion and endovascular coil embolization for the treatment of acutely ruptured cerebral aneurysms and to compare functional outcomes based on clinical and angiographic data. The 1-year results have been previously reported.

METHODS

Two-hundred thirty-eight patients were assigned to clip occlusion and 233 to coil embolization. There were no anatomical exclusions. Crossovers were allowed based on the treating physician's determination, but primary outcome analysis was based on the initial assignment to treatment modality. Patient outcomes were assessed independently using the modified Rankin Scale (mRS). A poor outcome was defined as an mRS score>2. At 3 years' follow-up 349 patients who had actually undergone treatment were available for evaluation. Of the 170 patients who had been originally assigned to coiling, 64 (38%) crossed over to clipping, whereas 4 (2%) of 179 patients assigned to surgery crossed over to clipping.

RESULTS

The risk of a poor outcome in patients assigned to clipping compared with those assigned to coiling (35.8% vs 30%) had decreased from that observed at 1 year and was no longer significant (OR 1.30, 95% CI 0.83-2.04, p=0.25). In addition, the degree of aneurysm obliteration (p=0.0001), rate of aneurysm recurrence (p=0.01), and rate of retreatment (p=0.01) were significantly better in the group treated with clipping compared with the group treated with coiling. When outcomes were analyzed based on aneurysm location (anterior circulation, n=339; posterior circulation, n=69), there was no significant difference in the outcomes of anterior circulation aneurysms between the 2 assigned groups across time points (at discharge, 6 months, 1 year, or 3 years after treatment). The outcomes of posterior circulation aneurysms were significantly better in the coil group than in the clip group after the 1st year of follow-up, and this difference persisted after 3 years of follow-up. However, while aneurysms in the anterior circulation were well matched in their anatomical location between the 2 treatment arms, this was not the case in the posterior circulation where, for example, 18 of 21 posterior inferior cerebellar artery aneurysms were in the clip group.

CONCLUSIONS

Based on mRS scores at 3 years, the outcomes of all patients assigned to coil embolization showed a favorable 5.8% absolute difference compared with outcomes of those assigned to clip occlusion, although this difference did not reach statistical significance (p=0.25). Patients in the clip group had a significantly higher degree of aneurysm obliteration and a significantly lower rate of recurrence and retreatment. In post hoc analysis examining only anterior circulation aneurysms, no outcome difference between the 2 treatment cohorts was observed at any recorded time point. CLINICAL TRIAL REGISTRATION NO.: NCT01593267 ( ClinicalTrials.gov ).

Coil embolization versus clipping for ruptured intracranial aneurysms: a meta-analysis of prospective controlled published studies

BACKGROUND AND PURPOSE

Coil embolization is an alternative to clipping for intracranial aneurysms. However, controversy exists regarding the best therapeutic strategy in patients with ruptured aneurysms, and there is great center- and country-related variability in the rates of clipping versus coiling. We performed a meta-analysis of prospective controlled trials of clipping versus coil embolization for ruptured aneurysms.

MATERIALS AND METHODS

We performed a search of the English literature for published prospective controlled trials comparing surgical clipping with endovascular coil embolization for ruptured intracranial aneurysms. Data were abstracted from the identified references. Outcomes of interest were the proportion of patients with a poor outcome at 1 year and episodes of rebleeding from the index treated aneurysm after the allocated treatment.

RESULTS

There were 3 prospective controlled trials eligible for inclusion. These studies enrolled 2723 patients. Meta-analysis of these studies showed that the rate of poor outcome at 1 year was significantly lower in patients allocated to coil embolization (risk ratio, 0.75; 95% confidence interval, 0.65-0.87). This relative effect is consistent with an absolute risk reduction of 7.8% and a number needed to treat of 13. The effect on mortality was not statistically different across the 2 treatments. Rebleeding rates within the first month were higher in patients allocated to endovascular coil embolization.

CONCLUSIONS

On the basis of the analysis of the 3 high-quality prospective controlled trials available, there is strong evidence to indicate that endovascular coil embolization is associated with better outcomes compared with surgical clipping in patients amenable to either therapeutic strategy.

Review of 2 decades of aneurysm-recurrence literature, part 2: Managing recurrence after endovascular coiling

Cerebral aneurysms are treated to prevent hemorrhage or rehemorrhage. Angiographic recurrences following endovascular therapy have been a problem since the advent of this treatment technique, even though posttreatment hemorrhage remains rare. Notwithstanding its unclear clinical significance, angiographic recurrence remains not only a prime focus in the literature but also frequently leads to potentially risky retreatments. The literature regarding aneurysm recurrence following endovascular therapy, spanning 2 decades, is immense and immensely confusing. We review the topic of recurrence following endovascular treatment of cerebral aneurysms in an effort to distill it down to fundamental material relevant to clinical practice.

European Stroke Organization guidelines for the management of intracranial aneurysms and subarachnoid haemorrhage

BACKGROUND

Intracranial aneurysm with and without subarachnoid haemorrhage (SAH) is a relevant health problem: The overall incidence is about 9 per 100,000 with a wide range, in some countries up to 20 per 100,000. Mortality rate with conservative treatment within the first months is 50-60%. About one third of patients left with an untreated aneurysm will die from recurrent bleeding within 6 months after recovering from the first bleeding. The prognosis is further influenced by vasospasm, hydrocephalus, delayed ischaemic deficit and other complications. The aim of these guidelines is to provide comprehensive recommendations on the management of SAH with and without aneurysm as well as on unruptured intracranial aneurysm.

METHODS

We performed an extensive literature search from 1960 to 2011 using Medline and Embase. Members of the writing group met in person and by teleconferences to discuss recommendations. Search results were graded according to the criteria of the European Federation of Neurological Societies. Members of the Guidelines Committee of the European Stroke Organization reviewed the guidelines.

RESULTS

These guidelines provide evidence-based information on epidemiology, risk factors and prognosis of SAH and recommendations on diagnostic and therapeutic methods of both ruptured and unruptured intracranial aneurysms. Several risk factors of aneurysm growth and rupture have been identified. We provide recommendations on diagnostic work up, monitoring and general management (blood pressure, blood glucose, temperature, thromboprophylaxis, antiepileptic treatment, use of steroids). Specific therapeutic interventions consider timing of procedures, clipping and coiling. Complications such as hydrocephalus, vasospasm and delayed ischaemic deficit were covered. We also thought to add recommendations on SAH without aneurysm and on unruptured aneurysms.

CONCLUSION

Ruptured intracranial aneurysm with a high rate of subsequent complications is a serious disease needing prompt treatment in centres having high quality of experience of treatment for these patients. These guidelines provide practical, evidence-based advice for the management of patients with intracranial aneurysm with or without rupture. Applying these measures can improve the prognosis of SAH.

Surgical treatment of unruptured intracranial middle cerebral artery aneurysms: angiographic and clinical outcomes in 143 aneurysms

Objective

The purpose of this study was to determine the outcomes of surgical clipping in patients with unruptured middle cerebral artery (MCA) aneurysms.

Methods

A retrospective single-center database of 125 consecutive patients with 143 small MCA aneurysms (< 10 mm) who underwent surgical clipping was reviewed from January 2007 to December 2010. Clinical outcomes were assessed based on surgery-related complications and follow-up (mean: 17 months) using the modified Rankin scale (mRS). Angiographic outcomes were evaluated by conventional angiography (N = 96) or computed tomography angiography (N = 29) at postoperative weeks 1 and 6.

Results

There were no cases of mortality. There were three surgery-related complications (intracranial hemorrhage, meningitis and wound infection, respectively). The hemorrhagic event caused transient neurological deficits. All patients showed good clinical outcomes during follow-up (mRS 0-1). There was angiographic evidence of complete occlusion in 137 aneurysms (95.8%), a small residual neck in three aneurysms (2.2%) and partial for three aneurysms. In the three cases with partial clipping, the decision was made preoperatively to leave the residual sac to maintain distal flow, and muscular wrapping was performed.

Conclusion

Our study demonstrates that surgical clipping of unruptured small MCA aneurysms yields favorable clinical and angiographic outcomes. Aneurysmal clipping can be safely recommended for patients with small unruptured MCA aneurysms.