A comparison between endovascular and surgical management of basilar artery apex aneurysms

Microsurgery for basilar apex aneurysms: a case series

Although endovascular management has been increasingly adopted for basilar apex aneurysms (BAAs), microsurgery still represents an amenable treatment option. In this case series, six female patients (median age: 46 years) with six saccular high-riding BAAs (50% ruptured) were included. The median neck size was 5.3 mm (range: 2.9-7.9), and the median length from base to dome was 7.25 mm (range: 5.2-11.4). Preoperative complications included hydrocephalus (22%) and rebleeding (22%). All patients underwent clipping with a pterional craniotomy with extension into the temporal bone base. Intraoperative aneurysm rupture occurred in one patient (17%). Postoperative complications occurred in two patients (34%), of which one died because of extensive cerebral vasospasm and hospital-acquired pneumonia. At the 6-month follow-up, all remaining patients had modified Rankin scale scores ≤ 2. Microsurgery remains a viable option for BAAs in limited-resource settings. Technical success depends on delicate tissue work, in-depth anatomical knowledge, and maneuverability in narrow corridors.

Basilar apex aneurysm systematic review: Microsurgical versus endovascular treatment

BACKGROUND

Both microsurgical and endovascular techniques continued to be treatment options for basilar apex aneurysms (BAA). We conducted a systematic review to compare both treatment options in terms of both clinical and radiological outcomes.

METHODS

The PRISMA method was used to identify related articles. Data collected from each article and the two treatment approaches were compared in terms of favorable clinical outcome and complete/near complete occlusion rate. Subgroup analysis was done based on the size and the rupture status of BAA.

RESULTS

Fifty-nine (59) and 32 articles reported a measurable clinical and radiological outcome respectively. The weighted average favorable clinical outcome was significantly higher in the endovascular group (86.4% vs 79.6%, P<0.0001), while the weighted average complete/near complete occlusion rate was significantly higher in the surgical group (92.6% vs 83.8%, P<0.0001). In the subgroup analysis, the favorable clinical outcome remained significantly higher in the endovascular group for the ruptured, unruptured and giant/large BAA (P<0.001), but not in the small BAA subgroup (P=0.26). The occlusion rate remained significantly higher in the surgical group for all subgroups (P<0.001).

CONCLUSION

Treatment of BAA remains in a trade-off between favorable clinical outcome and complete or near-complete occlusion depending on the treatment modality selected. Careful selection of cases and judicial discussion between open surgical and endovascular team is warranted for treatment optimization.

Endovascular embolization versus surgical clipping in a single surgeon series of basilar artery aneurysms: a complementary approach in the endovascular era

Background

Currently, most basilar artery aneurysms (BAAs) are treated endovascularly. Surgery remains an appropriate therapy for a subset of all intracranial aneurysms. Whether open microsurgery would be required or utilized, and to what extent, for BAAs treated by a surgeon who performs both endovascular and open procedures has not been reported.

Methods

Retrospective analysis of prospectively maintained, single-surgeon series of BAAs treated with endovascular or open surgery from the first 5 years of practice.

Results

Forty-two procedures were performed in 34 patients to treat BAAs—including aneurysms arising from basilar artery apex, trunk, and perforators. Unruptured BAAs accounted for 35/42 cases (83.3%), and the mean aneurysm diameter was 8.4 ± 5.4 mm. Endovascular coiling—including stent-assisted coiling—accounted for 26/42 (61.9%) treatments and led to complete obliteration in 76.9% of cases. Four patients in the endovascular cohort required re-treatment. Surgical clip reconstruction accounted for 16/42 (38.1%) treatments and led to complete obliteration in 88.5% of cases. Good neurologic outcome (mRS ≤ 2) was achieved in 88.5% and 75.0% of patients in endovascular and open surgical cohorts, respectively (p = 0.40). Univariate logistic regression analysis demonstrated that advanced age (OR 1.11[95% CI 1.01–1.23]) or peri-procedural adverse event (OR 85.0 [95% CI 6.5–118.9]), but not treatment modality (OR 0.39[95% CI 0.08–2.04]), was the predictor of poor neurologic outcome.

Conclusions

Complementary implementation of both endovascular and open surgery facilitates individualized treatment planning of BAAs. By leveraging strengths of both techniques, equivalent clinical outcomes and technical proficiency may be achieved with both modalities.

Endovascular Reconstruction of Intracranial Aneurysms with the Pipeline Embolization Device in Pediatric Patients: A Single-Center Series

Background

Pediatric intracranial aneurysms tend to differ in etiology, size, and location from their adult counterparts, and they are often less amenable to microsurgical clip reconstruction techniques. Endovascular treatment with detachable coils is an accepted treatment technique for pediatric patients, though high recurrence rates have been reported with coil embolization of large and giant aneurysms in this population. While the Pipeline Embolization Device (PED) is FDA-approved for adult intracranial aneurysms, the use of PEDs in pediatric patients is considered off-label.

Case Descriptions

We present 3 cases of pediatric intracranial aneurysms in a 5-year-old male, a 12-year-old male, and a 12-year-old female who presented with symptoms including seizure, headache, and blurred vision. The 2 male patients were found to have intradural vertebral artery saccular aneurysms, while the female patient had a paraophthalmic right internal carotid complex aneurysm. After endovascular reconstruction of the aneurysms with PEDs, follow-up angiography showed complete occlusion of the previous aneurysms with no residual aneurysm filling in all 3 cases.

Conclusion

While further investigation is needed, the evidence presented here supports the conclusion that the PED can be an effective and viable treatment strategy in the pediatric population.

Should we still consider clips for basilar apex aneurysms? A critical appraisal of the literature

Background:

Basilar apex aneurysms constitute 5–8% of all intracranial aneurysms, and their treatment remains challenging for both microsurgical and endovascular approaches. The perceived drawback of the microsurgical approach is its invasiveness leading to increased surgical morbidity. However, many high-volume centers have shown excellent clinical results with better occlusion rates compared to endovascular treatment. With endovascular therapy taking a larger role in the management of cerebral aneurysms, the future role of microsurgery for basilar apex aneurysm treatment is unclear.

Methods:

We performed a literature search to review the microsurgical and endovascular outcomes for basilar apex aneurysms.

Results:

Many studies have examined the efficacy of microsurgical and endovascular treatment for intracranial aneurysms, including large randomized trials such as ISAT and BRAT, prospective observational series such as ISUIA, and many single-center retrospective reviews. The recruitment number for posterior circulation aneurysms, specifically for basilar apex aneurysms, was limited in most prospective trials, thus failing to offer clear guidance on basilar apex aneurysm treatment. Recent single-center series report good clinical outcomes between 57–92% for surgical series and 73–96% in endovascular series. The durability of aneurysm occlusion remains superior in surgical cases. The techniques and devices in endovascular treatment have improved treatment aneurysm occlusion rates but more follow-up is needed to confirm long-term durability.

Conclusions:

Both microsurgical and endovascular approaches should be complementing each other to treat basilar apex aneurysms. Although endovascular therapy has taken a larger role in the treatment of basilar apex aneurysms, many indications still exist for the use of microsurgery. Advancements in microsurgical techniques and good case selection will allow for acceptably low morbidity after surgical treatment while maintaining its superior durability.

Comparison of endovascular and microsurgical management of 208 basilar apex aneurysms

OBJECTIVE

The deep and difficult-to-reach location of basilar apex aneurysms, along with their location near critical adjacent perforating arteries, has rendered the perception that microsurgical treatment of these aneurysms is risky. As a result, these aneurysms are considered more suitable for treatment by endovascular intervention. The authors attempt to compare the immediate and long-term outcomes of microsurgery versus endovascular therapy for this aneurysm subtype.

METHODS

A prospectively maintained database of 208 consecutive patients treated for basilar apex aneurysms between 2000 and 2012 was reviewed. In this group, 161 patients underwent endovascular treatment and 47 were managed microsurgically. The corresponding records were analyzed for presenting characteristics, postoperative complications, discharge status, and Glasgow Outcome Scale (GOS) scores up to 1 year after treatment and compared using chi-square and Student t-tests.

RESULTS

Among these 208 aneurysms, 116 (56%) were ruptured, including 92 (57%) and 24 (51%) of the endovascularly and microsurgically managed aneurysms, respectively. The average Hunt and Hess grade was 2.4 (2.4 in the endovascular group and 2.2 in the microsurgical group; p = 0.472). Postoperative complications of cranial nerve deficits and hemiparesis were more common in patients treated microsurgically than endovascularly (55.3% vs 16.2%, p < 0.05; and 27.7% vs 10.6%, p < 0.05, respectively). However, aneurysm remnants and need for retreatment were more common in the endovascular than the microsurgical group (41.3% vs 2.3%, p < 0.05; and 10.6% vs 0.0%, p < 0.05, respectively). Stent placement significantly reduced the need for retreatment. Rehemorrhage rates and average GOS score at discharge and 1 year after treatment were not statistically different between the two treatment groups.

CONCLUSIONS

Patients with basilar apex aneurysms were significantly more likely to be treated via endovascular management, but compared with those treated microsurgically, they had higher rates of recurrence and need for retreatment. The current study did not detect an overall difference in outcomes at discharge and 1 year after either treatment modality. Therefore, in a select group of patients, microsurgical treatment continues to play an important role.

Aneurismal subarachnoid hemorrhage: who remains for surgical treatment in the post-ISAT era?

INTRODUCTION

Although there have been a number of studies on changes and trends in the management of aneurismal subarachnoid hemorrhage (aSAH) since publication of the International Subarachnoid Aneurysm Trial (ISAT), no data exist on what category of patients still remains for surgical treatment. Our goal was to investigate the changes that occurred in the characteristics of a population of aSAH patients treated surgically in the post-ISAT period in a single neurosurgical center, with limited availability of endovascular service.

MATERIAL AND METHODS

The study included 402 aSAH patients treated surgically in our unit between January 2004 and December 2011. Each year, data regarding number of admissions, age, aneurysm location and size, clinical and radiological presentation, outcome and mortality rates were collected and analyzed.

RESULTS

The annual number of admissions more than halved in the study period (from 69 in 2004 to 32 in 2011). There were no linear trends regarding patients' mean age, clinical presentation and outcomes, but the number of patients in Fisher grade 4 increased and mortality slightly decreased. An unexpected, statistically significant increase occurred in the incidence of anterior communicating artery aneurysms (from 36.2% to 50%) and medium size aneurysms (from 34.7% to 56.2%) treated surgically, with a corresponding decrease in the incidence of middle cerebral artery aneurysms (from 40.5% to 34.3%) and large aneurysms (from 21.7% to 12.5%).

CONCLUSIONS

Unexpected trends in characteristics of aSAH patients treated surgically could be related to treatment decision modality. Trend patterns could be properly expressed in the constant availability of endovascular services.

Endovascular embolization is applicable for large and giant intracranial aneurysms: experience in one center with long-term angiographic follow-up

BACKGROUND

Endovascular treatment of large and giant intracranial aneurysms and long-term results of angiographic follow-up of these aneurysms treated endovascularly are not known currently.

PURPOSE

To investigate the outcome of endovascular treatment of large and giant aneurysms and the long-term angiographic follow-up results.

MATERIAL AND METHODS

A retrospective analysis of all patients with endovascular treatment of large and giant aneurysms between 1998 and 2009 was performed. There were 90 large or giant aneurysms treated with coiling alone, stent-assisted coiling, covered-stent deployment, or parent artery occlusion (PAO) in 88 patients (female/male, 54/34; age range, 23-92 years; mean age, 56 years).

RESULTS

Immediately after the initial endovascular embolization procedure, complete occlusion was achieved in 56.7%, near complete occlusion in 37.8%, and incomplete occlusion in 5.5%. The total periprocedural complication rate excluding subarachnoid hemorrhage (SAH)-induced vasospasm was 10.2% with a mortality rate of 2.3%. Follow-up angiography was performed in all of the aneurysms with the longest follow-up duration of 131 months. Among 38 aneurysms initially treated with coiling alone and 17 initially treated with stent-assisted coiling, 22 (57.9%) and four (23.5%) recurred, respectively, during follow-up. No recurrence occurred in aneurysms initially treated with covered-stent deployment or PAO. Aneurysm recurrence was predominantly seen in older and female patients, in larger aneurysms, and in aneurysms treated with coiling alone. Twenty-three aneurysms were successfully retreated endovascularly.

CONCLUSION

Endovascular intervention with coiling alone or stent-assisted coiling for large and giant cerebral aneurysms is not very effective, while covered stents are more promising. Better endovascular devices are needed to obtain more secure closure.

Adverse events after unruptured cerebral aneurysm treatment: a single-center experience with clipping/coil embolization combined units

BACKGROUND

Indications of clipping (Clip) or coil embolization (Coil) for unruptured cerebral aneurysms (uAN) was not elaborated because prediction of rupture and risk of treatment are difficult. This study aims to determine the risk-benefit analysis of treating uAN by a comprehensive and retrospective investigation of the adverse events and sequelae in patients treated by our Clip/Coil combined units.

METHODS

Clip and Coil were performed in 141 and 80 patients, respectively; Clip for middle cerebral artery AN and Coil for paraclinoid or basilar apex AN. Worsening of modified Rankin scale or mini-mental state examination was defined as major morbidity. Minor morbidity or transient morbidity was defined as other neurologic deficits. Mortality and these morbidities were considered as serious adverse events. Convulsion or events outside the brain were defined as mild adverse events.

RESULTS

Total mortality and major morbidity were low. Incidence of serious adverse events was not significantly different between the Clip and Coil (17 patients [12.1%] and 6 patients [7.5%]), but the number of total adverse events was significantly different (32 patients [22.7%] in Clip vs. 8 patients [10.0%] in Coil). Because mild morbidities were significantly more frequent in the Clip (20 patients [14.2%]) compared with the Coil (2 patients [2.5%]). Convulsion occurred in 11 (7.8%) patients in the Clip but none in the Coil.

CONCLUSIONS

Our combined unit decreased the occurrence of mortality/major morbidity; however, minor adverse effects were common, especially in the Clip group because of many intrinsic problems of Clip itself. This result suggests further consideration for the treatment modality for uAN.

Extended subtemporal transtentorial approach to the anterior incisural space and upper clival region: experience with posterior circulation aneurysms

BACKGROUND

Although most posterior circulation aneurysms are currently treated by endovascular means, some are not amenable to this treatment modality. The narrow working window afforded by the anterolateral and lateral surgical approaches often translates into suboptimal visualization and limited maneuverability.

OBJECTIVE

We present a modified technique of tentorial incision and reflection that optimizes the exposure achieved with the traditional subtemporal approach and report our clinical experience in a series of posterior circulation aneurysms.

METHODS

Retrospective review of patients operated via an extended subtemporal transtentorial approach for posterior circulation aneurysms. The modified tentorial incision implies dissection of the trochlear nerve along its dural canal up to its entrance into the cavernous sinus and incision of a tentorial flap that extends up to Meckel cave, which is then reflected far anterolaterally. Clinical and radiological data were reviewed.

RESULTS

This series comprises 18 patients (21 procedures). Ten patients presented (56%) with a subarachnoid hemorrhage. Aneurysms most frequently arose from the basilar tip (61%) and were of small size (50%) and saccular morphology (72%). Two patients underwent surgery following unsuccessful endovascular treatment. Aneurysm treatment was successful on the first attempt in 90% (19/21) and after a second attempt in 10% (2/21). Documented postoperative palsies of the oculomotor (n = 3) and trochlear (n = 1) nerves were all transient. No procedure-related mortality occurred.

CONCLUSION

This modified technique of tentorial incision and reflection optimizes visibility, anatomic orientation, and maneuverability by increasing the rostrocaudal and anterolateral exposure obtained via the extended subtemporal transtentorial route without permanent postoperative trochlear nerve deficit.

Patient selection for endovascular treatment of intracranial aneurysms

With recent advancement in medical imaging, techniques, and endovascular tools more patients are diagnosed with unruptured intracranial aneurysms. The main aim of offering aneurysm treatment is to ameliorate the risk of future aneurysm bleeding, while not posing additional risks on the patient from the treatment itself. We discuss in this paper our approach of selecting patients for treatment (simple coiling, balloon-assisted, stent-assisted, vessel sacrifice, or flow-divertion stents). Our decision-making is based on the published data and our center experience. Risks of all option are compared to each other and weighed against natural history of intracranial aneurysms. In this paper, literature is cited and case illustrations are presented to support this approach. Factors that affect our decision-making are aneurysm location, presentation, size, aneurysm geometry, parent vessel anatomy, and relevant co-morbidities.

Endovascular treatment of posterior circulation aneurysms

Endovascular techniques are well suited for the treatment of posterior circulation aneurysms. This review describes the endovascular management of these aneurysms and discusses relevant technical advances.

A Multicenter Study of Stent-Assisted Coiling of Cerebral Aneurysms With a Y Configuration

BACKGROUND:

Stent-assisted coiling with 2 stents in a Y configuration is a technique for coiling complex wide-neck bifurcation aneurysms.

OBJECTIVE:

We sought to provide long-term clinical and angiographic outcomes with Y-stent coiling, which are not currently established.

METHODS:

Seven centers provided deidentified, retrospective data on all consecutive patients who underwent stent-assisted coiling for an intracranial aneurysm with a Y-stent configuration.

RESULTS:

Forty-five patients underwent treatment by Y-stent coiling. Their mean age was 57.9 years. Most aneurysms were basilar apex (87%), and 89% of aneurysms were unruptured. Mean size was 9.9 mm. Most aneurysms were treated with 1 open-cell and 1 closed-cell stent (51%), with 29% treated with open-open stents and 16% treated with 2 closed-cell stents. Initial aneurysm occlusion was excellent (84% in Raymond grade I or II). Procedural complications occurred in 11% of patients. Mean clinical follow-up was 7.8 months, and 93% of patients had a modified Rankin Scale score of 0 to 2 at last follow-up. Mean angiographic follow-up was 9.8 months, and 92% of patients had Raymond grade I or II occlusion on follow-up imaging. Of those patients with initial Raymond grade III occlusion and follow-up imaging, all but 1 patient progressed to a better occlusion grade (83%; P &lt; .05). Three aneurysms required retreatment because of recanalization (10%). There was no difference in initial or follow-up angiographic occlusion, clinical outcomes, incidence of aneurysm retreatment, or in-stent stenosis among open-open, open-closed, or closed-closed stent groups.

CONCLUSION:

In a large multicenter series of Y-stent coiling for bifurcation aneurysms, there were low complication rates and excellent clinical and angiographic outcomes.

Long-term Economic Impact of Coiling vs Clipping for Unruptured Intracranial Aneurysms

BACKGROUND:

Treatment of unruptured intracranial aneurysms (UIAs) involves endovascular coiling or aneurysm clipping. While many studies have compared these treatment modalities with respect to various clinical outcomes, few studies have investigated the economic costs associated with each procedure.

OBJECTIVE:

To determine the reoperation rate, postoperative complications, and inpatient and outpatient costs associated with surgical or endovascular treatment of patients with UIAs in the United States.

METHODS:

We utilized the MarketScan database to examine patients who underwent surgical clipping or endovascular coiling procedures for UIAs from 2000 to 2009, comparing reoperation rates, complications, and angiogram and healthcare resource use. Propensity score matching techniques were used to match patients.

RESULTS:

We identified 4,504 patients with surgically treated UIAs, with propensity score matching of 3,436 patients. Reoperation rates were significantly lower in the clipping group compared to the coiling group at 1- (P &lt; .001), 2- (P &lt; .001), and 5 years (P &lt; .001) following the procedure. However, postoperative complications (immediate, 30 and 90 days) were significantly higher in those undergoing surgical clipping. Although hospital length of stay and costs were higher in the clipping group for the index procedure, the number of postoperative angiograms and outpatient services used at 1, 2, and 5 years were significantly higher in the coiling group.

CONCLUSION:

Though surgical clipping resulted in lower reoperation rates, it was associated with higher complication rates and initial costs. However, overall costs at 2 and 5 years were similar to endovascular coiling due to the significantly higher number of follow-up angiograms and outpatient costs in these patients.

Update on the management of subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) is a devastating cerebrovascular disease. Outcome after SAH is mainly determined by the initial severity of the hemorrhage. Neuroimaging, in particular computed tomography, and aneurysm repair techniques, such as coiling and clipping, as well as neurocritical care management, have improved during the last few years. The management of a patient with SAH should have an interdisciplinary approach with case discussions between the neurointensivist, interventionalist and the neurosurgeon. The patient should be treated in a specialized neurointensive care unit of a center with sufficient SAH case volume. Poor-grade patients can be observed for complications and delayed cerebral ischemia through continuous monitoring techniques in addition to transcranial Doppler ultrasonography such as continuous electroencephalography, brain tissue oxygenation, cerebral metabolism, cerebral blood flow and serial vascular imaging. Neurocritical care should focus on neuromonitoring for delayed cerebral ischemia, management of hydrocephalus, seizures and intracranial hypertension, as well as of medical complications such as hyperglycemia, fever and anemia.

Risk Factors Affecting Clinical Outcome of Ruptured Vertebrobasilar Saccular Aneurysms

Objective

Ruptured vertebrobasilar (VB) saccular aneurysm is a difficult lesion to treat, and is associated with high rates of morbidity and mortality. The aim of this study is to investigate the risk factors associated with the clinical outcome of ruptured VB aneurysms.

Methods

A retrospective review of 29 patients with ruptured VB saccular aneurysms between 2002 and 2010 was conducted between Jan 2002 and Dec 2010. Univariate and multivariate analyses were performed for determination of the statistical significance of the Glasgow Outcome Scale (GOS) at three months, according to age, initial Hunt-Hess grade, the presence of acute hydrocephalus, and treatment modality.

Results

The study included 24 (82.7%) females and five (17.3%) males, with a mean age of 59 years (range, 22-78 years). Seventeen patients were treated with surgical clipping and 12 patients were treated with endovascular coil embolization. No statistical significance was observed between clinical outcome and treatment modalities (clipping or coiling; p = 0.803). Seventeen (58.6%) patients achieved favorable outcome, defined as GOS score of 4-5, at 3 months. Procedure-related complications occurred in seven patients (24.1%). Results of multivariate analysis indicated that initial Hunt-Hess grade and the presence of acute hydrocephalus were independent predictors of unfavorable outcome, defined as GOS score of 1-3 (Odds ratio (OR) = 8.63, Confidence interval (CI) [95%] 1.11-66.84, p = 0.039 and OR = 36.64, CI [95%] 2.23-599.54, p = 0.012, respectively).

Conclusion

The present study suggests that the clinical outcomes are related to the initial Hunt-Hess grade and the presence of acute hydrocephalus in ruptured saccular VB aneurysms.

Endovascular management of intracranial aneurysms

Data from our clinical series and others supports the idea that endovascular coil embolization is a reliable form of treatment for both ruptured and unruptured cerebral aneurysms. This form of treatment appears from preliminary data to be protective against subarachnoid hemorrhage. Although not likely to replace open surgery, the continued advancements in technology and supportive clinical data will allow endovascular therapy to become a more durable mode of treatment.

Clipping Versus Coiling for Ruptured Intracranial Aneurysms

OBJECTIVE

Patients with intracranial aneurysms, both ruptured and unruptured, are frequently eligible for both open surgery (“clipping”) and endovascular repair (“coiling”). Although results of randomized trials have informed this decision, the actual choice of clipping or coiling for individual patients remains complex. At the 2007 Congress of Neurological Surgeons (CNS) Annual Meeting, a novel active learning process called Integrated Medical Learning (IML) was applied to education about this critical treatment choice.

METHODS

CNS members received an electronically distributed premeeting survey and educational materials about the clipping versus coiling decision and related topics. At the Annual Meeting, participants used handheld devices to choose clipping or coiling for treatment of individual aneurysms, both before and after expert opinion presentations. After the meeting, members who had answered premeeting surveys received a follow-up questionnaire.

RESULTS

In the premeeting poll, respondents with self-described specialties of “vascular,” Cerebrovascular Section members, surgeons with active cerebrovascular practices, and surgeons in practice for less than 20 years had higher levels of baseline knowledge of cerebrovascular literature (P &lt; .03). Surgeons' clinical volumes of clipping and coiling strongly influenced their vote for clipping or coiling for a hypothetical patient (P &lt; .01). At the meeting, in 6 of 8 cases of ruptured aneurysms the audience was split 75%:25% or closer to “clinical equipoise” (50:50 split). Surgeons with vascular specialty, academic surgeons, and residents were more likely to recommend clipping for individual cases (P &lt; .05). After experts' presentations, in 6 of 8 cases the audience opinion changed significantly. Vascular specialists and younger surgeons were less likely to change their opinion (P &lt; .03). The 2 cases with no shift in opinion were the most-clippable and most-coilable cases. Postmeeting surveys showed evidence of retained knowledge from the meeting, and respondents thought IML had been helpful.

CONCLUSIONS

Using IML, we were able to study baseline knowledge and practice patterns for an important cerebrovascular treatment decision. Evidence suggested that expert presentations were effective in changing audience opinion, at least in cases where preexisting opinion was close to clinical equipoise.

The effect of coiling versus clipping of ruptured and unruptured cerebral aneurysms on length of stay, hospital cost, hospital reimbursement, and surgeon reimbursement at the university of Florida

OBJECTIVE

There are few studies comparing the economic costs and reimbursements for aneurysm clipping versus coiling, and none are from the United States. Our hypothesis predicted that coiling would result in shorter lengths of hospitalization than clipping in patients with unruptured aneurysms and would therefore result in lower hospital charges. However, because of the severity of subarachnoid hemorrhage, there would be no difference in length of hospitalization or hospital charges in patients with ruptured aneurysms.

METHODS

We compared aneurysm coiling with aneurysm clipping in patients with unruptured and ruptured aneurysms treated at the University of Florida from January 2005 to June 2007 for differences in length of hospitalization, hospital costs, hospital collections, and surgeon collections. Patient demographic and aneurysm characteristic data were obtained from a clinical database. Length of hospitalization, cost, billing, and collection data were obtained from the hospital cost accounting database. Multivariate statistical analyses of length of hospitalization, hospital costs, hospital collections, and surgeon collections were performed using factors including patient age, sex, aneurysm size, aneurysm location, aneurysm treatment, presence of subarachnoid hemorrhage, clinical grade, payor, hospital billing, and surgeon billing.

RESULTS

There were 565 patients with cerebral aneurysms treated either surgically (306 patients, 54%) or endovascularly (259 patients, 46%). In patients without subarachnoid hemorrhage (unruptured aneurysms) (n = 367), surgery, compared with endovascular treatment, was associated with longer hospitalization (P < 0.001), but lower hospital costs (P < 0.001), higher surgeon collections (P = 0.003), and similar hospital collections. In patients with subarachnoid hemorrhage (ruptured aneurysms) (n = 198), surgery was associated with lower hospital costs (P = 0.011), but similar length of stay, surgeon collections, and hospital collections. Larger aneurysm size was significantly associated with longer hospitalization in the patients with unruptured aneurysms (P < 0.001) and higher hospital costs for both patients with unruptured (P < 0.001) and ruptured (P = 0.015) aneurysms. The payor was significantly associated with hospital costs in patients with ruptured aneurysms (P = 0.034) and length of stay (unruptured aneurysms, P < 0.001; ruptured aneurysms, P < 0.001), hospital collections (unruptured aneurysms, P < 0.001; ruptured aneurysms, P < 0.001), and surgeon collections (unruptured aneurysms, P < 0.001; ruptured aneurysms, P < 0.001) in both patients with unruptured and ruptured aneurysms. A worse clinical grade was significantly associated with higher hospital costs (P < 0.001).

CONCLUSION

Despite a shorter length of hospitalization in patients with unruptured aneurysms, coiling was associated with higher hospital costs in both patients with unruptured and ruptured aneurysms. This is likely attributable to the higher device cost of coils than clips. The advantages of coiling over clipping would be better realized if the cost of coils could be comparably reduced to that of clips.

Clinical outcomes of basilar artery aneurysms

To evaluate the effects of endovascular treatments, we retrospectively analyzed a consecutive series of patients with basilar artery aneurysms (BAAs) treated endovascularly. During a seven year period, 43 patients (mean age 42.2 years, male/female ratio 21:22) with BAAs were treated mainly with endovascular techniques at Beijing Tiantan Hospital. Pretreatment clinical grades were determined using the Hunt-Hess scale. Outcome was evaluated using the Glasgow Outcome Scale scores (GOS) during a mean follow-up period of 21.1 months (range, 1 to 72 months). Forty-three patients had 44 BAAs, one MCA aneurysm and one P1 aneurysm. Endovascular treatment was technically feasible in 40 patients. One aneurysm thrombosed spontaneously after initial angiography. Four (9.3%) patients died periprocedurally. Immediate postprocedural angiograms in 44 BAAs showed that complete occlusion was achieved in 33 BAAs, subtotal occlusion in one and incomplete occlusion in seven. Follow-up angiographic results in 30 patients confirmed complete occlusion of 27 aneurysms, subtotal occlusion in one, and incomplete occlusion in two. Two patients with vertebrobasilar atheromatous fusiform aneurysms were treated with antiplatelet medications. Long-term outcome was good (GOS Score 4 or 5) in 39 patients (90.7%) and fatal (GOS Score 1) in four (9.3%). Favorable overall long-term outcome can be achieved in patients with BA apex aneurysms, and in 78.6% of those with BA trunk aneurysms when using endovascular techniques. Endovascular coil embolization of BAAs is an effective treatment in the long-term. Patients with vertebrobasilar atheromatous fusiform aneurysms can be treated with antiplatelet medications.

Plical resection in pre-temporal approach for basilar bifurcation aneurysms: preliminary surgical experience and cadaveric study

OBJECT

Although a pre-temporal approach (PA) can provide a wide space for preservation of thalamoperforating atrteries in direct surgery for basilar bifurcation aneurysms (BBAs), it cannot always secure adequate proximal control. The authors described the advantages of plical resection added to PA for BBAs.

METHODS

Between October 1998 and April 2000, eight consecutive patients with BBAs were treated in the neurosurgical department of Kurashiki Central Hospital. Among them, five patients received direct clipping using this method. There were four females and one male, ages ranging from 61 to 77 (mean 70.8 years). Mean aneurysmal size and distance between the in"terclinoidal line and the aneurysmal neck was 4.5 and 9.5 mm, respectively. The operative procedures consisted of the following components; 1) fronto-temporal craniotomy with translocation of orbito-zygomatico-malar bone for PA, 2) preservation of lateral branches of the superficial sylvian veins, 3) resection of plica dural folds to increase the operative field up to the oculomotor nerve (OMN).

RESULTS

Complete clipping was achieved without thalamic infarction or temporal contusion in all patients. Three of the five patients suffered from transient right OMN palsy which recovered within two months after surgery.

CONCLUSION

Plical resection in the pre-temporal approach might be beneficial in the surgical treatment of BBAs when proximal control seems difficult.

Complications of Neuroform stent in endovascular treatment of intracranial aneurysms

BACKGROUND

The Neuroform stent can help in the treatment of difficult, wide-necked intracranial aneurysms. The objective of our study is to report some of the challenges associated with the Neuroform stent in the treatment of intracranial aneurysms.

METHODS

From January 2003 to August 2006, consecutive patients treated with Neuroform stent for intracranial aneurysms were prospectively enrolled. Information on patient demographics, cerebrovascular risk factors, aneurysm size and location were collected. Technical and clinical complications as well as clinical outcomes were measured. Data were analyzed retrospectively using SPSS software version 11.5.

RESULTS

Successful deployment of the stent, in the target artery, was achieved in 65/67 (97%) patients. Stent deployment failed in two cases and the migration of stent developed in one during coiling. Postoperative thromboembolic events developed in three patients. These three patients possessed hyperactive platelets, and were treated with intravenous eptifibatide. Intraoperative rupture of aneurysm developed in one patient, which was secured by subsequent coiling. Majority of the patients had good outcomes GOS (Glasgow Outcome Score) 1 or NIHSS (National Institute of Health Stroke Scale) 0 in 63/67 (94%), GOS 2 or NIHSS 2 in one patient and GOS 3 or NIHSS 4 was observed in three cases.

CONCLUSION

Despite a low rate of intraoperative complications, post-procedural thromboembolic events were common in Neuroform stent-treated patients, which might be associated with hyperactive platelets. Further studies are warranted to identify any potential relationship between post-stent hyperactive platelets and thromboembolism.

Comparison of endovascular and surgical treatments for intracranial aneurysms: an evidence-based review

Intracranial aneurysms can be treated with endovascular or surgical techniques. We provide an objective comparison of these treatments, using data from single-centre studies, multicentre studies with and without independent outcome ascertainment, and randomised clinical trials. We compared the outcomes of patients who were candidates for endovascular treatment, surgical treatment, or both. In patients with ruptured intracranial aneurysms, rates of aneurysm obliteration were higher, and need for second treatment was lower, after surgery than after endovascular treatment. However, in observational studies and randomised trials, outcome at discharge, at 2-6 months, and at 1 year, and later survival, were all better after endovascular treatment than after surgery. The results suggest that the higher rates of incomplete obliteration and retreatment after endovascular treatment do not affect patients' clinical outcome. In observational studies of patients with unruptured intracranial aneurysms, discharge outcomes were better and hospital costs were lower after endovascular treatment than after surgery. These patients showed no difference between the two treatments in 1-year outcomes and later rebleeding, although few data were available for this comparison.

Sapphire® platinum detachable coil experience in a tertiary-care facility

BACKGROUND

The Guglielmi Detachable Coil introduced by the Boston Scientific Corporation has been widely used for endovascular coiling of aneurysm. Recently, Sapphire platinum detachable coils (eV3, Irvine, CA) have been introduced for aneurysm coiling. Herein, we report our clinical experience with the Sapphire coil to evaluate the incidence of coil related complications and the rate of aneurysm occlusion.

METHODS

Consecutive patients who underwent embolization with Sapphire detachable coils were prospectively enrolled from January 2004 to September 2004 and the data were retrospectively analyzed. Patient demographics, including age, gender, presenting symptoms, Hunt and Hess grade, Fisher grade and locations of the vascular anomalies were collected. Additionally, complications associated with the coils and rates of aneurysm occlusion were observed and the data compiled.

RESULTS

29 patients underwent Sapphire coil embolization for intracranial aneurysms. Mean age was 50 +/- 18 (mean +/- SD) years with 81% being females. Aneurysm neck reconstruction was required in 7 cases, 6 with Neuroform stent (5 unruptured aneurysms) and 1 with balloon assistance (ruptured aneurysm). In 7 cases, Sapphire coils were used along with other coils. There were no events of thromboembolism or ruptures of aneurysms during coil embolization. However, multi-diameter coils demonstrated stretching in 4 stent-assisted cases without any adverse consequences. Complete occlusion of the aneurysm was achieved in 79.31% of the patients, neck remnant in 6.89, and partial coiling was achieved in 13.79%.

CONCLUSION

The Sapphire coil could safely be used in the treatment of both ruptured and unruptured aneurysms. However, multi-diameter non-stretch resistant coils may be associated with coil stretching when used in conjunction with a stent. Further study is still required for definitive results.

Endovascular management of intracranial aneurysms: current experience and future advances

OBJECTIVE

The past 15 years have seen a revolution in the treatment of intracranial aneurysms. Endovascular technology has evolved rapidly since the Food and Drug Administration approval of Guglielmi detachable coils in 1995, which now allows successful treatment of most aneurysms. The authors provide a review of their 11-year experience at Jefferson Hospital for Neuroscience with endovascular embolization of intracranial aneurysms and discuss clinical trial outcomes and future directions of this treatment method.

METHODS

The authors reviewed the clinical and angiographic outcomes for 1307 patients undergoing endovascular treatment of intracranial aneurysms. Their analysis focuses on posterior circulation and middle cerebral artery aneurysms, as well as cases of stent-assisted coil embolization. They review their procedural protocol and patient selection criteria for endovascular management.

RESULTS

Several large clinical trials have demonstrated the safety and efficacy of endovascular treatment of intracranial aneurysms. The International Subarachnoid Aneurysm Trial provides Level I evidence demonstrating a significant reduction in disability or death with endovascular treatment compared with surgical clipping. The most common procedural complications include intraprocedural rupture and thromboembolic events; avoidance strategies are also discussed. Vasospasm after subarachnoid hemorrhage causes neurological morbidity and mortality and can be successfully managed by early recognition and interventional treatment with angioplasty, pharmacologic agents, or both.

CONCLUSION

Long-term studies evaluating experience with aneurysm coil embolization during the past decade indicate that this is a safe and durable treatment method. The introduction of stent-assist techniques has improved the management of wide-neck aneurysms. Future technology developments will likely improve the durability of endovascular treatment further by delivering bioactive agents that promote aneurysm thrombosis beyond the coil mass alone. It is clear that endovascular therapy of both ruptured and unruptured aneurysms is becoming a mainstay of practice in this patient population. Although not replacing open surgery, the continued improvements have allowed aneurysms that previously were amenable only to open clip ligation to be treated safely with durable long-term outcomes.

ENDOVASCULAR COIL EMBOLIZATION OF RUPTURED AND UNRUPTURED POSTERIOR CIRCULATION ANEURYSMS

OBJECTIVE

Treatment of posterior circulation aneurysms poses a great technical challenge for the practicing neurosurgeon. The advent of endovascular techniques has made such treatment more feasible. We report our experience with the endovascular management of ruptured and unruptured posterior circulation aneurysms during the past 10 years.

METHODS

A retrospective analysis was performed on all patients with posterior circulation aneurysms undergoing endovascular treatment at Jefferson Hospital for Neuroscience between July 1995 and December 2005. This yielded 275 patients (67 men and 208 women). The degree of aneurysm occlusion was determined by the operating endovascular neurosurgeon at the time of the procedure. Successful embolization was defined as greater than 95% occlusion of the dome without any coil prolapsing into the parent vessel. Clinical outcome was evaluated using the modified Glasgow Outcome Scale. Clinical follow-up data was obtained for 262 patients (95.3%); the follow-up period ranged from 1 to 94 months (mean, 31.8 mo for procedures performed before 2004 and 13.3 mo for procedures performed during 2004 and 2005). Angiographic follow-up data was obtained for 224 patients (84.8%) for periods ranging from 6 to 94 months (mean, 31.3 mo for procedures performed before 2004 and 13.7 mo for procedures performed during 2004 and 2005).

RESULTS

Based on the Hunt and Hess grading scale, the patient population included 106 patients (38.5%) with unruptured aneurysms, 43 patients (15.6%) with Grade I aneurysms, 16 patients (5.8%) with Grade II aneurysms, 56 patients (20.5%) with Grade III aneurysms, and 54 patients (19.6%) with Grade IV aneurysms. The locations of the posterior circulation aneurysms included 189 (68.7%) in the basilar apex or posterior cerebral artery, 23 (8.4%) in the basilar trunk/anterior inferior cerebellar artery, 22 (8%) in the superior cerebellar artery, and 41 (14.9%) in the vertebral artery or posterior inferior cerebellar artery. Of the 275 patients, 208 (76%) were women and 67 (24%) were men. The mean age at the time of treatment was 53.9 years (range, 7–90 yr). Of all patients treated, 237 patients (87.8%) had successful embolization (&gt;95% occlusion of the dome). On angiographic follow-up, 55 patients (24.5%) developed recanalization of at least 5%. Retreatment was required in 11 patients (4.9%; 0.01%/patient yr) and rehemorrhage occurred in three patients (1.1%; 0.003%/patient yr). Clinical follow-up was graded using the modified Glasgow Outcome Scale (mGOS) and revealed 229 patients (87.4%) in the mGOS I category, 12 patients (4.6%) in the mGOS II category, eight patients (3%) in the mGOS III category, two patients (0.8%) in the mGOS IV category, and 11 patients (4.2%) were deceased (mGOS V). Clinically significant vasospasm requiring angioplasty occurred in 11 patients (6.5%) with subarachnoid hemorrhage, and 120 patients (71%) with subarachnoid hemorrhage required ventricular shunts. Complications causing clinical morbidity occurred in 14 patients (5.1%) and ranged from postoperative ischemia to recurrent subarachnoid hemorrhage. Of all clinical factors evaluated, Hunt and Hess grade was the strongest predictor of good clinical outcome (P &lt; 0.0001).

CONCLUSION

Endovascular coil embolization of posterior circulation aneurysms is an effective treatment in the short term but is associated with recurrence, which requires close surveillance, possible retreatment, and can, albeit very rarely, lead to rehemorrhage. Future technological advancements such as the development of biologically active coils will be essential in the permanent obliteration of aneurysms.

Aneurysms of the posterior circulation: detection and treatment planning using volume-rendered three-dimensional helical computerized tomography angiography

Object. The aim of this study was to determine whether computerized tomography (CT) angiography could be used to identify and characterize aneurysms of the posterior circulation and guide optimal treatment selection, and how data obtained using this method compared with intraoperative findings.

Methods. Patients suspected of harboring brain aneurysms underwent CT angiography and digital subtraction (DS) angiography; the results were prospectively interpreted by blinded independent evaluators. All patients with posterior circulation aneurysms were consecutively enrolled in the study. After treatment, neurosurgeons and endovascular therapists evaluated the ability of CT and DS angiography to demonstrate features of the lesions important for triage between treatment options (Wilcoxon signed-rank test) and to allow for coil or clip preselection and complete treatment planning (McNemar test of proportions), while using intraoperative findings as the basis of truth.

In 242 patients overall, CT angiography detected 38 aneurysms and two aneurysmal blisters in 32 patients. The sensitivity of CT angiography in revealing posterior circulation aneurysms was 100% compared with DS angiography, with no false-positive results. Furthermore, CT angiography was sufficient as the sole study at triage for 65% of the posterior circulation aneurysms (26 of 40 lesions; p < 0.001), including 62% of the complex lesions (p < 0.001), and permitted coil or clip preselection in 74% of treated cases (20 of 27 cases; p < 0.002). Results of CT angiography revealed information about mural calcification and intraluminal thrombus not available on DS angiography, which affected patient care.

Conclusions. In this study population, CT angiography was comparable to DS angiography in the detection and characterization of aneurysms of the posterior circulation. Computerized tomography angiography was used successfully to triage patients between endovascular and neurosurgical treatment options in a significant proportion of cases and permitted treatment planning in more than 70% of treated cases.

Anévrismes intracrâniens non rompus : que proposer ?

Intracranial unruptured aneurysm (ICUA) has become a common condition for patient consultation. The mortality rate after fissuration is estimated to be between 52% and 85.7%. The final therapeutic decision results from a balance between the risk of rupture and risks related to the aneurysmal exclusion. Analysis of the risk of rupture risk enables a classification of risk factors. Depending on the circumstances of diagnosis, we considered the ICUA at high risk of rupture for incidental ICUA larger than 7 mm and in the event of associated aneurysms. Classifying by morphologic features, high-risk ICUA were located in the vertebrobasilar system (RR: 4.4; 95%CI: 2.7-6.8), those with a size between 7 and 12 mm (RR: 3.3; 95%CO: 1.3-8.2), larger than 12 mm (RR: 17; 95%CI: 8-36.1), those that were multilobular or a larger size and those ones with a index P/L superior to 3.4 (risk x20). Familial ICUA would expose to a major rupture risk (2 to 7 times sporadic ICUA). Some systemic factors were related to ICUA rupture: arterial hypertension (RR: 1.46; 95%CI: 1.01-2.11) and smoking addiction (RR: 3.04; 95%CI: 1.21-7.66). After microsurgical exclusion, the morbidity and mortality rates were 10% and 2% respectively. Some microsurgical morbidity factors were identified: age (32%>65 years), size (14%>15 mm), vertebrobasilar location and temporary occlusion. The rupture incidence after microsurgical exclusion was estimated 0.26%/year. After endovascular exclusion, the morbidity and mortality rates were 8% and 1% respectively. The complete exclusion rate varied between 47% and 67%. The rupture risk was estimated at 0.9%/year. Treatment recommendations were classified into 3 categories.

Subarachnoid hemorrhage: neurointensive care and aneurysm repair

Aneurysmal subarachnoid hemorrhage (SAH) is often a neurologic catastrophe. Diagnosing SAH can be challenging, and treatment is complex, sophisticated, multidisciplinary, and rarely routine. This review emphasizes treatment in the intensive care unit, surgical and endovascular therapeutic options, and the current state of treatment of major complications such as cerebral vasospasm, acute hydrocephalus, and rebleeding. Outcome assessment in survivors of SAH and controversies in screening of family members are discussed.

Conventional microsurgical technique and endovascular method for the treatment of cerebral aneurysms: a comparative view

Endovascular embolization using Guglielmi Detachable Coils (GDCs) for complicated intracranial aneurysms has become widely accepted as an alternative to direct surgery. There is now a choice of therapeutic options for the management of cerebral aneurysms. The decision for treatment of an individual patient should be based on objective selection of the safest and most effective treatment. In addition, less invasive and cost effective treatment should be chosen. It is self-evident that the primary consideration in the selection process must be the immediate and long-term welfare of the individual patient, rather than the physician's preference for any specific treatment modality. GDC embolization is a less invasive and safe treatment with low incidence of periprocedural morbidity, and has been successful in preventing acute subsequent bleeding, whereas follow-up results are less satisfactory in cases involving incompletely obliterated lesions. High incidence of recanalization was promoted in cases with neck remnant and/or body filling. In contrast, the most important advantage of direct surgery is long-term durability, while conditions of patients and aneurysmal geometry limit the indication of direct surgery. In addition, direct surgery could be applied to complicated aneurysms with wide-neck or branching from the neck in combination with vascular reconstruction technique, such as EC-IC bypass. With these limitations in mind, patients need to be very carefully chosen for GDC embolization or direct surgery.

Basilar bifurcation aneurysms. Lessons learnt from 40 consecutive cases

Basilar bifurcation aneurysms are lately treated frequently with endovascular technique. Microsurgical clipping occlusion technique has, however, still its solid position because of its completeness. This standard technique is required often due to unfeasibility and/or incompleteness at the time of application of the endovascular technique for aneurysms of this location. The authors suggest following strategies and tactics for safe and secure occlusion of aneurysms of this location: pterional approach, selective extradural anterior clinoidectomy SEAC, no transection of the posterior communicating artery, isolation of perforating arteries at the time of neck clipping with oxycellulose and combination of the use of fenestrated clip and conventional clip (especially for aneurysms projected posteriorly), controlled hypotension (systolic pressure of around 100 mmHg), temporary clipping (trapping) procedures of usually less than 15 min. All these are aimed for prevention of intraoperative premature rupture, and of injury of perforating arteries and for complete occlusion of aneurysms in the narrow depth of the operative field.

Stent-assisted coil placement for unruptured cerebral aneurysms

OBJECT

The treatment of wide-necked cerebral aneurysms represents a challenging problem for neurosurgeons. The recent development of stents has provided clinicians with the ability to treat these aneurysms while keeping the parent vessel patent. The long-term occlusion rate of aneurysms treated with stent-assisted coil placement has yet to be investigated. The authors report the use of a new intracranial stent-the Neuroform microstent-in the treatment of unruptured wide-necked cerebral aneurysms.

METHODS

Thirty-two patients harboring unruptured wide-necked intracranial aneurysms underwent a stent-assisted coil placement procedure. Patients were pretreated with antiplatelet agents, and a stent was positioned across the neck of the aneurysm. The next step was the insertion of coils into the aneurysm cavity. Patients received anticoagulation therapy for 24 hours after the procedure. All 32 patients with unruptured wide-necked cerebral aneurysms were suitable candidates for this procedure. Occlusion of at least 90% of the aneurysm was achieved in 24 patients (75%) and 0% occlusion was observed in five patients (15%). Two patients experienced thromboembolic events, one of which was directly related to the stent. The overall complication rate was 6.3%.

CONCLUSIONS

Intracranial stents will be used more frequently in the new era of endovascular management of widenecked cerebral aneurysms. With some technical improvements and more data on long-term occlusion rates, this new modality should improve the occlusion of wide-necked cerebral aneurysms while protecting the parent vessel.

Current treatment options for unruptured intracranial aneurysms

A patient with an unruptured intracranial aneurysm has three options: surgical clip placement, endovascular coil occlusion, and observation. The decision making about management of these lesions should be based on the risk of aneurysm rupture and the risks associated with surgical or endovascular intervention. For patients who require interventions, factors such as aneurysm recurrence rate, its location, surgical or endovascular accessibility, the patient's general medical condition, and the individual's treatment preference should be taken into account to determine the choice of therapies. Currently, a team approach by neurosurgeons and endovascular interventionists is recommended to evaluate each patient and to tailor the best treatment plan.

Effect of Clipping, Craniotomy, or Intravascular Coiling on Cerebral Vasospasm and Patient Outcome after Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE:

Although several recent studies have suggested that the incidence of vasospasm after aneurysmal subarachnoid hemorrhage is lower in patients undergoing aneurysmal coiling as compared with clipping, other studies have had conflicting results. We reviewed our experience over 8 years and assessed whether clipping, craniotomy, or coiling affects patient outcomes or the risk for vasospasm.

METHODS:

We included 515 patients with aneurysmal subarachnoid hemorrhage, identified prospectively from November 2000 to February 2003 (243 patients) and retrospectively from November 1995 to October 2000 (272 patients), by using International Classification of Diseases, 9th Revision, codes for subarachnoid hemorrhage. We classified patients as follows: clipping (413 patients), coiling (79 patients), and craniotomy (436 patients, including all 413 patients who underwent clipping plus 23 who underwent coiling as well as craniotomy for various reasons). We studied four outcome measures: total vasospasm, symptomatic vasospasm, poor outcome (modified Rankin score 3–6), and in-hospital mortality. To assess the risk of total vasospasm and symptomatic vasospasm, we performed multivariate regression analyses adjusting for age, Fisher grade, Hunt and Hess grade, aneurysm location (anterior versus posterior circulation), and aneurysm treatment modality. To assess the risk for poor outcome and in-hospital mortality, we adjusted for all the above variables as well as for total and symptomatic vasospasm.

RESULTS:

In the clipping group there was 63% total vasospasm and 28% symptomatic vasospasm; in the coiling group there was 54% total vasospasm and 33% symptomatic vasospasm; and in the craniotomy group there was 64% total vasospasm and 28% symptomatic vasospasm. In the multivariate analysis, age &lt;50 years (P = 0.0099) and Fisher Grade 3 (P &lt; 0.00001) predicted total vasospasm, and Fisher Grade 3 (P &lt; 0.000001) and Hunt and Hess Grade IV or V (P = 0.018) predicted symptomatic vasospasm. Predictors of poor outcome were age ≥50 years (P &lt; 0.0001), Fisher Grade 3 (P = 0.0072), Hunt and Hess Grade IV or V (P &lt; 0.00001), symptomatic vasospasm (P &lt; 0.0001), and coiling (P = 0.0314 versus clipping and P = 0.045 versus craniotomy). Predictors of in-hospital mortality were age ≥ 50 years (P = 0.0030), Hunt and Hess Grade IV or V (P = 0.0001), symptomatic vasospasm (P &lt; 0.00001), and coiling (P = 0.008 versus clipping and P = 0.0013 versus craniotomy). There was no significant difference in total vasospasm or symptomatic vasospasm when patients who underwent clipping or craniotomy were compared with patients who underwent coiling. In patients with Hunt and Hess Grade I to III (“good grade”), clipping and craniotomy were associated with better outcome and less in-hospital mortality, but there was no difference in total vasospasm or symptomatic vasospasm versus coiling. In patients with Hunt and Hess Grade IV or V (“poor grade”), there was no difference in any outcome measure among the treatment groups.

CONCLUSION:

In a single-center, retrospective, nonrandomized study, performance of clipping and/or craniotomy had significantly better outcome and lower mortality at discharge than coiling in good-grade patients but had no effect on total vasospasm or symptomatic vasospasm in good- or poor-grade patients.

Endovascular occlusion of wide-necked aneurysms with a new intracranial microstent (Neuroform) and detachable coils

OBJECTIVE

The long-term durability of the endovascular occlusion of cerebral aneurysms is one of the major factors limiting the more widespread use of this technique. Long-term occlusion of wide-necked aneurysms has improved with new assistive devices that seem to improve aneurysm occlusion while protecting the parent vessel. We report the use of a new intracranial stent--the Neuroform microstent--in the treatment of patients with wide-necked cerebral aneurysms.

METHODS

Patients identified as harboring wide-necked intracranial aneurysms were evaluated for stent-assisted coiling. After appropriate anticoagulation was performed, depending on whether the aneurysm was ruptured or unruptured, the Neuroform stent was delivered across the neck of the aneurysm and deployed with a coil pusher. After stent placement, standard coil occlusion of the aneurysm was achieved in the majority of cases.

RESULTS

Fifty-six patients were identified as having wide-necked intracranial aneurysms suitable for stent-assisted coiling. A total of 49 aneurysms in 48 patients were treated with this procedure. In eight cases, stent deployment failed. Forty-one of the aneurysms were initially stented, followed by coil placement. Six aneurysms were stented only, and one aneurysm was initially coiled, followed by stent placement. There were five deaths (8.9%), one of which occurred secondary to a stroke after the procedure (1.8%). Four patients (7%) experienced thromboembolic events, three of which were considered to have been secondary to the procedure (5.3%). In addition, there were two femoral pseudoaneurysms. The overall complication rate was 10.7%. Five patients were available for follow-up angiographic evaluation, and their cases are discussed.

CONCLUSION

Intracranial stenting may overcome important technical limitations in current endovascular therapy by improving the occlusion of wide-necked aneurysms while protecting the parent vessel.

Comparison of Endovascular and Surgical Treatment for Ruptured Cerebral Aneurysms with respect to Short and Long-Term Outcome

SUMMARY

We compared the treatment for ruptured aneurysms from the clinical and radiological follow-ups after endovascular (GDC) or surgical treatment. There were 142 surgically treated cases and 38 endovascular treated cases from May 1997 to December 2001. In endovascular cases there were four A-com, four MCA, 12 ICA and 18 posterior circulation aneurysms. In surgical cases, there were 53 A-com ACA, 51 MCA, 36 ICA and two posterior circulation aneurysms. The clinical outcomes of endovascular and surgical treatments were correlated with the H & H grades before treatments. At short stage, 71% of endovascular and 78.2% of surgical cases showed a favorable outcome (GOS GR or MD) (p=0.3). Long-term clinical follow ups (14.5 to 58 months) showed 77.7% of endovascular and 87.7% of surgical cases resulted in GR or MD (p=0.17). In endovascular cases, 22.2% showed recurrence during the follow-up period and five of them needed re-treatment. We experienced failed endovascular approach at acute stage in seven cases which changed to surgery. In conclusion, the short and long term clinical results of endovascular treatment were acceptable comparing surgical clipping. High recurrence rate after GDC treatment did not permit future completeness of the treatment. Still the treatment alternative between endovascular or surgical treatment may change depending on the criteria of each institution, attention should be paid to the disadvantages of endovascular treatment as the first choice for ruptured aneurysms.