Clipping of very large or giant unruptured intracranial aneurysms in the anterior circulation: an outcome study

A giant partial thrombosed aneurysm of the internal cavernous carotid artery mimicking a meningioma of the lesser wing of the sphenoid bone

Giant intracranial aneurysms are defined as those with diameters of 25 mm or more and represent about 5% of all intracranial aneurysms. These aneurysms typically manifest during the fifth to seventh decades of life. Due to their size, giant aneurysms are responsible for intracranial mass effect rather than hemorrhage. Clinical symptoms depend on aneurysm's location. Radiological features are not common for aneurysms of the internal cavernous carotid artery. Differential diagnosis includes pituitary adenoma, meningioma, craniopharyngioma, hamartoma, glioma, teratoma, and even granuloma.

Here, the authors report a case of a 63-year-old female patient with a giant partial thrombosed aneurysm of the internal cavernous carotid artery mimicking a meningioma of the lesser wing of the sphenoid bone who presented for visual defect, and raised intracranial pressure. The authors will proceed with a literature review investigating this entity as well its ability of mimicking meningioma.

Microsurgery of Giant Intracranial Aneurysm: A Single Institution Outcome Study

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.

[Surgical treatment of a patient with saccular arterial aneurysm of the cavernous-ophthalmic segment]

Presented in the article are the results of surgical management of a patient with an extremely rare pathology - a saccular arterial aneurysm of the cavernous-ophthalmic segment of the left internal carotid artery. We performed multistage open surgical intervention in the following scope: osteoplastic pterional craniotomy on the left, creation of a wide-lumen anastomosis between the left external carotid artery and M2 segment of the left middle cerebral artery with the use of the radial artery, ligation of the cervical portion of the left internal carotid artery and clipping of its supraclinoid portion. The chosen surgical policy made it possible to create sufficient volumetric blood flow through the shunt, comparable to the blood flow through the internal carotid artery, which helped avoid ischaemic stroke after exclusion of the aneurysm from circulation. A conclusion was drawn on efficacy of this method of treatment.

Morphological parameters as factors of 12-month neurological worsening in surgical treatment of patients with unruptured saccular intracranial aneurysms: importance of size ratio

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.

A Retrospective Study in Microsurgical Procedures of Large and Giant Intracranial Aneurysms: An Outcome Analysis

OBJECTIVE

Intracranial aneurysms are considered large if >10 mm and giant if >25 mm. The risk of aneurysmal rupture compounds with increase in size of the aneurysm, thus, warranting appropriate intervention. In this study, we have analyzed the outcome and effectiveness of microsurgical procedures in large and giant aneurysms.

METHODS

A retrospective analysis of all the patients who underwent microsurgical procedures for large and giant cerebral aneurysms from 2014-2018 in our institute was conducted. There were a total of 52 patients, in which direct clipping was performed in 42 (80.7%) patients, proximal trapping in 3 (5.7%) patients, trapping with bypass in 3 (5.7%) patients, suction decompression in 3 (5.7%) patients, and 1 (1.9%) patient underwent surgical reconstruction.

RESULTS

Among the 52 patients, in the postoperative period, 1 (1.9%) patient became comatose, 1 (1.9%) patient developed hemiplegia, 1 (1.9%) patient had a transient hemiparesis, and 1 (1.9%) patient had transient lower cranial nerve palsy. Two (3.8%) patients had chronic subdural hematoma during the 3-month follow-up. There was no mortality in our series.

CONCLUSIONS

There are several treatment strategies available to manage large and giant cerebral aneurysms. In this study, we had minimal morbidity (3.8%), favorable outcome (96.1%), and no mortality. Therefore, we would like to conclude that appropriate microsurgical procedures, in experienced hands, can be considered as first line in the management for large and giant intracranial aneurysms, especially those with complex anatomy, wide neck, mass effect, partial thrombosis, and the presence of critical perforating vessels from the aneurysm wall.

The 25th anniversary of the retrograde suction decompression technique (Dallas technique) for the surgical management of paraclinoid aneurysms: historical background, systematic review, and pooled analysis of the literature

OBJECTIVE

Paraclinoid internal carotid artery (ICA) aneurysms frequently require temporary occlusion to facilitate safe clipping. Brisk retrograde flow through the ophthalmic artery and cavernous ICA branches make simple trapping inadequate to soften the aneurysm. The retrograde suction decompression (RSD), or Dallas RSD, technique was described in 1990 in an attempt to overcome some of those treatment limitations. A frequent criticism of the RSD technique is an allegedly high risk of cervical ICA dissection. An endovascular modification was introduced in 1991 (endovascular RSD) but no studies have compared the 2 RSD variations.

METHODS

The authors performed a systematic review of MEDLINE/PubMed and Web of Science and identified all studies from 1990-2016 in which either Dallas RSD or endovascular RSD was used for treatment of paraclinoid aneurysms. A pooled analysis of the data was completed to identify important demographic and treatment-specific variables. The primary outcome measure was defined as successful aneurysm obliteration. Secondary outcome variables were divided into overall and RSD-specific morbidity and mortality rates.

RESULTS

Twenty-six RSD studies met the inclusion criteria (525 patients, 78.9% female). The mean patient age was 53.5 years. Most aneurysms were unruptured (56.6%) and giant (49%). The most common presentations were subarachnoid hemorrhage (43.6%) and vision changes (25.3%). The aneurysm obliteration rate was 95%. The mean temporary occlusion time was 12.7 minutes. Transient or permanent morbidity was seen in 19.9% of the patients. The RSD-specific complication rate was low (1.3%). The overall mortality rate was 4.2%, with 2 deaths (0.4%) attributable to the RSD technique itself. Good or fair outcome were reported in 90.7% of the patients.Aneurysm obliteration rates were similar in the 2 subgroups (Dallas RSD 94.3%, endovascular RSD 96.3%, p = 0.33). Despite a higher frequency of complex (giant or ruptured) aneurysms, Dallas RSD was associated with lower RSD-related morbidity (0.6% vs 2.9%, p = 0.03), compared with the endovascular RSD subgroup. There was a trend toward higher mortality in the endovascular RSD subgroup (6.4% vs 3.1%, p = 0.08). The proportion of patients with poor neurological outcome at last follow-up was significantly higher in the endovascular RSD group (15.4% vs 7.2%, p < 0.01).

CONCLUSIONS

The treatment of paraclinoid ICA aneurysms using the RSD technique is associated with high aneurysm obliteration rates, good long-term neurological outcome, and low RSD-related morbidity and mortality. Review of the RSD literature showed no evidence of a higher complication rate associated with the Dallas technique compared with similar endovascular methods. On a subgroup analysis of Dallas RSD and endovascular RSD, both groups achieved similar obliteration rates, but a lower RSD-related morbidity was seen in the Dallas technique subgroup. Twenty-five years after its initial publication, RSD remains a useful neurosurgical technique for the management of large and giant paraclinoid aneurysms.

Neurointerventional "Near Morbidity": A Candid Appraisal of an Early Case Series

Background

Modern case series often focus on emphasizing low complication rates, "safety," and "efficacy." Although patients may not suffer significant or obviously apparent neurological complications, many lessons are buried in the "no complications" cohort.

Methods

The junior author's prospectively maintained caselog was reviewed over a 1-year period for both symptomatic and "minor"/technical complications of neurointerventional cases, the latter referring to an intraprocedural inability to treat a lesion, suboptimal result, or potentially morbid angiographic occurrence/finding that did not result in permanent neurological morbidity - neurointerventional "near morbidity" (NNM).

Results

Of 602 treatments performed over the reviewed period, 163 were interventional neuroendovascular procedures. The most common neuroendovascular procedure performed was stroke thrombectomy (67 cases). Major neurological complications, defined as symptomatic stroke or hemorrhage, occurred in 7 cases (4%). NNM, consisting of instructive, technical issues arose in an additional 9 cases that did not result in neurological morbidity (6%). Overall, in 20/163 cases (12%), there were either major neurological complications, NNM, groin complications, or major medical complications.

Conclusions

"Minor"/technical complications - NNM - can be as instructive and illustrative as major complications despite not resulting in permanent morbidity. In reviewing case series, particularly early in one's career, these cases should be highlighted.

Modified extradural temporopolar approach with suction decompression for clipping of large paraclinoid aneurysm: Technical note

Background:

Surgical clipping of complicated large paraclinoid aneurysms are still challenging because strong adhesion of aneurysm itself may hinder the dissection of the perforators and the surrounding anatomical structures from the aneurysm dome.

Methods:

We describe 13 consecutive patients and the clipping of complicated, large-sized paraclinoid aneurysms using a modified extradural temporopolar approach combined with retrograde suction decompression and discuss its advantages and pitfalls.

Results:

Modified extradural temporopolar approach with suction decompression (SD) assistance was performed in all patients. There was no complication related to the surgical procedure. Postoperative outcome was good recovery in 7 patients, moderate disability in 4, and severe disability in 2 caused by severe subarachnoid hemorrhage. Favorable outcomes were achieved in 10 patients (84.6%).

Conclusion:

We recommend its less invasive, safe, and useful combined technique in the treatment of symptomatic paraclinoid aneurysms, which carry the risk of neurovascular injury caused by dissection from the aneurysm dome.

The Silk flow-diverter stent for endovascular treatment of intracranial aneurysms

Flow diverter (FD) stents represent a new endovascular technique developed for the treatment of complex intracranial aneurysms (wide neck, fusiform, large, and giant aneurysms) that are challenging for classic endovascular techniques such as coiling, balloon-assisted coiling and stent-assisted coiling. Low porosity, high metal coverage, and high pore density are the main properties of FD stents. These properties induce hemodynamic changes redirecting the blood flow away from the aneurysm and into the parent artery leading to gradual thrombosis of the aneurysm. FD stents also provide scaffolding for subsequent neoendothelial proliferation, and vessel wall remodeling. This is considered as a paradigm shift compared to prior endovascular methods, which predominantly aimed at providing treatment inside the aneurysmal sac. This paper describes in detail the first released FD stent, the Silk flow-diverter stent (Balt Extrusion, Montmorency, France), its mechanism of action and deployment technique. It reviews the pertinent literature regarding safety, efficacy and potential risks and complications associated with the use of this stent.

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

PURPOSE

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

METHODS

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

RESULTS

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

Visual outcomes of endovascular and microsurgical treatment for large or giant paraclinoid aneurysms

BACKGROUND

The optimal treatment for large or giant paraclinoid aneurysms is still controversial. The present study evaluated the results of endovascular coiling and microsurgical clipping with special reference to visual outcomes.

METHODS

The clinical data and treatment outcomes of 39 cases of large (>15 mm) paraclinoid aneurysms were retrospectively reviewed. Presenting symptoms were subarachnoid hemorrhage in 16 aneurysms and visual impairment in 18. Twenty-one aneurysms were treated by endovascular therapy and 18 were treated by direct surgery.

RESULTS

Maximal aneurysm diameter ≥25 mm and preoperative visual acuity <20/100 were significantly related to poor visual outcome in univariate analysis. However, preoperative visual acuity was the only significant prognostic factor in multivariate analysis (odds ratio [OR] 0.12, 95 % confidence interval [CI] 0.01-0.95, p = 0.04). Although patients treated with endovascular coiling tended to have more favorable outcome than those with surgical clipping, adjustment for other confounding factors reduced the OR of favorable outcome following each treatment modality to nearly one (OR 1.14, 95 % CI 0.17-7.46, p = 0.89). Deteriorations in the visual field showed different patterns: upper visual field deficit after endovascular coiling, and inferior nasal quadrantanopia after microsurgical clipping.

CONCLUSIONS

Preoperative visual acuity was the only independent predictor of visual outcome in patients with large paraclinoid aneurysms. Although adjusted visual outcomes with microsurgical clipping and endovascular coiling were almost the same, selection of the optimal treatment for each aneurysm is essential with recognition of the potential risks and mechanisms of visual impairment.

Cerebrovascular neurosurgery in evolution: the endovascular paradigm

Endovascular technique represents an important, minimally invasive approach to treating cerebrovascular disease. In this article, we discuss the origins of endovascular neurosurgery as a discipline in the context of important technical milestones, evidence-based medicine, and future cerebrovascular neurosurgical training. Cerebrovascular neurosurgery has seen a steady, convergent evolution toward the surgeon capable of seamless incorporation of open and endovascular approaches to any complex vascular disease affecting the central nervous system. Neurosurgery must assume the leadership role in the multidisciplinary neurovascular team.

The impact of patient age and comorbidities on the occurrence of "never events" in cerebrovascular surgery: an analysis of the Nationwide Inpatient Sample

OBJECT

As health care administrators focus on patient safety and cost-effectiveness, methodical assessment of quality outcome measures is critical. In 2008 the Centers for Medicare and Medicaid Services (CMS) published a series of "never events" that included 11 hospital-acquired conditions (HACs) for which related costs of treatment are not reimbursed. Cerebrovascular procedures (CVPs) are complex and are often performed in patients with significant medical comorbidities.

METHODS

This study examines the impact of patient age and medical comorbidities on the occurrence of CMS-defined HACs, as well as the effect of these factors on the length of stay (LOS) and hospitalization charges in patients undergoing common CVPs.

RESULTS

The HACs occurred at a frequency of 0.49% (1.33% in the intracranial procedures and 0.33% in the carotid procedures). Falls/trauma (n = 4610, 72.3% HACs, 357 HACs per 100,000 CVPs) and catheter-associated urinary tract infections (n = 714, 11.2% HACs, 55 HACs per 100,000 CVPs) were the most common events. Age and the presence of ≥ 2 comorbidities were strong independent predictors of HACs (p < 0.0001). The occurrence of HACs negatively impacts both LOS and hospital costs. Patients with at least 1 HAC were 10 times more likely to have prolonged LOS (≥ 90th percentile) (p < 0.0001), and 8 times more likely to have high inpatient costs (≥ 90th percentile) (p < 0.0001) when adjusting for patient and hospital factors.

CONCLUSIONS

Improved quality protocols focused on individual patient characteristics might help to decrease the frequency of HACs in this high-risk population. These data suggest that risk adjustment according to underlying patient factors may be warranted when considering reimbursement for costs related to HACs in the setting of CVPs.

Surgical outcome of primary clipping for anterior circulation aneurysms of size 2 centimeters or larger

BACKGROUND

Aneurysms of the anterior circulation larger than 2cm have a complex relationship to the anterior skull base, requiring a multi-modality management approach. This retrospective study of 54 patients with such aneurysms who underwent clipping between 2001 and 2012 analyzes clinical and surgical data, aneurysm characteristics and correlates them with respect to the Glasgow outcome score at follow-up and immediate post-operative clinical status.

METHODS

Patients with an outcome score of 5 or 4 were categorized as "good", while those with score 3-1 were "poor". Fisher's exact test and paired T-test (p<0.5) were used to test statistical significance for discrete and continuous variables respectively.

RESULTS

44 (81.4%) patients had a good outcome. Patients with non-ophthalmic/paraclinoid aneurysms had significantly lower incidence of adverse intra-operative events (p=0.035). Patients older than 50 years (p=0.045), with adverse intra-operative events (p=0.015) and post-operative infarction (p<0.001) had a poor outcome compared to those younger than 50 years age and those without adverse intra-operative events or infarctions. The grouped age variable had maximum influence on patient outcome. Location and size of aneurysm did not have an overall impact on surgical outcome. There were 4 mortalities.

CONCLUSIONS

Primary clipping of proximal non-cavernous aneurysms on the internal carotid artery is associated with adverse intra-operative events. A multi-modality treatment approach in these aneurysms should be individualized, more so in patients older than 50 years.

Microsurgical clipping of large and giant cerebral aneurysms: a single-center contemporary experience

Several treatment strategies are available to manage large and giant cerebral aneurysms, including surgical, endovascular and combined approaches. We present our experience with microsurgical clipping of large and giant aneurysms. A total of 138 patients with 139 aneurysms of which 128 were large (≥10mm) and 11 were giant (≥25mm) were treated at our institution between 2004 and 2011. Data were collected from a prospectively maintained neurovascular database. Of 138 patients, 53 (38.4%) patients presented with subarachnoid hemorrhage (SAH). Peri-operative complications occurred in 16.7% of patients causing permanent morbidity in 4.4% and death in 0.7%. Complete occlusion, as evident on intra-operative angiography, was achieved in all clipped aneurysms (100%). Long-term follow-up angiography showed no recurrence (mean follow-up time, 43.9 months; range: 1-72 months). Favorable outcomes at discharge (Glasgow Outcome Scale score 4 or 5) were noted in 64.1% of SAH patients and 93% of non-SAH patients. Favorable outcomes at follow-up (mean follow up time, 42.5 months) were seen in 96% of patients. In our experience, microsurgical clipping of large and giant aneurysms carries low rates of morbidity and mortality with high rates of favorable outcomes. The excellent durability of surgical treatment stands in stark contrast with the high recurrence rates observed with coiling for this subset of aneurysms. These data suggest that microsurgical clipping continues to be a viable option that can be offered for patients with large and giant aneurysms.

Parent artery reconstruction for large or giant cerebral aneurysms using a Tubridge flow diverter (PARAT): study protocol for a multicenter, randomized, controlled clinical trial

BACKGROUND

The treatment of large (10-25 mm) or giant (≥25 mm) cerebral aneurysms remains technically challenging, with a much higher complication and recanalization rate than that is observed for smaller aneurysms. The use of a flow diverter seems to facilitate the treatment of this special entity. In a previous single-center prospective study approved by the Ethics Committee and China Food and Drug Administration (CFDA), we obtained promising results, showing remarkable safety and effectiveness for the Tubridge flow diverter. Nevertheless, the previous study may have been limited by biases due to its single-center design and limited number of subjects. Furthermore, although various articles have reported durable results from treating aneurysms using flow diverters, increasing questions have arisen about this form of treatment. Thus, prospective, multiple-center, randomized trials containing more subjects are needed.

METHODS/DESIGN

This study is a multicenter, randomized, controlled clinical trial comparing clinical outcomes for patients with unruptured large/giant intracranial aneurysms treated with either conventional stent-assisted coiling or flow diverter implantation. A total of 124 patients who fulfill the inclusion and exclusion criteria will be randomized into either a treatment group or a control group in the ratio of 1:1. The treatment group will receive Tubridge implantation alone or combined with bared coils, and the control group will be treated with stent-assisted coiling (bare coils). The primary endpoint will be the complete occlusion rate at 6-month follow-up. Secondary endpoints include the immediate technique success rate, overall mortality, adverse events (ischemic stroke or intracranial bleeding) within 30 days, 90 days and 1 year post-operation, and the rate of intra-stent stenosis and thrombosis 6 months post-operation.

DISCUSSION

This prospective trial may provide more information on the safety and efficacy of the Tubridge flow diverter and may potentially change the strategy for treatment of large or giant aneurysms.

TRIAL REGISTRATION

The trial is registered on the Chinese Clinical Trial Registry: ChiCTR-TRC-13003127.

Transradial access or Simmons shaped 8F guide enables delivery of flow diverters in patients with large intracranial aneurysms and type III aortic arch: technical case report

BACKGROUND AND IMPORTANCE

Flow diversion with the pipeline embolization device (PED) is an emerging endovascular technology allowing curative embolization of very large and giant intracranial aneurysms. Many patients with these complex aneurysms are older. The presence of a tortuous type III aortic arch reduces the chances of successful PED delivery and increases the risk of complications. We report 2 technical nuances regarding the delivery of the PED in older patients with a complex aortic arch.

CLINICAL PRESENTATION

In case 1, an 87-year-old woman presented with acute-onset left third nerve palsy. Workup demonstrated an 18-mm left posterior carotid wall aneurysm with a large daughter aneurysm on its dome. Endovascular access was complicated by a type III aortic arch with a hyperacute angle at the origin of the left common carotid artery. An 8F Simmons II shaped guide formed a stable platform, allowing successful PED delivery. In case 2, a 76-year-old woman experienced a transient ischemic attack. She harbored a right-sided 20-mm cavernous internal carotid artery aneurysm. She was treated with 2 PEDs deployed via a transradial approach.

CONCLUSION

Transradial access or guide support with the 8F Simmons II catheter grants stable access for curative embolization with the PED in elderly patients with a large intracranial aneurysm and a complex aortic arch.

Advances in Endovascular Approaches to Cerebral Aneurysms

Recent advancements in all phases of endovascular aneurysm treatment, including medical therapy, diagnostics, devices, and implants, abound. Advancements in endovascular technologies and techniques have enabled treatment of a wide variety of intracranial aneurysms. In this article, technical advances in endovascular treatment of cerebral aneurysms are discussed, with an effort to incorporate a clinically relevant perspective. Advancements in diagnostic tools, medical therapy, and implants are reviewed and discussed.

Perioperative variables contributing to the rupture of intracranial aneurysm: an update

Background. Perioperative aneurysm rupture (PAR) is one of the most dreaded complications of intracranial aneurysms, and approximately 80% of nontraumatic SAHs are related to such PAR aneurysms. The literature is currently scant and even controversial regarding the issues of various contributory factors on different phases of perioperative period. Thus this paper highlights the current understanding of various risk factors, variables, and outcomes in relation to PAR and try to summarize the current knowledge. Method. We have performed a PubMed search (1 January 1991–31 December 2012) using search terms including “cerebral aneurysm,” “intracranial aneurysm,” and “intraoperative/perioperative rupture.” Results. Various risk factors are summarized in relation to different phases of perioperative period and their relationship with outcome is also highlighted. There exist many well-known preoperative variables which are responsible for the highest percentage of PAR. The role of other variables in the intraoperative/postoperative period is not well known; however, these factors may have important contributory roles in aneurysm rupture. Preoperative variables mainly include natural course (age, gender, and familial history) as well as the pathophysiological factors (size, type, location, comorbidities, and procedure). Previously ruptured aneurysm is associated with rupture in all the phases of perioperative period. On the other hand intraoperative/postoperative variables usually depend upon anesthesia and surgery related factors. Intraoperative rupture during predissection phase is associated with poor outcome while intraoperative rupture at any step during embolization procedure imposes poor outcome. Conclusion. We have tried to create such an initial categorization but know that we cannot scale according to its clinical importance. Thorough understanding of various risk factors and other variables associated with PAR will assist in better clinical management as well as patient care in this group and will give insight into the development and prevention of such a catastrophic complication in these patients.

A pictorial essay of brain perfusion-CT: not every abnormality is a stroke!

Perfusion-CT (PCT) of the brain is a rapidly evolving imaging technique used to assess blood supply to the brain parenchyma. PCT is readily available at most imaging centers, resulting in steadily increasing use of this imaging technique. Though PCT was initially introduced and still most widely used to evaluate patients with acute ischemic stroke, a wide variety of other pathologic processes demonstrate abnormal perfusion maps. Therefore, it is important for the radiologist to recognize altered perfusion patterns observed in diseases other than typical ischemic stroke. The goal of this article is to show the perfusion maps and review the perfusion patterns observed in some subtypes of atypical stroke and in neurological entities other than stroke, so that they are recognized and not confused with the PCT patterns observed in patients with typical ischemic stroke.

Treatment strategies for complex intracranial aneurysms: review of a 12-year experience at the university of cincinnati

Complex intracranial aneurysms (CIAs) include those classified as giant, those located in brain regions of technically difficult access, or that involve arterial trunks/branches, and/or have complicated wall structure. We reviewed retrospectively our management of such lesions in a 12-year period. From 1997 to 2009, 192 patients were admitted with CIAs (133 females, 59 males; average age 55 years); 128 presented with subarachnoid hemorrhage (SAH) and 64 with unruptured, symptomatic CIAs. The SAH group had 73 anterior- and 55 posterior-circulation aneurysms. Most frequent location was middle cerebral artery. Treatment strategies included clipping (65.6%), coiling/stenting (28.1%), bypass (3.1%), no treatment (3.1%). Coiling/stenting was exclusively used for posterior-circulation aneurysms. Outcomes were good (modified Rankin Scale [mRS] 0 to 2) in 54 patients (42.2%), fair (mRS = 3 to 4) in 38 (29.7%), and poor (mRS = 5 to 6) in 36 (28.1%). Among unruptured CIAs, there were 47 anterior- and 17 posterior-circulation aneurysms. Most frequent location was ophthalmic. Thirty (46.9%) were clipped, 19 (29.7%) coiled, 6 (9.4%) by-passed, 2 (3.1%) wrapped, and 7 (10.9%) had no treatment. Outcomes were good in 57 patients (89%) and fair in 7 (11%). Good outcomes were obtained in unruptured CIAs using a multidisciplinary approach. Ruptured CIAs carry a significantly worse prognosis than overall SAH patients.

Giant intracranial aneurysms: evolution of management in a contemporary surgical series

BACKGROUND

Many significant microsurgical series of patients with giant aneurysms predate changes in practice during the endovascular era.

OBJECTIVE

A contemporary surgical experience is presented to examine changes in management relative to earlier reports, to establish the role of open microsurgery in the management strategy, and to quantify results for comparison with evolving endovascular therapies.

METHODS

During a 13-year period, 140 patients with 141 giant aneurysms were treated surgically. One hundred aneurysms (71%) were located in the anterior circulation, and 41 aneurysms were located in the posterior circulation.

RESULTS

One hundred eight aneurysms (77%) were completely occluded, 14 aneurysms (10%) had minimal residual aneurysm, and 16 aneurysms (11%) were incompletely occluded with reversed or diminished flow. Three patients with calcified aneurysms were coiled after unsuccessful clipping attempts. Eighteen patients died in the perioperative period (surgical mortality, 13%). Bypass-related complications resulted from bypass occlusion (7 patients), aneurysm hemorrhage due to incomplete aneurysm occlusion (4 patients), or aneurysm thrombosis with perforator or branch artery occlusion (4 patients). Thirteen patients were worse at late follow-up (permanent neurological morbidity, 9%; mean length of follow-up, 23 ± 1.9 months). Overall, good outcomes (Glasgow Outcome Score 5 or 4) were observed in 114 patients (81%), and 109 patients (78%) were improved or unchanged after therapy.

CONCLUSION

A heavy reliance on bypass techniques plus indirect giant aneurysm occlusion distinguishes this contemporary surgical experience from earlier ones, and obviates the need for hypothermic circulatory arrest. Experienced neurosurgeons can achieve excellent results with surgery as the "first-line" management approach and endovascular techniques as adjuncts to surgery.

Recipient targeting for revascularization using pulsed Doppler ultrasonography for the treatment of an intracranial giant aneurysm

Aneurysmal occlusion after blood flow revascularization is a promising management strategy for the treatment of intracranial giant aneurysms. However, it is necessary to design robust revascularization for preventing postoperative flow-related infarctions caused by abrupt occlusion of the parent vessels. Since direct anastomosis of donor vessels to recipient vessels near giant aneurysms is often difficult, it is preferable to select cortical recipient branches away from the aneurysm, thus providing a sufficient working space for the surgeon. In this paper, the authors' goal was to identify distal cortical recipient arteries on the brain surface, based on pulsed Doppler ultrasonography analysis of blood flow alteration after temporary closure of the efferent vessels. This method is used to visualize the area around the sacrificed vessels, omits intraoperative arteriography or the risk of a surgical trace of the vessels by dissecting the distal sulci, and could be advantageous for necessary and sufficient revascularization.

Role of calcification in the outcomes of treated, unruptured, intracerebral aneurysms

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).

Predictors of Clinical and Angiographic Outcome After Surgical or Endovascular Therapy of Very Large and Giant Intracranial Aneurysms

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 &lt; .01), and posterior circulation location (OR, 0.18; 95% CI: 0.07-0.43; P &lt; .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 &lt; .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.

Evaluation of the prognostic indicators of giant intracranial aneurysms

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.

A novel aneurysm clip design for atheromatous, thrombotic, or previously coiled lesions: preliminary experience with the "compression clip" in 6 cases

BACKGROUND

Large and giant lesions often have thicker, atheromatous walls as well as intra-aneurysmal thrombus that combine to prevent traditional clips from closing properly in some cases.

OBJECTIVE

To report the development and use of a novel clip design specifically tailored to treat atheromatous, thrombotic, or previously coiled aneurysms.

METHODS

We retrospectively reviewed the records of 6 patients with complex aneurysms not amenable to simple neck clipping and not considered appropriate for endovascular therapy who were treated using a novel "compression" clip design. We describe the development and use of a novel aneurysm clip design with blades that are not opposed at rest to allow direct clipping of atheromatous, thrombotic, and previously coiled aneurysms.

RESULTS

Four patients had recurrent, previously coiled aneurysms; one of these also had a large thrombotic component. Two patients had complex lesions with heavy atheroma involving a portion of their aneurysms. There were no complications related to the use of the clip, and all patients did well without neurological complications. In every case, the clip allowed straightforward obliteration of the aneurysm without the need for temporary vascular occlusion, aneurysmorrhaphy, or removal of an intra-aneurysmal coil mass. All patients underwent intraoperative angiography to confirm obliteration of the aneurysm with preservation of the normal vasculature.

CONCLUSION

Atheromatous, thrombotic, and previously coiled aneurysms may not be treatable with simple neck clipping and may not be curable with endovascular therapy. For such cases, we designed a novel "compression" clip that has been used safely and successfully in our experience with good short-term follow-up.

Treatment of complex intracranial aneurysms of anterior circulation using multiple clips

OBJECTIVE

To evaluate the efficacy of multiple clip application for the occlusion of complex intracranial aneurysms, analyzing the technique and outcome of big and giant cerebral aneurysms clipped in our institution.

METHOD

A total of 259 giant and large intracranial aneurysms (65 ruptured and 193 unruptured) were treated at Fujita Health University Hospital by clipping from January 1975 till December 2008. All patients were treated by multiple clipping according to our multiple clipping technique with reconstruction of the parent vessel. All patients underwent preoperative 3D computed tomography and some patients in addition received digital subtraction angiography. We examined the patients' clinical records and pre- and postoperative case notes, diagnostic and intraoperative images. There were 97 (giant 43, big 54) ICA aneurysms, 105 (giant 45, big 60) MC aneurysms and 32 (giant 7, big 25) AC aneurysms, 25 (giant 14, big 11) VB aneurysms. All patients underwent thorough pre-surgical planning of approach and clipping technique.Surgical technique involved the use of multiple clips with the initial clip securing the deepest neck part and the others successively occluding the rest by remnant clips, occluding along the best plane of neck obliteration.

RESULTS

Out of 193 cases, 165 cases were without any complications. Temporary complications were seen in 18 cases and permanent in 10. In our 65 ruptured aneurysms operated on, outcome was in line with standard outcome according to the SAH grade on admission (H&H, WFNS grade). In total, 183 cases had good results (94.8%).

CONCLUSIONS

The "multi" clip method for the treatment of complex intracranial aneurysms can be a safe and effective method where a single clip cannot obtain complete neck closure. Proper preoperative understanding of the three-dimensional anatomy of the aneurysm and appropriate preoperative planning and selection of suitable clipping method, using an appropriate combination of clips, definitely can reduce the morbidity and mortality in these patients.

Intraoperative angiography should be standard in cerebral aneurysm surgery

Intraoperative angiography (IOA) has proven to be a safe and effective adjunct to surgical repair of cerebral aneurysms. Substantial practice variation exists regarding use of this modality in different centers, including use of IOA routinely, selectively, or rarely. In this editorial, we discuss our experience and review the existing literature to develop an argument for routine use of IOA during cerebral aneurysm surgery.