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Fotakopoulos G, Lempesis IG, Georgakopoulou VE, Trakas N, Sklapani P, Faropoulos K, Fountas KN. Surgical outcomes of patients with unruptured anterior vs. inferior circulation aneurysms: A meta‑analysis. MEDICINE INTERNATIONAL 2024; 4:5. [PMID: 38283132 PMCID: PMC10811444 DOI: 10.3892/mi.2023.129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 12/15/2023] [Indexed: 01/30/2024]
Abstract
The treatment option for unruptured intracranial aneurysms (UIAs) depends on their natural history-related risk of rupture vs. the risk of surgical management. The present meta-analysis sought to assess the association between the surgical outcomes of anterior and posterior circulation UIAs. The present study investigated the comparative articles involving the surgical treatment of anterior vs. posterior circulation UIAs through electronic databases, including the Cochrane Library, PubMed (1980 to March, 2023), Medline (1980 to March, 2023) and EMBASE (1980 to March, 2023). Quoting all exclusion and inclusion criteria, nine articles finally remained for statistical analysis. The entire number of patients included in these nine articles was 3,253 (2,662 in the anterior and 591 in the posterior circulation UIAs group). The present meta-analysis proposes that the surgical treatment of anterior circulation UIAs is associated with better outcomes compared with the surgical management of posterior circulation UIAs.
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Affiliation(s)
- George Fotakopoulos
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
| | - Ioannis G. Lempesis
- Department of Pathophysiology, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | | | - Nikolaos Trakas
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Pagona Sklapani
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | | | - Kostas N. Fountas
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
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Toma A, De La Garza Ramos R, Altschul DJ. Risk Factors for Headache Disorder in Patients With Unruptured Intracranial Aneurysms. Cureus 2023; 15:e38385. [PMID: 37265887 PMCID: PMC10231404 DOI: 10.7759/cureus.38385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2023] [Indexed: 06/03/2023] Open
Abstract
OBJECTIVE Headache disorders are a prevalent yet frequently underestimated issue in patients with unruptured intracranial aneurysms (UIAs). The primary aim of this study is to systematically examine the incidence, specific characteristics, and associated risk factors of headache disorders in the context of individuals diagnosed with UIAs. Through this investigation, we hope to contribute valuable insights to the current understanding of this complex relationship and potentially inform future diagnostic and treatment approaches. METHODS Data from 146 consecutive patients harboring UIAs were evaluated. The location and morphological characteristics of the aneurysm were analyzed. Factors associated with headache incidence and methods of treatment were investigated. The headache pattern in 48 patients was assessed using self-reported questionnaires. RESULTS A total of 146 patients were identified. Out of 146 patients, 95 (65%) were in the Headache Group (HG) and 51 (35%) were asymptomatic and in the No Headache Group (NHG). Factors associated with a higher likelihood of headache were past or current tobacco, alcohol, and illicit drug use (p=0.029). On average, patients had 1.49 (SD=1) aneurysms in the HG and 1.43 (SD=.92) in the NHG group, respectively. In our series, the size of aneurysms, the status of the aneurysm (treated vs untreated), and the method of treatment did not significantly differ between the groups. There was a high incidence of headaches in patients with aneurysms of the ophthalmic segment (C6) of the internal carotid artery (ICA) and sphenoidal segment (M1) of the middle cerebral artery (MCA). Of 48 patients that completed headache questionnaires, 25 had headaches on more than 15 days a month. The majority of participants (85.4%) reported the severity of their pain as being greater than 5 on a scale of 10, while one-third (33.3%) experienced the maximum pain level of 10 out of 10. CONCLUSION Headache more often occurs in patients with aneurysms of the ophthalmic segment (C6) of the ICA and sphenoidal segment (M1) of the MCA. Its distinctive features are deep pain for more than 15 days a month. Although the treatment of aneurysms reduces the risk of aneurysmal rupture, its efficacy in relieving the headache is still uncertain.
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Affiliation(s)
- Aureliana Toma
- Neurological Surgery, Albert Einstein College of Medicine, Bronx, USA
| | | | - David J Altschul
- Neurological Surgery, Albert Einstein College of Medicine, Bronx, USA
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Tsuboki S, Todaka T, Hasegawa S, Kaku Y, Ohmori Y, Mukasa A. Olfactory hallucinations caused by an unruptured posterior communicating artery aneurysm improved by clipping: A case report with literature review. Surg Neurol Int 2023; 14:152. [PMID: 37151441 PMCID: PMC10159313 DOI: 10.25259/sni_173_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/12/2023] [Indexed: 05/09/2023] Open
Abstract
Background Unruptured cerebral aneurysms that lead to epilepsy are rare and olfactory hallucinations caused by such an aneurysm are extremely rare. Various treatments have been proposed, including wrapping, clipping with or without cortical resection, and coil embolization, but there is no consensus on the best approach. Case Description We present a case of a 69-year-old female who experienced olfactory hallucinations caused by a posterior communicating artery aneurysm and was treated with clipping without cortical resection, with a positive outcome. Conclusion According to our knowledge, there has been only one report of a posterior communicating artery aneurysm presenting with olfactory hallucinations has been reported, where clipping and cortical resection were performed. This is the first report of a posterior communicating artery aneurysm with olfactory hallucinations that was effectively treated with clipping alone. There have been a few similar reports of large middle cerebral artery aneurysms, most of which are believed to be caused by entorhinal cortex compression. Although a definitive treatment protocol for this condition remains elusive, we suggest that elimination of the pulsatile compressive stress exerted on the cerebral cortex through surgical clipping or coil embolization is crucial for achieving efficacious seizure management.
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Affiliation(s)
- Shimpei Tsuboki
- Department of Neurosurgery, Japanese Red Cross Kumamoto Hospital, Kumamoto City, Japan
| | - Tatemi Todaka
- Department of Neurosurgery, Japanese Red Cross Kumamoto Hospital, Kumamoto City, Japan
| | - Shu Hasegawa
- Department of Neurosurgery, Japanese Red Cross Kumamoto Hospital, Kumamoto City, Japan
| | - Yasuyuki Kaku
- Department of Neurosurgery, Kumamoto University Hospital, Kumamoto City, Japan
| | - Yuki Ohmori
- Department of Neurosurgery, Kumamoto University Hospital, Kumamoto City, Japan
| | - Akitake Mukasa
- Department of Neurosurgery, Kumamoto University Hospital, Kumamoto City, Japan
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Sirakova K, Penkov M, Matanov S, Minkin K, Ninov K, Hadzhiyanev A, Karakostov V, Ivanova I, Sirakov S. Progressive volume reduction and long-term aneurysmal collapse following flow diversion treatment of giant and symptomatic cerebral aneurysms. Front Neurol 2022; 13:972599. [PMID: 36034286 PMCID: PMC9403733 DOI: 10.3389/fneur.2022.972599] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 07/18/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe primary goal of conventional endovascular and microvascular approaches is the clinical and radiological resolution of the symptomatic aneurysm-induced mass effect. This study assessed the volume changes and mass effect reduction due to sac shrinkage after treatment with flow diverter stents (FD) for unruptured cerebral aneurysms.MethodsWe analyzed retrospectively 36 symptomatic aneurysms that were larger or equal to 25 mm in diameter in patients treated at our center from January 2016 to April 2022. Radiological and clinical outcomes were analyzed, including aneurysmal volume changes and resolution of aneurysm-related symptoms.ResultsAt 6 months, 25 aneurysms decreased in size, 2 remained unchanged, and 9 aneurysms demonstrated a post-treatment dimensional increase. At 12 months, 30 aneurysms showed a progressive radiological volume reduction. Either no change or negligible shrinkage was observed in the remaining six aneurysms. At 24 months, 32 aneurysms showed aneurysmal shrinkage by a mean 47% volume loss with respect to baseline. At the last follow-up, all 13 patients who had presented with third cranial nerve palsy showed improvements. Complete reversal of the pretreatment edematous changes was confirmed in all cases. The overall post-treatment complication rate was 8.3%, as 3 patients experienced non-fatal delayed rupture of their aneurysm. There was no mortality in this study.ConclusionFlow diversion could effectively induce progressive aneurysmal shrinkage and resolution of the mass effect associated with giant symptomatic cerebral aneurysms.
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Affiliation(s)
| | - Marin Penkov
- Radiology Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Svetozar Matanov
- Radiology Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Krasimir Minkin
- Neurosurgery Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Kristian Ninov
- Neurosurgery Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Asen Hadzhiyanev
- Neurosurgery Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Vasil Karakostov
- Neurosurgery Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Irena Ivanova
- Clinical Laboratory Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Stanimir Sirakov
- Radiology Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
- *Correspondence: Stanimir Sirakov
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Misra BK, Warade AG, Rohan R, Sarit S. Microsurgery of Giant Intracranial Aneurysm: A Single Institution Outcome Study. Neurol India 2021; 69:984-990. [PMID: 34507426 DOI: 10.4103/0028-3886.325355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Giant intracranial aneurysms (GIAs) are treacherous lesions and in spite of the many advances, endovascular therapy (EVT) of GIAs is challenging. Objective A retrospective analysis of our results with microsurgery of GIAs is presented to examine the role of microsurgery in the current trend of EVT. Materials and Methods Between 1996 and 2019, 134 patients with 147 GIAs had microsurgery by the senior author in a single institute. The medical and imaging records for all the patients were reviewed. The patient outcome was determined by modified Rankin scale (mRS); ≤3 was considered as a good outcome. Statistical analysis was done using the SPSS program and odds ratios and their 95% confidence intervals were computed; a probability value of < 0.05 was considered significant. Results There were 123 aneurysms (83.7%) in the anterior circulation and 24 aneurysms (16.3%) in the posterior circulation. Overall 103 out of 134 (76.8%) patients had a good outcome postoperatively. Good preoperative mRS score (≤3) had an overall good prognosis in the postoperative period and was statistically significant (P = 0.000, odds ratio: 0.036, 95% CI: 0.008-0.171). Presence of subarachnoid hemorrhage (SAH) was also statistically significant for good outcome (P = 0.04, odds ratio: 2.898, 95% CI: 1.051-7.991), but age was not a significant prognostic factor. Mortality within 30 days of treatment was 4.47%. Conclusion GIAs need treatment because of their dismal natural history. Results of microsurgical treatment by a single surgeon of the large current series compare well with the results of EVT and justifies pursuing microsurgery for GIAs.
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Affiliation(s)
- Basant K Misra
- Department of Neurosurgery and Gamma Knife Surgery, P. D. Hinduja Hospital and MRC, Mumbai, Maharashtra, India
| | - Abhijit G Warade
- Department of Neurosurgery and Gamma Knife Surgery, P. D. Hinduja Hospital and MRC, Mumbai, Maharashtra, India
| | - Roy Rohan
- Department of Neurosurgery and Gamma Knife Surgery, P. D. Hinduja Hospital and MRC, Mumbai, Maharashtra, India
| | - Shah Sarit
- Department of Neurosurgery and Gamma Knife Surgery, P. D. Hinduja Hospital and MRC, Mumbai, Maharashtra, India
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Manzoor MU, AlRashed AA, Alghabban FA, Alqahtani SM, Alturki AY. Salvage flow diverter stent across the posterior communicating artery for persistent retrograde filling of a giant internal carotid artery aneurysm after parent vessel occlusion. J Cerebrovasc Endovasc Neurosurg 2021; 23:123-129. [PMID: 34038995 PMCID: PMC8256022 DOI: 10.7461/jcen.2021.e2020.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 12/01/2020] [Indexed: 11/23/2022] Open
Abstract
Giant internal carotid artery (ICA) aneurysms are complex vascular lesions which are difficult to treat with open as well as endovascular surgery. Parent vessel occlusion is a well-established treatment option for such aneurysms. However, there have been a few reported cases of ruptured aneurysms related to the persistent retrograde filling after parent vessel occlusion. We report a case which highlights the usage of the flow diverter stent as a potential treatment strategy for the management of retrograde filling of aneurysms. A 54-year-old female was found to have a giant left ICA aneurysm on a brain magnetic resonance imaging during workup for headaches. She underwent occlusion of the left ICA proximal to the aneurysm using multiple coils. However, follow up angiograms after 6 months and 2 years demonstrated persistent retrograde filling of the left ICA aneurysm through the posterior communicating (PCOM) artery. Eventually, she was successfully treated with a flow diverter stent across the PCOM artery into the distal ICA. Follow up angiogram after 6 months showed patent flow in the PCOM artery and the distal ICA. with complete occlusion of the aneurysm. Using a flow diverter stent after insufficient parent vessel occlusion for giant intracranial aneurysms may be a feasible treatment option and an addition to the neurovascular treatment armamentarium.
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Affiliation(s)
| | | | - Fatimah A Alghabban
- Department of Neurosurgery, King Abdulaziz Speciality Hospital, Taif, Saudi Arabia
| | | | - Abdulrahman Y Alturki
- Department of Adult Neurosurgery, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
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Dellaretti M, do Nascimento LM, de Oliveira Lima AD, de Almeida JC, Quadros RS. Efficacy and safety of surgical treatment for middle cerebral artery aneurysms: A retrospective case series. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.101018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Jang LK, Alvarado JA, Pepona M, Wasson EM, Nash LD, Ortega JM, Randles A, Maitland DJ, Moya ML, Hynes WF. Three-dimensional bioprinting of aneurysm-bearing tissue structure for endovascular deployment of embolization coils. Biofabrication 2020; 13. [DOI: 10.1088/1758-5090/abbb9b] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 09/25/2020] [Indexed: 01/30/2023]
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Dasenbrock HH, Rudy RF, Smith TR, Gormley WB, Patel NJ, Frerichs KU, Aziz-Sultan MA, Du R. Adverse events after clipping of unruptured intracranial aneurysms: the NSQIP unruptured aneurysm scale. J Neurosurg 2020; 132:1123-1132. [PMID: 30875693 DOI: 10.3171/2018.12.jns182873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 12/10/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The complex decision analysis of unruptured intracranial aneurysms entails weighing the benefits of aneurysm repair against operative risk. The goal of the present analysis was to build and validate a predictive scale that identifies patients with the greatest odds of a postsurgical adverse event. METHODS Data on patients who underwent surgical clipping of an unruptured aneurysm were extracted from the prospective National Surgical Quality Improvement Program registry (NSQIP; 2007-2014); NSQIP does not systematically collect data on patients undergoing intracranial endovascular intervention. Multivariable logistic regression evaluated predictors of any 30-day adverse event; variables screened included patient demographics, comorbidities, functional status, preoperative laboratory values, aneurysm location/complexity, and operative time. A predictive scale was constructed based on statistically significant independent predictors, which was validated using both NSQIP (2015-2016) and the Nationwide Inpatient Sample (NIS; 2002-2011). RESULTS The NSQIP unruptured aneurysm scale was proposed: 1 point was assigned for a bleeding disorder; 2 points for age 51-60 years, cardiac disease, diabetes mellitus, morbid obesity, anemia (hematocrit < 36%), operative time 240-330 minutes; 3 points for leukocytosis (white blood cell count > 12,000/μL) and operative time > 330 minutes; and 4 points for age > 60 years. An increased score was predictive of postoperative stroke or coma (NSQIP: p = 0.002, C-statistic = 0.70; NIS: p < 0.001, C-statistic = 0.61), a medical complication (NSQIP: p = 0.01, C-statistic = 0.71; NIS: p < 0.001, C-statistic = 0.64), and a nonroutine discharge (NSQIP: p < 0.001, C-statistic = 0.75; NIS: p < 0.001, C-statistic = 0.66) in both validation populations. Greater score was also predictive of increased odds of any adverse event, a major complication, and an extended hospitalization in both validation populations (p ≤ 0.03). CONCLUSIONS The NSQIP unruptured aneurysm scale may augment the risk stratification of patients undergoing microsurgical clipping of unruptured cerebral aneurysms.
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Three-dimensional visualization of aneurysm wall calcification by cerebral angiography: Technical case report. J Clin Neurosci 2020; 73:290-293. [PMID: 32067827 DOI: 10.1016/j.jocn.2020.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 02/09/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND We describe on a 57-year-old man with an incidental middle cerebral artery (MCA) aneurysm in whom a preoperative standard three-dimensional rotational angiogram (3D-RA) was used to depict luminal morphology along with 3D density rendering to precisely locate aneurysm wall calcification. METHODS To detect aneurysm calcification, a native 3D rotational angiogram was acquired for calcium density visualization, followed by an intraarterial contrast-enhanced 3D rotational angiogram in the same location. Both data sets were postprocessed obtaining a 3D calcium volume rendering on a 3D-RA. RESULTS Depiction of both the MCA luminal aneurysm morphology as well as calcium-rich components in the aneurysm wall was valuable to determine treatment strategy towards surgery. CONCLUSION Imaging of luminal morphology and calcification within the same angiographic procedure allows for a plain and simple estimation of the degree and distribution of brain aneurysm wall calcification with limited amount of additional radiation dosage.
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Matsukawa H, Kamiyama H, Kinoshita Y, Saito N, Hatano Y, Miyazaki T, Ota N, Noda K, Shonai T, Takahashi O, Tokuda S, Tanikawa R. Morphological parameters as factors of 12-month neurological worsening in surgical treatment of patients with unruptured saccular intracranial aneurysms: importance of size ratio. J Neurosurg 2019; 131:852-858. [PMID: 30239320 DOI: 10.3171/2018.4.jns173221] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 04/05/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE It is well known that larger aneurysm size is a risk factor for poor outcome after surgical treatment of unruptured saccular intracranial aneurysms (USIAs). However, the authors have occasionally observed poor outcome in the surgical treatment of small USIAs and hypothesized that size ratio has a negative impact on outcome. The aim of this paper was to investigate the influence of size ratio on outcome in the surgical treatment of USIAs. METHODS Prospectively collected clinical and radiological data of 683 consecutive patients harboring 683 surgically treated USIAs were evaluated. Dome-to-neck ratio was defined as the ratio of the maximum width of the aneurysm to the average neck diameter. The aspect ratio was defined as the ratio of the maximum perpendicular height of the aneurysm to the average neck diameter of the aneurysm. The size ratio was calculated by dividing the maximum aneurysm diameter (height or width, mm) by the average parent artery diameter (mm). Neurological worsening was defined as an increase in modified Rankin Scale score of 1 or more points at 12 months. Clinical and radiological variables were compared between patients with and without neurological worsening. RESULTS The median patient age was 64 years (IQR 56-71 years), and 528 (77%) patients were female. The median maximum size, dome-to-neck ratio, aspect ratio, and size ratio were 4.7 mm (IQR 3.6-6.7 mm), 1.2 (IQR 1.0-1.4), 1.0 (IQR 0.76-1.3), and 1.9 (IQR 1.4-2.8), respectively. The size ratio was significantly correlated with maximum size (r = 0.83, p < 0.0001), dome-to-neck ratio (r = 0.69, p < 0.0001), and aspect ratio (r = 0.74, p < 0.0001). Multivariate logistic regression analysis showed that the specific USIA location (paraclinoid segment of the internal carotid artery: OR 6.2, 95% CI 2.6-15, p < 0.0001; and basilar artery: OR 8.4, 95% CI 2.8-25, p < 0.0001), size ratio (OR 1.3, 95% CI 1.1-1.6, p = 0.021), and postoperative ischemic lesion (OR 9.4, 95% CI 4.4-19, p < 0.0001) were associated with neurological worsening (n = 52, 7.6%), and other characteristics showed no significant differences. CONCLUSIONS The present study showed that size ratio, and not other morphological parameters, was a risk factor for 12-month neurological worsening in surgically treated patients with USIAs. The size ratio should be further studied in a large, prospective observational cohort to predict neurological worsening in the surgical treatment of USIAs.
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Affiliation(s)
| | | | | | | | - Yuto Hatano
- 1Department of Neurosurgery, Stroke Center, and
| | | | - Nakao Ota
- 1Department of Neurosurgery, Stroke Center, and
| | - Kosumo Noda
- 1Department of Neurosurgery, Stroke Center, and
| | | | - Osamu Takahashi
- 3Center for Clinical Epidemiology, Internal Medicine, St. Luke's International Hospital, Tokyo, Japan
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AlMatter M, Bhogal P, Aguilar Pérez M, Hellstern V, Bäzner H, Ganslandt O, Henkes H. Evaluation of safety, efficacy and clinical outcome after endovascular treatment of aneurysmal subarachnoid hemorrhage in coil-first setting. A 10-year series from a single center. J Neuroradiol 2018; 45:349-356. [PMID: 29544998 DOI: 10.1016/j.neurad.2018.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 01/20/2018] [Accepted: 02/24/2018] [Indexed: 10/17/2022]
Abstract
INTRODUCTION The endovascular treatment (EVT) of ruptured cerebral aneurysms has been widely adopted after the publication of the International Subarachnoid Aneurysm Trial. In this study, we sought to evaluate the safety and efficacy of the EVT for ruptured aneurysms based on 10-year series from a single center with coil-first strategy. METHODS All patients with aneurysmal subarachnoid hemorrhage (aSAH) treated between 2007 and 2016 were retrospectively reviewed and divided according to initial treatment into an EVT and a microsurgical clipping (MSC) group. Clinical and radiological findings at presentation, treatment modalities and procedural complications were recorded. The angiographic and clinical outcome was compared between the two groups. RESULTS A total of 587 patients with aSAH were reviewed (452 EVT, 135 MSC). There were no significant differences in mean age or the Hunt and Hess grades. Parenchymal hemorrhage (PH) was more frequent in the MSC. Procedure related complications of the acute treatment were recorded in 5.5% and 32% in the EVT and MSC, respectively. The rate of retreatment was 21.9% in the EVT and 5.9% in the MSC. Late rehemorrhage was not observed in either group. There was no significant difference in the clinical outcome between the two treatment groups after adjustment for other prognostic factors. CONCLUSION The majority of ruptured intracranial aneurysms can be managed via an endovascular approach in the acute phase with excellent safety profile and good efficacy. Despite the high rate of reperfusion after primary endovascular approach, retreatment has a very low rate of complications and the rate of recurrent hemorrhage is very low.
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Affiliation(s)
| | | | | | | | | | | | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, Germany; Medizinische Fakultät, Universitätsklinikum Essen, Essen, Germany
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Akimoto J, Ichimasu N, Haraoka R, Fukami S, Kohno M. A case of unruptured aneurysm of the internal carotid artery presenting as olfactory hallucinations. Surg Neurol Int 2017; 8:197. [PMID: 28904824 PMCID: PMC5590341 DOI: 10.4103/sni.sni_134_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 06/17/2017] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Olfactory hallucination, a symptom of medial temporal lobe epilepsy, is rarely associated with unruptured intracranial aneurysms. CASE DESCRIPTION We encountered this situation in a 70-year-old woman with an unruptured aneurysm at the bifurcation of the internal carotid and posterior communicating artery. We were able to achieve epileptic control by craniotomy clipping and medial temporal lesionectomy. CONCLUSION According to our knowledge, previous reports are limited to cases of large middle cerebral artery aneurysms compressing the lateral orbitofrontal cortex, and this is apparently the first report of a case where olfactory hallucinations occurred from direct stimulation of the entorhinal cortex by an internal carotid and posterior communicating artery bifurcation aneurysm. We examined the pathophysiology underlying the development of olfactory hallucinations. We found craniotomy clipping and focal resection to be useful from the standpoint of seizure control. Whether seizure control can also be obtained with intracranial aneurysm coiling should be investigated in the future.
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Affiliation(s)
- Jiro Akimoto
- Department of Neurosurgery, Tokyo Medical University, Shinjukuku, Tokyo, Japan
| | - Norio Ichimasu
- Department of Neurosurgery, Tokyo Medical University, Shinjukuku, Tokyo, Japan
| | - Rei Haraoka
- Department of Neurosurgery, Tokyo Medical University, Shinjukuku, Tokyo, Japan
| | - Shinjiro Fukami
- Department of Neurosurgery, Tokyo Medical University, Shinjukuku, Tokyo, Japan
| | - Michihiro Kohno
- Department of Neurosurgery, Tokyo Medical University, Shinjukuku, Tokyo, Japan
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14
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Zhang L, Wang Y, Zhang Q, Ge W, Wu X, Di H, Wang J, Cao X, Li B, Liu R, Yu S. Headache improvement after intracranial endovascular procedures in Chinese patients with unruptured intracranial aneurysm: A prospective observational study. Medicine (Baltimore) 2017; 96:e6084. [PMID: 28178166 PMCID: PMC5313023 DOI: 10.1097/md.0000000000006084] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The aim of this study was to investigate whether there is a long-term improvement in headache of patients with unruptured intracranial aneurysms (UIAs) treated with intracranial endovascular procedures.Using a prospective design, consecutive patients with UIAs with neuroendovascular treatment from January 2014 to December 2014 were asked to participate. Headache outcomes were established before aneurysm treatment and for 6 months following treatment. Factors associated with different headache outcomes were investigated.Ultimately, 58 patients completed the 6-month follow-up. In total, 29 patients had preoperative headache. Six months after the intracranial endovascular procedure, 13 patients (44.8%) stated that their headaches were relieved after endovascular treatment; headache in 1 patient improved slightly, and 12 reported disappearance of headache and marked improvement. Overall, the mean headache scores of 29 patients improved on the self-reported Numeric Rating Scale (NRS) after endovascular treatment (6.00 vs. 2.30; P < 0.001). Patients with pretreatment tension-type headache, more severe headaches, stent-assisted coiling, and stent implantation of the aneurysm were the important disadvantage for patients in improvement of post-procedure headache.Treatment of UIAs resulted in relief of headaches in about half of patients who had headaches pre-operatively.
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Affiliation(s)
- Linjing Zhang
- Department of Neurology, Chinese PLA General Hospital, Beijing, PR China
| | - Yunxia Wang
- Department of Neurology, the First Hospital Affiliated to the Chinese PLA General Hospital, Beijing, PR China
| | - Qingkui Zhang
- Department of Neurology, Chinese PLA General Hospital, Beijing, PR China
| | - Wei Ge
- Department of Neurology, Chinese PLA General Hospital, Beijing, PR China
| | - Xiancong Wu
- Department of Neurology, Chinese PLA General Hospital, Beijing, PR China
| | - Hai Di
- Department of Neurology, Chinese PLA General Hospital, Beijing, PR China
| | - Jun Wang
- Department of Neurology, Chinese PLA General Hospital, Beijing, PR China
| | - Xiangyu Cao
- Department of Neurology, Chinese PLA General Hospital, Beijing, PR China
| | - Baomin Li
- Department of Neurology, Chinese PLA General Hospital, Beijing, PR China
| | - Ruozhuo Liu
- Department of Neurology, Chinese PLA General Hospital, Beijing, PR China
- Department of Neurology, Hainan Branch of Chinese PLA General Hospital, Sanya, PR China
| | - Shengyuan Yu
- Department of Neurology, Chinese PLA General Hospital, Beijing, PR China
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15
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Lin F, Wan H, Kang D, Lin Y. Small Unruptured Intracranial Aneurysm (≤5 mm) Associated with Epilepsy: Report of 2 Cases and Literature Review. World Neurosurg 2016; 98:878.e1-878.e6. [PMID: 27890748 DOI: 10.1016/j.wneu.2016.11.070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 11/13/2016] [Accepted: 11/15/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Owing to the continuing improvements in imaging technology, an increasing number of epileptogenic small (≤5 mm) unruptured intracranial aneurysms (sUIAs) are being diagnosed. However, these sUIAs have not been systematically described and reviewed until now. CASE DESCRIPTION AND LITERATURE REVIEW We report 2 patients with sUIAs who initially presented with complex partial seizures. Scalp electroencephalography identified the seizure activity as arising from the mesial temporal/frontal areas, but conventional magnetic resonance imaging (MRI) was normal in both patients. The diagnosis of sUIA was achieved by cerebral angiography. One of the patients had idiopathic seizures and sustained a subarachnoid hemorrhage before the final diagnosis of sUIA. Both of the patients were treated by surgical clipping without resection of the adjacent discolored brain tissue, and the seizures were controlled after surgery. Furthermore, we thoroughly reviewed the relevant literature. We analyzed a total of 5 documented cases, including out 2 cases, and described the clinical characteristics, diagnosis, underlying mechanism, treatment, and prognosis of epileptogenic sUIA. CONCLUSIONS The seizures caused by sUIAs are most likely related to subclinical hemorrhages. Angiography may be helpful in identifying seizures associated with sUIA in patients with normal conventional MRI findings. For epileptogenic sUIA with normal preoperative MRI, clipping without damaging the surrounding brain tissue may be sufficient to resolve this complex issue.
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Affiliation(s)
- Fuxin Lin
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fujian Medical University, Fuzhou, Fujian, China
| | - Hui Wan
- Department of Neurosurgery, The Fourth Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Dezhi Kang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fujian Medical University, Fuzhou, Fujian, China
| | - Yuanxiang Lin
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fujian Medical University, Fuzhou, Fujian, China.
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16
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Comprehensive Overview of Contemporary Management Strategies for Cerebral Aneurysms. World Neurosurg 2015; 84:1147-60. [DOI: 10.1016/j.wneu.2015.05.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 05/19/2015] [Accepted: 05/20/2015] [Indexed: 01/06/2023]
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17
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Baron EP, Hui FK, Kriegler JS. Case Report of Debilitating Headaches and a Coexisting Ophthalmic Artery Aneurysm: An Indication for Treatment? Headache 2015; 56:567-72. [PMID: 26234769 DOI: 10.1111/head.12632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We present a case of a patient who had severe unilateral headaches related to a small, unruptured ophthalmic artery aneurysm, who experienced complete headache cessation following endovascular coiling. BACKGROUND Small unruptured intracranial aneurysms are generally managed and followed conservatively due to minimal risk of rupture. Headaches are frequently reported in patients with intracranial aneurysms, but these aneurysms are typically considered incidental and unrelated, given the undefined association between headaches and most aneurysms. CONCLUSION There may be some unruptured intracranial aneurysms that can cause intractable headaches and warrant interventional treatment. Future prospective studies are needed that compare pre- and post-procedure headache character and diagnosis, aneurysm characteristics such as size, location, orientation, and shape, type of aneurysm repair with materials used, and other potential risk factors for worsening post-procedure headache in order to better predict headache association to aneurysms, as well as outcomes following endovascular aneurysm treatment.
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Affiliation(s)
- Eric P Baron
- Department of Neurology, Center for Headache and Pain, Cleveland Clinic, Neurological Institute, Cleveland, OH, USA
| | - Ferdinand K Hui
- Cerebrovascular Center, Cleveland Clinic, Neurological Institute, Cleveland, OH, USA
| | - Jennifer S Kriegler
- Department of Neurology, Center for Headache and Pain, Cleveland Clinic, Neurological Institute, Cleveland, OH, USA
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18
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Baron EP. Headache, cerebral aneurysms, and the use of triptans and ergot derivatives. Headache 2015; 55:739-47. [PMID: 25903747 DOI: 10.1111/head.12562] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2015] [Indexed: 01/02/2023]
Abstract
BACKGROUND Uncertainty exists regarding the correlation between unruptured cerebral aneurysms and their role in headache etiology. It is also unclear whether surgical endovascular treatment may improve or worsen the headache, and if there are predictable factors for headache outcome such as pre-existing headache features, aneurysm characteristics, or other medical history. There is debate regarding safe treatment of migraine in patients with aneurysms, both before and after endovascular treatments. Particularly, there is hesitancy to use the triptans and ergot derivatives such as dihydroergotamine because of their vasoconstrictive effects and concern for adverse events related to the aneurysm such as aneurysmal instability and rupture. OBJECTIVE To review the literature regarding the anatomy, pathophysiology, and association between headache, untreated vs surgically treated aneurysms, and the use of triptans and ergot derivatives for migraine treatment in this setting. CONCLUSION Associations between some headaches and aneurysms may exist. Some chronic headaches may respond to surgical aneurysm repair while others may worsen. These associations are undefined by current literature because of variable results, study methods, and limited data. Prospective studies are needed which incorporate pre- and post-procedure headache character and diagnosis, aneurysm characteristics, type of aneurysm repair, associated risk factors for worsening post-procedure headache, and ultimately combining all of these data to better predict headache outcome following surgical aneurysm treatment. Lastly, the caution and avoidance of triptan and ergot derivative use for migraine in the setting of aneurysm is not supported by the current evidence, and much of this concern may be excessive and unwarranted, although more evidence confirming safety is needed.
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Affiliation(s)
- Eric P Baron
- Department of Neurology, Cleveland Clinic Neurological Institute, Center for Headache and Pain, Cleveland, OH, USA
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19
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Patil A, Menon GR, Nair S. Unruptured anterior communicating artery aneurysms presenting with seizure: Report of three cases and review of literature. Asian J Neurosurg 2014; 8:164. [PMID: 24403964 PMCID: PMC3877508 DOI: 10.4103/1793-5482.121693] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Aneurysms generally present with bleed and epileptogenic aneurysms are rare. Unruptured epilpetogenic anterior communicating artery aneurysms are extremely rare and anecdotal. We present three patients with unruptured anterior communicating artery aneurysms who presented with seizures and were surgically managed. Seizure might be related to the large size, presence of thrombus, microbleeds and surrounding gliosis. We suggest that large thrombosed anterior communicating artery aneurysms should be considered in the differential diagnosis of patients presenting with late onset of seizure and having a suprasellar lesion on imaging. Surgical clipping offers a fair chance of seizure freedom in selected patients.
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Affiliation(s)
- Akshay Patil
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical, Sciences and Technology, Trivandrum, India
| | - Girish R Menon
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical, Sciences and Technology, Trivandrum, India
| | - Suresh Nair
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical, Sciences and Technology, Trivandrum, India
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20
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Darsaut TE, Jack AS, Kerr RS, Raymond J. International Subarachnoid Aneurysm Trial - ISAT part II: study protocol for a randomized controlled trial. Trials 2013; 14:156. [PMID: 23714335 PMCID: PMC3680206 DOI: 10.1186/1745-6215-14-156] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Accepted: 05/16/2013] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Tim E Darsaut
- University of Alberta, Department of Surgery, Division of Neurosurgery, 2D.1 Mackenzie Health Sciences Center, 8440 – 112 St, Edmonton, AB T6G 2B7, Canada
| | - Andrew S Jack
- University of Alberta, Department of Surgery, Division of Neurosurgery, 2D.1 Mackenzie Health Sciences Center, 8440 – 112 St, Edmonton, AB T6G 2B7, Canada
| | - Richard S Kerr
- Neurovascular Research Unit, Nuffield Department of Surgery, University of Oxford and Oxford Radcliffe Hospitals NHS Trust, John Radcliffe Hospital, Headley Way, Headington, Oxford, Oxfordshire OX3 9DU, UK
| | - Jean Raymond
- Department of Radiology, Centre Hospitalier de l’Universite de Montreal, Notre-Dame Hospital, 1560 Sherbrooke East, Pavillion Simard, Room Z12909, Montreal, QC H2L 4M1, Canada
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21
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Ishibashi T, Murayama Y, Saguchi T, Ebara M, Arakawa H, Irie K, Takao H, Abe T. Justification of unruptured intracranial aneurysm repair: a single-center experience. AJNR Am J Neuroradiol 2013; 34:1600-5. [PMID: 23578669 DOI: 10.3174/ajnr.a3470] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Whether to treat UIAs is controversial. The aim of the study was to compare the clinical outcome of patients with UIAs who were either treated conservatively or preventively. MATERIALS AND METHODS Patients with UIAs referred to our institution were prospectively enrolled in the study. Data collected included baseline characteristics, aneurysmal features, and procedural and follow-up information. Preventive treatment was recommended if the aneurysm was larger than 5 mm and was considered safely treatable. Endovascular surgery was the first-line therapy if the aneurysmal shape was appropriate for coiling. RESULTS From January 2003 through April 2008, a total of 879 patients with 1110 UIAs were enrolled; 325 patients with 369 UIAs (mean size, 7.8 mm) were treated (treatment group), and 603 patients with 741 UIAs (mean size, 4.4 mm) were managed conservatively (observation group). Mean follow-up was 692.5 days (1405.5 person-years). In the observation group, 26 aneurysms (3.5%) had ruptured (1.8% per year; 1405.5 person-years), 10 patients died, and 7 were disabled (mRS, 3-6: 2.8%). Aneurysmal size was a significant risk factor for rupture (P = .001). The treatment group included aneurysms treated either with coiling (n=315), clipping (n=32), or a combined approach (n=9); 1 patient died, and 3 were disabled (mRS, 3-6: 1.2%). Therapeutic intervention was equal (UIAs of all sizes) or superior (UIAs > 5 mm; P = .025) to conservative management. CONCLUSIONS Treatment of UIAs was justified in aneurysms larger than 5 mm, and EVS can be safely applied to nearly 90% of UIAs.
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Affiliation(s)
- T Ishibashi
- Division of Endovascular Neurosurgery, Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan.
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22
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Ha SW, Jang SJ. Clinical analysis of giant intracranial aneurysms with endovascular embolization. J Cerebrovasc Endovasc Neurosurg 2012; 14:22-8. [PMID: 23210026 PMCID: PMC3471252 DOI: 10.7461/jcen.2012.14.1.22] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Revised: 11/08/2011] [Accepted: 02/23/2012] [Indexed: 12/02/2022] Open
Abstract
Objective The purpose of this study was to perform a clinical analysis of nine patients with giant aneurysms managed with endovascular embolization. Methods From March 2000 to September 2009, nine cases of giant intracranial aneurysms were treated (five unruptured and four ruptured). The nine patients included two males and seven females who were 47 to 72 years old (mean, 59.2 years old). The types of giant intracranial aneurysms were eight internal carotid artery aneurysms and one vertebral artery aneurysm. Treatment for each aneurysm was chosen based on anatomic relationships, aneurysmal factors, and the patients' clinical state. Three patients underwent endovascular coiling with stent and six initially underwent endovascular coiling alone. Medical records, operation records, postoperative angiographies, and follow-up angiographies were reviewed retrospectively. Results Eight out of nine patients showed good clinical outcomes. (six were excellent and two were good) after a mean follow-up period of 27.9 months. Six (67%) of the nine patients had a near-complete occlusions on the post-operative angiogram (mean, 13.5 months after the procedure). Occlusion rates of 90% or higher were obtained for eight (89%) of all the patients. One patient died due to multiple organ failure. Stents were ultimately required at some point for managing four aneurysms. Two patients needed additional procedures because of aneurysm regrowth. Conclusion Endovascular treatment could be an alternative option for managing giant aneurysms adjuvant to surgical intervention.
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Affiliation(s)
- Sang Woo Ha
- Department of Neurosurgery, College of medicine, Chosun University, Gwangju, Korea
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23
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Sekhar LN, Tariq F, Mai JC, Kim LJ, Ghodke B, Hallam DK, Bulsara KR. Unyielding Progress. Neurosurgery 2012; 59:6-21. [DOI: 10.1227/neu.0b013e3182698b75] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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24
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Aydın Y, Cavuşoğlu H, Kahyaoğlu O, Müslüman AM, Yılmaz A, Türkmenoğlu ON, Can SM, Yüce I. Clip ligation of unruptured intracranial aneurysms: a prospective midterm outcome study. Acta Neurochir (Wien) 2012; 154:1135-44. [PMID: 22644505 DOI: 10.1007/s00701-012-1397-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 05/15/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND We conducted a prospective study to investigate the clinical and radiological outcome in a surgical case series of 176 patients with 203 unruptured intracranial aneurysms (UIA). METHODS The success of aneurysm obliteration was assessed within 2 weeks after surgery by digital subtraction angiography (DSA). Patients also underwent angiography 5 years after surgery. Clinical outcomes were assessed using the modified Rankin Scale (mRS). All predictors of poor surgical outcomes were assessed using an exact logistic regression. RESULTS Overall, 83 % of the patients had a good outcome (mRS score 0 or 1); 10.8 % of the patients had a slight disability (mRS score 2), and 6.2 % of the patients had a moderate or moderate-severe disability (mRS score 3 or 4). The mortality rate was 0 % overall. The most important predictors of outcome were presence of history of ischemic cerebrovascular disease and postoperative stroke. Complete aneurysm occlusion was achieved in 93.5 % of all aneurysms. Sixty percent of treated aneurysms were checked with late follow-up DSA. No cases of hemorrhage from a surgically obliterated UIA were documented in this series during the 7.3 ± 1.4 (SD)-year follow-up period. CONCLUSIONS If patients are carefully selected and individually assigned to their optimum treatment modality, IUAs can be obliterated by surgery with a low percentage of unfavorable outcomes.
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Affiliation(s)
- Yunus Aydın
- Clinic of Neurosurgery, Şişli Etfal Education and Research Hospital, Istanbul, 34077, Turkey
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25
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Kotowski M, Naggara O, Darsaut T, Raymond J. Systematic reviews of the literature on clipping and coiling of unruptured intracranial aneurysms. Neurochirurgie 2012; 58:125-39. [DOI: 10.1016/j.neuchi.2012.02.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Accepted: 02/27/2012] [Indexed: 10/28/2022]
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26
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Kotowski M, Naggara O, Darsaut T, Raymond J. Revues systématiques de la littérature sur le clipping et le coiling des anévrismes intracrâniens non rompus. Neurochirurgie 2012. [DOI: 10.1016/j.neuchi.2012.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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27
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Clip chirurgical, coil endovasculaire : comment choisir le traitement des anévrismes intracrâniens. Neurochirurgie 2012. [DOI: 10.1016/j.neuchi.2012.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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28
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Darsaut T, Kotowski M, Raymond J. How to choose clipping versus coiling in treating intracranial aneurysms. Neurochirurgie 2012; 58:61-75. [DOI: 10.1016/j.neuchi.2012.02.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Accepted: 02/27/2012] [Indexed: 10/28/2022]
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Seule MA, Stienen MN, Gautschi OP, Richter H, Desbiolles L, Leschka S, Hildebrandt G. Surgical treatment of unruptured intracranial aneurysms in a low-volume hospital--outcome and review of literature. Clin Neurol Neurosurg 2012; 114:668-72. [PMID: 22300889 DOI: 10.1016/j.clineuro.2011.12.054] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2010] [Revised: 11/27/2011] [Accepted: 12/21/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND The aim of this study was to evaluate surgical outcome of unruptured intracranial aneurysms (UIAs) in a low-volume hospital and compare the results with the recent literature. METHODS A retrospective review of all consecutive craniotomies for UIA from July 1999 through June 2009 was performed. Morbidity was defined as modified Rankin Scale (mRS) ≥ 3 and evaluated six weeks after surgery. Cognitive function was evaluated at rehabilitation-to-home discharge. A PubMed database search (2001-2011) seeking retrospective, single-center studies reporting on surgical outcome of UIAs was performed. RESULTS There were 47 procedures performed in 42 patients to treat 50 UIAs (mean of 5 annual craniotomies). The mean age was 54.7 ± 12.1 years and mean aneurysm size was 7.6 ± 4.0mm. Favorable outcome (mRS 0-2) at six weeks after surgery was achieved in 45 of 47 procedures (95.7%). Aneurysm size ≥ 12 mm was statistically significant related to adverse outcome defined as mRS change ≥ 1 (71% vs. 29%; p = 0.018). Five patients (10.6%) with favorable neurological outcome (mRS 2) presented with cognitive impairment at rehabilitation-to-home discharge. There was no significant difference in overall morbidity and mortality comparing low- and high-volume hospitals (4.0% vs. 4.8%; p = 0.85). CONCLUSIONS Low-volume hospitals may achieve good results for surgical treatment of UIAs. The results indicate that defining numeric operative volume thresholds is not feasible to guide centralization of aneurysm treatment.
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Affiliation(s)
- M A Seule
- Department of Neurosurgery, Kantonsspital St Gallen, St Gallen, Switzerland.
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30
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Guillon B, Daumas-Duport B, Delaroche O, Warin-Fresse K, Sévin M, Hérisson F, Auffray-Calvier E, Desal H. Cerebral ischemia complicating intracranial aneurysm: a warning sign of imminent rupture? AJNR Am J Neuroradiol 2011; 32:1862-5. [PMID: 21868623 DOI: 10.3174/ajnr.a2645] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Patients harboring nongiant cerebral aneurysms may rarely present with an ischemic infarct distal to the aneurysm. The aim of this case series was to report clinical and radiologic characteristics of these patients, their management, and outcome. MATERIALS AND METHODS We undertook a single-center retrospective analysis of consecutive patients admitted during an 8-year period with an acute ischemic stroke revealing an unruptured nongiant (<25 mm) sacciform intracranial aneurysm. Clinical, radiologic, therapeutic, and follow-up data were analyzed. RESULTS Nine patients were included. The mean size of aneurysms was 9.6 ± 6 mm, and 5 were partially or totally thrombosed. Two patients had a fatal SAH within 3 days after stroke-symptom onset, whereas asymptomatic meningeal bleeding was diagnosed or suspected in 2 others. Most of the patients with unthrombosed aneurysms were successfully treated by endovascular coiling in the acute phase. Thrombosed aneurysms were usually treated with antithrombotics, and most recanalized secondarily, requiring endovascular treatment or surgical obliteration. No recurrence of an ischemic event or SAH was observed during the 31 ± 12 months of follow-up (from 4 to 53 months). CONCLUSIONS In this single-center series, the frequency of early SAH in patients with ischemic stroke distal to an unruptured intracranial aneurysm was high. Acute management should be undertaken with care regarding antithrombotic use, and early endovascular coiling should be considered.
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Affiliation(s)
- B Guillon
- Department of Neurology, University Hospital of Nantes, France.
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31
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Huang MC, Baaj AA, Downes K, Youssef AS, Sauvageau E, van Loveren HR, Agazzi S. Paradoxical Trends in the Management of Unruptured Cerebral Aneurysms in the United States. Stroke 2011; 42:1730-5. [DOI: 10.1161/strokeaha.110.603803] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Michael C. Huang
- From the Department of Neurological Surgery & Brain Repair, University of South Florida, Tampa, FL
| | - Ali A. Baaj
- From the Department of Neurological Surgery & Brain Repair, University of South Florida, Tampa, FL
| | - Katheryne Downes
- From the Department of Neurological Surgery & Brain Repair, University of South Florida, Tampa, FL
| | - A. Samy Youssef
- From the Department of Neurological Surgery & Brain Repair, University of South Florida, Tampa, FL
| | - Eric Sauvageau
- From the Department of Neurological Surgery & Brain Repair, University of South Florida, Tampa, FL
| | - Harry R. van Loveren
- From the Department of Neurological Surgery & Brain Repair, University of South Florida, Tampa, FL
| | - Siviero Agazzi
- From the Department of Neurological Surgery & Brain Repair, University of South Florida, Tampa, FL
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Morgan MK, Mahattanakul W, Davidson A, Reid J. Outcome for middle cerebral artery aneurysm surgery. Neurosurgery 2011; 67:755-61; discussion 761. [PMID: 20651625 DOI: 10.1227/01.neu.0000378025.33899.26] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To assess in depth the variables contributing to adverse surgical outcome for repair of unruptured middle cerebral artery aneurysms. METHODS Prospectively collected data between October 1989 and June 2009 were examined retrospectively. Putative risk factors were investigated with univariate and multivariate logistic regression analyses. RESULTS In this study, 263 patients (339 aneurysms) underwent surgical clipping in 280 operations for unruptured middle cerebral artery aneurysms. The overall surgical mortality and morbidity rate was 5% (95% confidence interval [CI], 2.9-8.3). Multivariate logistic analysis of risk factors revealed that age and aneurysm size were independent predictors of surgical outcome. Patients < 60 years of age with an aneurysm < or = 12 mm constituted a low-risk group with a procedure-related combined mortality and morbidity of 0.6% (95% CI, 0-3.8). Patients < 60 years of age with an aneurysm > 12 mm had a procedure-related combined mortality and morbidity of 7.4% (95% CI, 1-24.5). Patients > or = 60 years of age with an aneurysm of < or = 12 mm had a procedure-related combined mortality and morbidity of 9.3% (95% CI, 4.3-18.3). Patients > or = 60 years of age with an aneurysm > 12 mm had a procedure-related combined mortality and morbidity of 22.2% (95% CI, 8.5-45.8). CONCLUSION Age and size of aneurysm were the only 2 independent predictors of surgical outcome.
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Affiliation(s)
- Michael K Morgan
- Australian School of Advanced Medicine, Level 1, 3 Dow Corning, Innovation Rd, Macquarie University, NSW 2109, Australia.
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33
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Role of calcification in the outcomes of treated, unruptured, intracerebral aneurysms. Acta Neurochir (Wien) 2011; 153:905-11. [PMID: 21286763 DOI: 10.1007/s00701-010-0846-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2009] [Accepted: 10/14/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE This study examined clinical and aneurysm characteristics in patients with unruptured aneurysms, treated with either coiling or clipping at a single institution, with the primary outcome-Glasgow Outcome Score (GOS)-measured at 6 months after treatment. METHODS Data was obtained by a retrospective review of a prospective registry of consecutive cases of unruptured intracranial aneurysms treated at a single institution from 2002 to mid 2007. Demographic data, number, location, and size of aneurysms, calcification, mode of treatment, ASA score, presence of a stroke on post-op imaging, and GOS were recorded. Medical 9.4 for PC was utilized for statistical analysis. RESULTS There were 225 procedures performed in 208 patients to treat 252 aneurysms. The mean age was 54.6 years, 74.5% were female, the mean ASA score was 2.45, and 72.2% were smokers. Mean aneurysm size was 8.6 mm. A total of 157 (70%) craniotomies and 68 (30%) coiling procedures were performed. Coiling was utilized more frequently in the posterior circulation [18/32 (56%) posterior circulation, 50/193 (29.9%) anterior circulation, p < 0.001 Chi-square]. Length of hospital stay averaged 5.3 days [6.2 vs. 3.2 clip/coil, p < 0.001, Mann-Whitney]. Overall favorable outcome of GOS 4-5 measured at 6 months post-procedure was 93.3% [145/157 (92.3%) clip, 66/68 (97%) coil, p = 0.3 Chi-square], with a single mortality in the coil group. There was radiographic evidence of a post-procedure stroke on CT in 31 (13.8%) [28/157 (17.8%) clip, 3/68 (4.4%) coil, p < 0.001, Chi-square], but only 11(35%) were symptomatic. All long-term morbidity was attributable to stroke except for one case of late hydrocephalus. Utilizing a logistic regression multivariate analysis (forward), none of the examined factors (age, ASA score, sex, surgeon, posterior circulation, number of aneurysms treated at one sitting, size of aneurysm, smoking status, or type of therapy) related to outcome except calcified aneurysm [20/25 (80%) calcified, 191/200 (95.5%) non-calcified, p < 0.01 Chi-square] with an OR = 7.8 (2.2-28.4, 95% C.I.). Although a univariate analysis of aneurysm size versus outcome achieves statistical significance [p = 0.05, logistic regression (forced)], when the calcified cases are removed from consideration, it does not [p = 0.55, OR = .95, (.82-1.1), 95% C.I.]. Excluding patients with calcified aneurysms resulted in the following calculation of favorable outcome: 94.2% (130/138) clip and 98.4% (61/62) coil [p = 0.33, Chi-square]. CONCLUSIONS In this study, the presence of calcification in an aneurysm was the sole marker of adverse outcome. Larger aneurysms tended to be more likely to be calcified. Size by itself did not have an adverse affect on outcome. Clipping or clip reconstruction of calcified aneurysms is a significant source of morbidity in the treatment of unruptured aneurysms (Odds ratio 7.8).
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Darsaut TE, Darsaut NM, Chang SD, Silverberg GD, Shuer LM, Tian L, Dodd RL, Do HM, Marks MP, Steinberg GK. Predictors of Clinical and Angiographic Outcome After Surgical or Endovascular Therapy of Very Large and Giant Intracranial Aneurysms. Neurosurgery 2011; 68:903-15; discussion 915. [DOI: 10.1227/neu.0b013e3182098ad0] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Risk factors for poor outcome in the treatment of very large (≥20-24 mm) and giant (≥25 mm) intracranial aneurysms remain incompletely defined.
OBJECTIVE:
To present an aggregate clinical series detailing a 24-year experience with very large and giant aneurysms to identify and assess the relative importance of various patient, aneurysm, and treatment-specific characteristics associated with clinical and angiographic outcomes.
METHODS:
The authors retrospectively identified 184 aneurysms measuring 20 mm or larger (85 very large, 99 giant) treated at Stanford University Medical Center between 1984 and 2008. Clinical data including age, presentation, and modified Rankin Scale (mRS) score were recorded, along with aneurysm size, location, and morphology. Type of treatment was noted and clinical outcome measured using the mRS score at final follow-up. Angiographic outcomes were completely occluded, occluded with residual neck, partly obliterated, or patent with modified flow.
RESULTS:
After multivariate analysis, risk factors for poor clinical outcome included a baseline mRS score of 2 or higher (odds ratio [OR], 0.23; 95% confidence interval [CI]: 0.08-0.66; P = .01), aneurysm size of 25 mm or larger (OR, 3.32; 95% CI: 1.51-7.28; P < .01), and posterior circulation location (OR, 0.18; 95% CI: 0.07-0.43; P < .01). Risk factors for incomplete angiographic obliteration included fusiform morphology (OR, 0.25; 95% CI: 0.10-0.66; P #x003C; .01), posterior circulation location (OR, 0.33; 95% CI: 0.13-0.83; P = .02), and endovascular treatment (OR, 0.14; 95% CI: 0.06-0.32; P < .01). Patients with incompletely occluded aneurysms experienced higher rates of posttreatment subarachnoid hemorrhage and had increased mortality compared with those with completely obliterated aneurysms.
CONCLUSION:
Our results suggest that patients with poor baseline functional status, giant aneurysms, and aneurysms in the posterior circulation had a significantly higher proportion of poor outcomes at final follow-up. Fusiform morphology, posterior circulation location, and endovascular treatment were risk factors for incompletely obliterated aneurysms.
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Affiliation(s)
- Tim E. Darsaut
- Department of Neurosurgery, Stanford Stroke Center and Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine, Stanford, California
| | - Nicole M. Darsaut
- Department of Neurosurgery, Stanford Stroke Center and Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine, Stanford, California
| | - Steven D. Chang
- Department of Neurosurgery, Stanford Stroke Center and Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine, Stanford, California
| | - Gerald D. Silverberg
- Department of Neurosurgery, Stanford Stroke Center and Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine, Stanford, California
- Current address: Department of Neurosurgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Lawrence M. Shuer
- Department of Neurosurgery, Stanford Stroke Center and Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine, Stanford, California
| | - Lu Tian
- Department of Health Research and Policy, Stanford Stroke Center and Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine, Stanford, California
| | - Robert L. Dodd
- Department of Neurosurgery, Stanford Stroke Center and Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine, Stanford, California
- Department of Radiology, and Stanford Stroke Center and Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine, Stanford, California
| | - Huy M. Do
- Department of Radiology, and Stanford Stroke Center and Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine, Stanford, California
| | - Michael P. Marks
- Department of Radiology, and Stanford Stroke Center and Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine, Stanford, California
| | - Gary K. Steinberg
- Department of Neurosurgery, Stanford Stroke Center and Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine, Stanford, California
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Choxi AA, Durrani AK, Mericle RA. Both Surgical Clipping and Endovascular Embolization of Unruptured Intracranial Aneurysms Are Associated With Long-term Improvement in Self-Reported Quantitative Headache Scores. Neurosurgery 2011; 69:128-33; discussion 133-4. [DOI: 10.1227/neu.0b013e318213437d] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
The most common presenting symptom for unruptured intracranial aneurysms (UIAs) is headache (HA). However, most experts believe that UIAs associated with HAs are unrelated and incidental.
OBJECTIVE:
To analyze the incidence and characterization of HAs in patients with UIAs before and after treatment with either surgical clipping or endovascular embolization.
METHOD:
We prospectively determined the presence, sidedness, and severity of HAs preoperatively in patients who presented to the senior author with a UIA. A validated, quantitative 11-point HA pain scale was used in all patients. The same HA assessments were performed again on these patients an average of 32.4 months postoperatively.
RESULTS:
In this study, 92.45% (n = 53) of patents for whom we were able to obtain both a preoperative and postoperative pain score had an improvement in their HAs. The average quantitative HA score was 5.87 preoperatively vs 1.39 postoperatively (P < .001). There was no relationship found between the following: (1) HA severity vs aneurysm size, (2) sidedness of aneurysm vs sidedness of HA, and (3) HA improvement after surgical vs endovascular treatment.
CONCLUSION:
This study suggests that surgical and endovascular treatment of a UIA is associated with dramatic improvement in self-reported HA score an average of 32.4 months postoperatively.
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Affiliation(s)
- Ankeet A Choxi
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alia K Durrani
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert A Mericle
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Vannemreddy PSSV, Nourbakhsh A, Nanda A. Evaluation of the prognostic indicators of giant intracranial aneurysms. Skull Base 2011; 21:37-46. [PMID: 22451798 DOI: 10.1055/s-0030-1263285] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The indicators of poor outcome in giant intracranial aneurysms have been the subject of several studies in the literature. We conducted a retrospective analysis to evaluate the predictors of poor outcome in giant intracranial aneurysms. We studied consecutive cases with aneurysms admitted over a 9-year period in our institution. All the aneurysms were treated with clipping. Patient demographics, clinical profile, and aneurysm characteristics were evaluated in a multivariate analysis as probable indicators of Glasgow Outcome Scale (GOS) score. The outcome of the aneurysms (GOS score) was compared with the remaining non-giant aneurysms. A total of 41 giant and 348 non-giant aneurysms were identified in our series. In the multivariate analysis, the indicators of poor outcome were identified as poor clinical grade (p < 0.0004), intraoperative rupture (p < 0.007), and posterior circulation of the aneurysms (p < 0.01). Non-giant aneurysms had a better outcome compared with the giant aneurysms (p < 0.01). Giant aneurysms impose a relatively higher risk of morbidity and mortality to the patients. The predictors of the postsurgical outcome of the giant aneurysms include the clinical condition of the patient, location of the aneurysm, and intraoperative rupture.
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Szelényi A, Beck J, Strametz R, Blasel S, Oszvald A, Raabe A, Seifert V. Is the surgical repair of unruptured atherosclerotic aneurysms at a higher risk of intraoperative ischemia? Clin Neurol Neurosurg 2010; 113:129-35. [PMID: 21095056 DOI: 10.1016/j.clineuro.2010.10.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Revised: 09/21/2010] [Accepted: 10/21/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND The incidence of ischemia might be increased in the surgical repair of atherosclerotic unruptured aneurysms compared to non-atherosclerotic aneurysms. The atherosclerotic wall might increase the occurrence of thrombembolic events or its rigidity might endanger the occlusion of perforators within the aneurysm vicinity. METHODS 87 patients (53 patients without and 34 patients with atherosclerotic unruptured aneurysms, 50.5 ± 9.7 years) were analyzed for severity of atherosclerosis within the aneurysm and the aneurysm bearing vessel, surgical maneuvers, intraoperative alterations in evoked potentials and clinical and neuroradiological results. RESULTS Temporary vessel occlusion (25% vs. 50%, p = 0.021), repositioning of a permanent clip (21% vs. 56%, p = 0.001) and aneurysm remnants (2% vs. 18%, p = 0.012) occurred more often in patients with atherosclerotic aneurysms. At 6 months, 3/34 patients with atherosclerosis (8.8%) had an unfavorable outcome, all patients without atherosclerosis had a favorable outcome (p = 0.056). CONCLUSION The surgical repair of unruptured aneurysms is safe but patients with atherosclerotic altered vessels and aneurysms accounted to a minor increase in unfavorable outcome and an increased risk of morbidity at 6 months postoperatively. This factor should be taken into consideration when performing surgery of atherosclerotic, unruptured aneurysms.
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Affiliation(s)
- Andrea Szelényi
- Department for Neurosurgery, Johann Wolfgang Goethe-University Hospital, Frankfurt, Germany.
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Pereira-Filho AA, Pereira AG, Faria MB, Lima LC, Portuguez MW, Kraemer JL. Microsurgical clipping in forty patients with unruptured anterior cerebral circulation aneurysms: an investigation into cognitive outcome. ARQUIVOS DE NEURO-PSIQUIATRIA 2010; 68:770-4. [DOI: 10.1590/s0004-282x2010000500018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Accepted: 04/08/2010] [Indexed: 11/21/2022]
Abstract
OBJECTIVE: It is a consensus that most unruptured intracranial aneurysms (UIA) can be treated with acceptably low morbidity. However, some studies recently reported postoperative cognitive impairment, suggesting that it could be attributable to surgical damage. Our goal is to evaluate cognitive function before and after microsurgical clipping in patients with UIA. METHOD: A consecutive series of 40 patients who underwent microsurgical clipping for UIA were studied. The cognitive assessment (Mini Mental State Examination, MMSE) was performed immediately before and at least one month after surgery. Paired Student's "t" test and analysis of variance (ANOVA) were used for statistical purposes. RESULTS: The mean MMSE score in the preoperative analysis was 28.12 (SD, 1.34). In the postoperative period the mean MMSE score was 28.40 (SD, 1.46). Paired Student's "t" test was applied to the scores and no significant difference was found (p=0.315). ANOVA did not find independent associations between MMSE scores and age, hypertension, smoking, dyslipidemia, education, aneurysm location, number, laterality or size. CONCLUSION: The present study suggests that microsurgical clipping for UIA does not result in major cognitive dysfunction as determined by the MMSE
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Affiliation(s)
- Arthur A Pereira-Filho
- Pontifícia Universidade Católica do Rio Grande do Sul, Brazil; Complexo Hospitalar Santa Casa de Porto Alegre, Brazil
| | | | - Mário B Faria
- Complexo Hospitalar Santa Casa de Porto Alegre, Brazil
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Nam KH, Choi CH, Lee JI, Ko JG, Lee TH, Lee SW. Unruptured Intracranial Aneurysms with Oculomotor Nerve Palsy : Clinical Outcome between Surgical Clipping and Coil Embolization. J Korean Neurosurg Soc 2010; 48:109-14. [PMID: 20856657 DOI: 10.3340/jkns.2010.48.2.109] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2010] [Revised: 06/18/2010] [Accepted: 08/09/2010] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To evaluate the clinical outcome of coil embolization for unruptured intracranial aneurysm (UIA) with oculomotor nerve palsy (ONP) compared with surgical clipping. METHODS A total of 19 patients presented with ONP caused by UIAs between Jan 2004 and June 2008. Ten patients underwent coil embolization and nine patients surgical clipping. The following parameters were retrospectively analyzed to evaluate the differences in clinical outcome observed in both coil embolization and surgical clipping : 1) gender, 2) age, 3) location of the aneurysm, 4) duration of the symptom, and 5) degree of ONP. RESULTS Following treatment, complete symptomatic recovery or partial relief from ONP was observed in 15 patients. Seven of the ten patients were treated by coil embolization, compared to eight of the nine patients treated by surgical clipping (p = 0.582). Patient's gender, age, location of the aneurysm, size of the aneurysm, duration of symptom, and degree of the ONP did not statistically correlate with recovery of symptoms between the two groups. No significant differences were observed in mean improvement time in either group (55 days in coil embolization and 60 days in surgical clipping). CONCLUSION This study indicates that no significant differences were observed in the clinical outcome between coil embolization and surgical clipping techniques in the treatment of aneurysms causing ONP. Coil embolization seems to be more feasible and safe treatment modality for the relief and recovery of oculomotor nerve palsy.
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Affiliation(s)
- Kyoung Hyup Nam
- Department of Neurosurgery, School of Medicine, Pusan National University, Busan, Korea
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Abstract
Object
Because the risks are reduced, larger basilar apex aneurysms are usually treated endovascularly instead of with surgery. However, small basilar apex aneurysms are more common and an unfavorable shape may prevent definitive endovascular treatment. The goal of this study was to reevaluate the outcome of traditional surgery for small unruptured basilar apex aneurysms as an alternative to the currently more accepted endovascular treatment.
Methods
The authors reviewed clinical data obtained in 21 patients who underwent surgery between 2000 and 2007 for unruptured basilar apex aneurysms < 7 mm.
Results
The median age of the 21 patients was 52 years (range 29–74 years). All patients experienced a good outcome. Two patients harbored a small residual aneurysm (> 95% occlusion). Eight patients (38%) suffered a temporary third nerve paresis, which resolved in all cases.
Conclusions
Surgical clip ligation remains an excellent treatment for small basilar apex aneurysms. The treatment is definitive and in experienced hands is associated with a low risk.
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DATE I. Symptomatic Unruptured Cerebral Aneurysms: Features and Surgical Outcome. Neurol Med Chir (Tokyo) 2010; 50:788-99. [DOI: 10.2176/nmc.50.788] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Isao DATE
- Department of Neurological Surgery, Okayama University Graduate School of Medicine
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The role of computational fluid dynamics in the management of unruptured intracranial aneurysms: a clinicians' view. COMPUTATIONAL INTELLIGENCE AND NEUROSCIENCE 2009:760364. [PMID: 19696903 PMCID: PMC2729101 DOI: 10.1155/2009/760364] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2009] [Revised: 04/24/2009] [Accepted: 06/09/2009] [Indexed: 11/18/2022]
Abstract
Objective. The
importance of hemodynamics in the
etiopathogenesis of intracranial aneurysms (IAs)
is widely accepted. Computational fluid dynamics
(CFD) is being used increasingly for hemodynamic
predictions. However, alogn with the continuing
development and validation of these
tools, it is imperative to collect
the opinion of the clinicians.
Methods. A workshop on CFD was
conducted during the European Society of
Minimally Invasive Neurological Therapy (ESMINT)
Teaching Course, Lisbon, Portugal.
36 delegates, mostly clinicians,
performed supervised CFD analysis for an IA, using the
@neuFuse software developed within the European
project @neurIST. Feedback on the workshop was
collected and analyzed. The
performance was assessed on a scale of 1 to 4
and, compared with experts' performance.
Results. Current dilemmas in
the management of unruptured IAs remained the
most important motivating factor to attend the
workshop and majority of participants showed interest in participating in a
multicentric trial. The participants achieved
an average score of 2.52 (range 0–4) which was 63% (range 0–100%) of an expert user. Conclusions.
Although participants showed a manifest interest
in CFD, there was a clear
lack of awareness concerning the role of
hemodynamics in the etiopathogenesis of IAs and
the use of CFD in this context. More efforts
therefore are required to enhance understanding of the
clinicians in the subject.
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Seifert V, Gerlach R, Raabe A, Güresir E, Beck J, Szelényi A, Setzer M, Vatter H, Du Mesnil de Rochemont R, Zanella F, Sitzer M, Berkefeld J. The interdisciplinary treatment of unruptured intracranial aneurysms. DEUTSCHES ARZTEBLATT INTERNATIONAL 2009; 105:449-56. [PMID: 19626180 DOI: 10.3238/arztebl.2008.0449] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2007] [Accepted: 02/06/2008] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The purpose of this article is to present the results of microsurgical clipping or endovascular coil obliteration of unruptured intracranial aneurysms (UIA), in a single cerebrovascular center with regard to successful obliteration and periprocedural complications. METHODS Data concerning patients with UIA were recorded in the neurovascular database of the neurosurgical department at the University of Frankfurt. The outcome of treatment was assessed with the modified Rankin Scale. RESULTS 126 patients were treated by open surgery and 74 patients by endovascular coil obliteration. After treatment, the rate of new, mostly transient neurological deficits was 5%, and there were no deaths related to any treatment in this series. The outcome was good in 124 (98.4%) of the surgically treated patients and 73 (98.6%) of the endovascularly treated patients, and only 3 patients (1.5%) had a treatment-related unfavorable outcome. 98% of the treated aneurysms were satisfactorily obliterated. Seven endovascularly treated patients required retreatment because of coil compaction leading to recanalization of the aneurysm. CONCLUSIONS The majority of patients with unruptured intracranial aneurysms, even complex ones, can be treated by microsurgery or endovascular aneurysm obliteration with very good clinical results and a very low percentage of unfavorable outcomes. With careful patient selection and individualized assignment of the best form of treatment to each patient, we were able to achieve a low overall complication rate and a very high rate of obliteration in our specialized neurovascular center.
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Affiliation(s)
- Volker Seifert
- Klinik für Neurochirurgie, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt am Main, Schleusenweg 2-16, Frankfurt/Main, Germany
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de Oliveira JG, Borba LAB, Rassi-Neto A, de Moura SM, Sanchez-Júnior SL, Rassi MS, de Holanda CVM, Giudicissi-Filho M. Intracranial aneurysms presenting with mass effect over the anterior optic pathways: neurosurgical management and outcomes. Neurosurg Focus 2009; 26:E3. [DOI: 10.3171/2009.3.focus0924] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Intracranial aneurysms may grow closer to anterior optic pathways, causing mass effect over these anatomical structures, including visual deficit. The authors retrospectively reviewed a series of aneurysms in patients presenting with visual field deficit caused by mass effect, to analyze the aneurysm's characteristics, the neurosurgical management of these aneurysms, as well as their clinical, visual, and radiological outcomes.
Methods
The authors reviewed the medical charts, neuroimaging examination results, and surgical videos of 15 patients presenting with visual symptoms caused by an aneurysm's mass effect over the anterior optic pathways. These patients were treated at the Department of Neurosurgery, Center of Neurology and Neurosurgery Associates, Hospital Beneficência Portuguesa de São Paulo, Brazil. Statistical analysis was performed to identify the variables related to partial or total recovery of the visual symptoms.
Results
All patients underwent microsurgical clip placement and emptying of their aneurysms. After a mean follow-up of 38.5 months, the mean postoperative Glasgow Outcome Scale score was 4.33, and the visual outcomes were as follows: 1 patient (6.6%) unchanged, 7 (46.6%) improved, and 7 (46.6%) experienced complete recovery from visual deficits. The variables that influenced the visual outcomes were the size of the aneurysm (p = 0.039), duration of the visual symptoms (p = 0.002), aneurysm wall calcification (p = 0.010), and intraluminal thrombosis (p = 0.007). Postoperative examination using digital subtraction angiography showed complete aneurysm occlusion in 14 (93.3%) of the 15 patients.
Conclusions
Intracranial aneurysms causing mass effect over the anterior optic pathways usually present with complex features. The best treatment option must include not only the aneurysm occlusion but also relief of the mass effect. Microsurgical clip placement with reduction of aneurysmal mass effect achieved improvement in visual ability or recovery from visual impairment, as well as total aneurysm occlusion, in 93.3% of the study group. Therefore, this option is well supported as the first choice of treatment for intracranial aneurysms presenting with mass effect over the anterior visual pathways.
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Hauck EF, Wohlfeld B, Welch BG, White JA, Samson D. Clipping of very large or giant unruptured intracranial aneurysms in the anterior circulation: an outcome study. J Neurosurg 2008; 109:1012-8. [DOI: 10.3171/jns.2008.109.12.1012] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Patients with very large or giant unruptured intracranial aneurysms present with ischemic stroke and progressive disability. The aneurysm rupture risk in these patients is extreme—up to 50% in 5 years. In this study the authors investigated the outcome of surgical treatment for these very large aneurysms in the anterior circulation.
Methods
Clinical data on 62 patients who underwent surgery for unruptured aneurysms (20–60 mm) between 1998 and 2006 were reviewed.
Results
Complete aneurysm occlusion (100%) was achieved in 90% of cases, near complete occlusion (90–99%) in 5%. The surgical risk in patients younger than 50 years of age was 8% (Glasgow Outcome Scale score of 1 or 3 within 1 year after surgery). In older patients, the risk increased with advancing age.
Conclusions
The treatment of very large or giant unruptured intracranial aneurysms is hazardous and complex and thus best performed only at major cerebrovascular centers with an experienced team of neurosurgeons, interventional neuroradiologists, neurologists, and neuroanesthesiologists. Surgery, with acceptable risks and excellent occlusion rates, is typically the treatment of choice in patients younger than 50 years of age. In older patients, the benefits of endovascular treatment versus surgery versus no treatment must be carefully weighed individually. Minimizing temporary occlusion and the consequent use of intraoperative angiography may help reduce surgical complications.
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Rinkel G. Natural history, epidemiology and screening of unruptured intracranial aneurysms. Rev Neurol (Paris) 2008; 164:781-6. [DOI: 10.1016/j.neurol.2008.07.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2008] [Accepted: 07/23/2008] [Indexed: 10/21/2022]
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Im SH, Han MH, Kwon OK, Kwon BJ, Kim SH, Kim JE, Oh CW. Endovascular coil embolization of 435 small asymptomatic unruptured intracranial aneurysms: procedural morbidity and patient outcome. AJNR Am J Neuroradiol 2008; 30:79-84. [PMID: 18768715 DOI: 10.3174/ajnr.a1290] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Whether treatment of small asymptomatic aneurysms is appropriate or not remains controversial. We performed a retrospective study on the procedural morbidity and mortality of coil embolization of small asymptomatic unruptured intracranial aneurysms (UIAs) to obtain a more generalized estimate of procedural risk. MATERIALS AND METHODS A total of 435 small (maximum diameter < or = 7 mm) asymptomatic UIAs in 370 patients were treated by coil embolization. Aneurysm sizes were determined by using 3D angiograms. We assessed procedure-related morbidity and mortality, immediate postprocedural angiographic results, short-term imaging follow-up results, and clinical outcomes. RESULTS Initial aneurysm occlusion was complete in 334 aneurysms, near complete in 78, and incomplete in 22. One internal carotid artery (ICA) aneurysm that ruptured during the procedure was treated with parent artery occlusion. Two hundred wide-neck aneurysms were coiled with the aid of various neck-remodeling techniques. The 44 procedure-related complications were the following: 24 thromboembolisms, 11 coil protrusions or prolapses into the parent vessel, 4 intraprocedural ruptures, 3 device-related complications, and 2 femoral-access complications. We had a total of 44 (10.1%) procedure-related complications with only 1 leading to persistent neurologic deficit. Procedure-related permanent morbidity and mortality were 0.27% (1/370) and 0%, respectively. CONCLUSIONS In this series of small unruptured asymptomatic aneurysms, endovascular treatment was achieved with good short-term angiographic outcome and low permanent neurologic impairment. The goal of this study was not to provide a conclusion about treatment guidelines for small UIA but rather to help guide future recommendations by presenting a more generalized estimate of endovascular treatment risk than is currently available.
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Affiliation(s)
- S-H Im
- Department of Neurosurgery, Dongguk University Hospital, Gyeonggido, Korea
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Mery FJ, Amin-Hanjani S, Charbel FT. Is an angiographically obliterated aneurysm always secure? Neurosurgery 2008; 62:979-82; discussion 982. [PMID: 18496204 DOI: 10.1227/01.neu.0000318190.63901.62] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Conventional cerebral angiography is the standard examination used to confirm aneurysm obliteration. Intraoperative indocyanine green (ICG) video angiography has recently been introduced as a valuable tool that is comparable to catheter intraoperative angiography. Intraoperative imaging evaluation is especially useful when complex aneurysm features are present, making direct clipping challenging. The aim of these angiographic evaluations is to assess parent vessel patency and to confirm lesion obliteration. However, there have been recent reports of growth or even rupture of angiographically obliterated aneurysms. CLINICAL PRESENTATION We report two patients in whom ICG video angiography falsely indicated that a clipped aneurysm was secure. INTERVENTION Both patients underwent direct clipping of unruptured aneurysms. ICG video angiography was performed, showing absence of residual filling of the sac. After incising the aneurysm dome, slow but significant dye extravasation was demonstrated. In the first patient, this occurred as a result of incomplete clipping of a wide aneurysm neck that was difficult to visualize; in the second patient, it occurred as a result of atheroma at the neck not allowing complete closure of the clip blades. This finding prompted clip readjustment and placement of an additional reinforcing clip in the two patients, respectively. CONCLUSION We demonstrate false indication of aneurysm obliteration by intraoperative video angiographic evaluation using ICG. It is possible that this limitation would also apply to catheter angiography. If certainty of complete exclusion of the aneurysm through opening the dome is not achieved, long-term follow-up angiographic evaluation would be strongly advised.
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Affiliation(s)
- Francisco J Mery
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
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Aghakhani N, Vaz G, David P, Parker F, Goffette P, Ozan A, Raftopoulos C. SURGICAL MANAGEMENT OF UNRUPTURED INTRACRANIAL ANEURYSMS THAT ARE INAPPROPRIATE FOR ENDOVASCULAR TREATMENT. Neurosurgery 2008. [DOI: 10.1227/01.neu.0000317273.53733.5f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Aghakhani N, Vaz G, David P, Parker F, Goffette P, Ozan A, Raftopoulos C. SURGICAL MANAGEMENT OF UNRUPTURED INTRACRANIAL ANEURYSMS THAT ARE INAPPROPRIATE FOR ENDOVASCULAR TREATMENT. Neurosurgery 2008; 62:1227-34; discussion 1234-5. [DOI: 10.1227/01.neu.0000333294.52115.28] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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