Category: Vascular

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Endoscopic endonasal clip ligation of cerebral aneurysms

Endoscopic endonasal clip ligation of cerebral aneurysms

J Neurosurg 124:463–468, 2016

The expansion of endovascular procedures for obliteration of cerebral aneurysms highlights one of the drawbacks of clip ligation through the transcranial route, namely brain retraction or brain transgression. Sporadic case reports have emerged over the past 10 years describing endonasal endoscopic clip ligation of cerebral aneurysms. The authors present a detailed anatomical study to evaluate the feasibility of an endoscopic endonasal approach for application of aneurysm clips.

Methods Nine human cadaveric head specimens were used to evaluate operative exposures for clip ligation of aneurysms in feasible anterior and posterior circulation locations. Measurements of trajectories were completed using a navigation system to calculate skull base craniectomy size, corridor space, and the surgeon’s ability to gain proximal and distal control of parent vessels.

Results In each of the 9 cadaveric heads, excellent exposure of the target vessels was achieved. The transplanum, transtuberculum, and transcavernous approaches were used to explore the feasibility of anterior circulation access. Application of aneurysm clips was readily possible to the ophthalmic artery, A1 and A2 segments of the anterior cerebral artery, anterior communicating artery complex, and the paraclinoid and paraclival internal carotid artery. The transclival approach was explored, and clips were successfully deployed along the proximal branches of the vertebrobasilar system and basilar trunk and bifurcation. The median sizes of skull base craniectomy necessary for exposure of the anterior communicating artery complex and basilar tip were 3.24 cm2 and 4.62 cm2, respectively. The mean angles of surgical corridors to the anterior communicating artery complex and basilar tip were 11.4° and 14°, respectively. Although clip placement was feasible on the basilar artery and its branches, the associated perforating arteries were difficult to visualize, posing unexpected difficulty for safe clip application, with the exception of ventrolateral-pointing aneurysms.

Conclusions The authors characterize the feasibility of endonasal endoscopic clip ligation of aneurysms involving the paraclinoid, anterior communicating, and basilar arteries and proximal control of the paraclival internal carotid artery. The endoscopic approach should be initially considered for nonruptured aneurysms involving the paraclinoid and anterior communicating arteries, as well as ventrolateral basilar trunk aneurysms. Clinical experience will be mandatory to determine the applicability of this approach in practice.

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Predictors of Poor Quality of Life 1 Year After Subarachnoid Hemorrhage

A Simple and Quantitative Method to Predict Symptomatic Vasospasm After Subarachnoid Hemorrhage Based on Computed Tomography- Beyond the Fisher Scale

Neurosurgery 78:256–264, 2016

Risk factors for poor quality of life (QOL) after subarachnoid hemorrhage (SAH) remain poorly described.

OBJECTIVE: To identify the frequency and predictors of poor QOL 1 year after SAH.

METHODS: We studied 1-year QOL in a prospectively collected cohort of 1181 consecutively admitted SAH survivors between July 1996 and May 2013. Patient clinical, radiographic, surgical, and acute clinical course information was recorded. Reduced QOL (overall, physical, and psychosocial) at 1 year was assessed with the Sickness Impact Profile and defined as 2 SD below population-based normative Sickness Impact Profile values. Logistic regression leveraging multiple imputation to handle missing data was used to evaluate reduced QOL.

RESULTS: Poor overall QOL was observed in 35% of patients. Multivariable analysis revealed that nonwhite ethnicity, high school education or less, history of depression, poor clinical grade (Hunt-Hess Grade $3), and delayed infarction were predictors of poor overall and psychosocial QOL. Poor physical QOL was additionally associated with older age, hydrocephalus, pneumonia, and sepsis. At 1 year, patients with poor QOL had increased difficulty concentrating, cognitive dysfunction, depression, and reduced activities of daily living. More than 91% of patients with poor QOL failed to fully return to work. These patients frequently received physical rehabilitation, but few received cognitive rehabilitation or emotional-behavioral support.

CONCLUSION: Reduced QOL affects as many as one-third of SAH survivors 1 year after SAH. Delayed infarction is the most important in-hospital modifiable factor that affects QOL. Increased attention to cognitive and emotional difficulties after hospital discharge may help patients achieve greater QOL.

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Hemodynamic response during aneurysm clipping surgery among experienced neurosurgeons

surgery_aneurysm

Acta Neurochir (2016) 158:221–227

Neurosurgery is a challenging field associated with high levels of mental stress. The goal of this study was to investigate the hemodynamic response of experienced neurosurgeons during aneurysm clipping surgery and to evaluate whether neurosurgeons’ hemodynamic responses are associated with patients’ clinical statuses.

Methods Four vascular neurosurgeons (all male; mean age 51 ± 10 years; post-residency experience ≥7 years) were studied during 42 aneurysm clipping procedures. Blood pressure (BP) and heart rate (HR) were assessed at rest and during seven phases of surgery: before the skin incision, after craniotomy, after dural opening, after aneurysm neck dissection, after aneurysm clipping, after dural closure and after skin closure.

Results HR and BP were significantly greater during surgery relative to the rest situation (p≤ 0.03). There was a statistically significant increase in neurosurgeons’ HR (F [6, 41] = 10.88, p <0.001), systolic BP (F [6, 41] =2.97, p =0.01), diastolic BP (F [6, 41] = 2.49, p = 0.02) and mean BP (F [6, 41] = 3.36, p = 0.003) during surgery. The greatest mean HR was after aneurysm clipping, and the greatest BP was after aneurysm neck dissection. Systolic, diastolic and mean BPs were significantly greater during surgical clipping for unruptured aneurysms compared to ruptured aneurysms across all stages of surgery (p ≤ 0.002); however, after adjusting for neurosurgeon experience, the difference in BP as a function of aneurysm rupture was not significant (p>0.08). Aneurysm location, intraoperative aneurysm rupture, admission WFNS score, admission Glasgow Coma Scale scores and Fisher grade were not associated with neurosurgeons’ intraoperative HR and BP (all p > 0.07).

Conclusions Aneurysm clipping surgery is associated with significant hemodynamic system activation among experienced neurosurgeons. The greatest HR and BP were after aneurysm neck dissection and clipping. Aneurysm location and patient clinical status were not associated with intraoperative changes of neurosurgeons’ HR and BP.

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A Reappraisal of Anterior Communicating Artery Aneurysms: A Case for Stent-Assisted Embolization

Anterior Communicating Artery Aneurysms- A Case for Stent-Assisted Embolization

Neurosurgery 78:200–207, 2016

Wide-necked anterior communicating artery aneurysms represent a subset of lesions with challenging endovascular treatment despite new endoluminal and intrasaccular devices.

OBJECTIVE: To assess the long-term clinical and angiographic outcomes of stentassisted embolization for wide-necked anterior communicating artery aneurysms.

METHODS: Between March 2008 and March 2014, 32 patients with unruptured widenecked AComm aneurysms were treated using stent-assisted embolization. The Glasgow Outcome Scale was reviewed at the time of discharge and at latest follow-up. Ischemic and hemorrhagic events were also recorded and analyzed. Aneurysm occlusion was evaluated post-intervention and on subsequent follow-up evaluations.

RESULTS: Successful stent deployment was achieved in all cases, but in 1 patient the coils could not be contained inside the aneurysm, and the procedure was aborted without complications. The distal segment of the stent was positioned in the ipsilateral A2 in 16 patients, in the contralateral A2 in 15 patients, and in the contralateral A1 in 1 patient. There were no periprocedural thromboembolic or hemorrhagic complications. The rate of major complications was 6%. One patient developed intracranial hemorrhage related to antiplatelet therapy and another had ischemic events due to in-stent stenosis. Angiographic follow-up was available for 26 aneurysms and during a mean follow-up of 22 months, 81% of the lesions were completely occluded and 8% had a small residual neck. The retreatment rate for residual aneurysms was 3%.

CONCLUSION: Our long-term results suggest that stent-assisted embolization for anterior communicating artery aneurysms may be considered an excellent treatment option with an adequate combination of safety profile and effectiveness.

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Determining Surgical Approaches to Basilar Bifurcation Aneurysms

Determining Surgical Approaches to Basilar Bifurcation Aneurysms

Neurosurgery 78:181–191, 2016

The basilar bifurcation aneurysm (BBA) is still considered to be one of the most challenging aneurysms for micro- and endovascular surgery. Classic surgical approaches, such as subtemporal, lateral supraorbital (LSO), and modified presigmoid, are still reliable and effective.

OBJECTIVE: To analyze the clinical and radiological factors that affect the selection of these classic surgical approaches and their outcomes.

METHODS: A retrospective analysis was conducted on the clinical and radiological data from computed tomographic angiography of BBA that have been clipped in the Department of Neurosurgery of Helsinki University Central Hospital between 2004 and 2014. Statistical analyses were performed using parametric and nonparametric tests where values were considered significant below P = .05.

RESULTS: One hundred four patients with BBA underwent surgical clipping in our department between 2004 and 2014. Eight patients were excluded from the study because of incomplete preoperative radiological evaluations, leaving 96 patients for further analysis. Multiple aneurysm clipping, mean basilar bifurcation angle, and aneurysm neck distance from posterior clinoid process were shown to be factors that determine the surgical approach. Unfavorable outcome is strongly associated with poor Hunt-Hess grade on admission, distance from aneurysm neck (the posterior clinoid process), thrombosis, and dome size.

CONCLUSION: Microsurgery for BBA clipping can be performed safely with simple surgical approaches: subtemporal and LSO. There are several factors determining the approach selected. Poor patient outcome in BBA was highly associated with poor preoperative clinical grade and large size of aneurysm dome.

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Endovascular Management of Deep Arteriovenous Malformations

Endovascular management AVM

Neurosurgery 78:34–41, 2016

The management of arteriovenous malformations (AVMs) in the basal ganglia, insula, and thalamus is demanding for all treatment modalities.

OBJECTIVE: To define safety and outcomes of embolization used as a stand-alone therapy for deep-seated AVMs.

METHODS: A cohort of 22 patients with AVMs located in the basal ganglia, thalamus, and insula who underwent embolization between January 2008 and December 2013.

RESULTS: Eighteen of 22 (82%) patients had anatomic exclusion. The mean size was 2.98 6 1.28 cm, and the mean number of sessions was 2.1 per patient. Most patients presented with hemorrhage (82%, n = 18), and 3 (14%) patients were in a deteriorated neurological status (modified Rankin Scale .2) at presentation. Sixty-eight percent of ruptured AVMs had size #3 cm. A single transarterial approach was performed in 9 (41%) cases, double catheterization was used in 4 (18%), and the transvenous approach was required in 8 (36%) cases. Procedure-related complications were registered in 3 (14%) cases. One death was associated with treatment, and complementary radiosurgery was required in 2 (9%) patients.

CONCLUSION: Embolization therapy appears to be safe and potentially curative for certain deep AVMs. Our results demonstrate a high percentage of anatomic obliteration with rates of complications that may approach radiosurgery profile. In particular, embolization as stand-alone therapy is most suitable to deep AVMs with small nidus size (#3 cm) and/or associated with single venous drainage in which microsurgery might not be indicated.

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Continuous cisternal irrigation with Mg solution for vasospasm

Mg sulfate irrigation

J Neurosurg 124:18–26, 2016

Although cerebral vasospasm (CV) is one of the most important predictors for the outcome in patients with subarachnoid hemorrhage (SAH), no treatment has yet been established for this condition. This study investigated the efficacy of continuous direct infusion of magnesium sulfate (MgSO4) solution into the intrathecal cistern in patients with an aneurysmal SAH.

Methods An SAH caused by a ruptured aneurysm was identified on CT scans within 72 hours after SAH onset. All patients were treated by surgical clipping and randomized into 2 groups: a control group of patients undergoing a standard treatment and a magnesium (Mg) group of patients additionally undergoing continuous infusion of 5 mmol/L MgSO4 solution for 14 days. The Mg2+ concentrations in serum and CSF were recorded daily. Neurological examinations were performed by intensive care clinicians. Delayed cerebral ischemia was monitored by CT or MRI. To assess the effect of the Mg treatment on CV, the CVs were graded on the basis of the relative degree of constriction visible on cerebral angiograms taken on Day 10 after the SAH, and transcranial Doppler ultrasonography was performed daily to measure blood flow velocity in the middle cerebral artery (MCA). Neurological outcomes and mortality rates were evaluated with the Glasgow Outcome Scale and modified Rankin Scale at 3 months after SAH onset.

Results Seventy-three patients admitted during the period of April 2008 to March 2013 were eligible and enrolled in this study. Three patients were excluded because of violation of protocol requirements. The 2 groups did not significantly differ in age, sex, World Federation of Neurosurgical Societies grade, or Fisher grade. In the Mg group, the Mg2+ concentration in CSF gradually increased from Day 4 after initiation of the continuous MgSO4 intrathecal administration. No such increase was observed in the control group. No significant changes in the serum Mg2+ levels were observed for 14 days, and no cardiovascular complications such as bradycardia or hypotension were observed in any of the patients. However, bradypnea was noted among patients in the Mg group. The Mg group had a significantly better CV grade than the control group (p < 0.05). Compared with the patients in the Mg group, those in the control group had a significantly elevated blood flow velocity in the MCA. Both groups were similar in the incidences of cerebral infarction, and the 2 groups also did not significantly differ in clinical outcomes.

Conclusions Continuous cisternal irrigation with MgSO4 solution starting on Day 4 and continuing to Day 14 significantly inhibited CV in patients with aneurysmal SAH without severe cardiovascular complications. However, this improvement in CV neither reduced the incidence of delayed cerebral ischemia nor improved the functional outcomes in patients with SAH.

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Preoperative predictive factors for surgical and functional outcomes in chronic subdural hematoma

Subdural Hematoma

Acta Neurochir (2016) 158:135–139

Chronic subdural hematoma (CSDH) is a frequently encountered neurosurgical condition, especially in the elderly. We investigated predictive factors for surgical and functional outcomes after burr-hole drainage (BHD) surgery.

Methods All patients with CSDH treated by BHD between January 2012 and December 2014 were included in this study. All patients were classified by symptom, clinical grade, time, location, hematoma density, midline shift, and other characteristics. Pre- and postoperative CT evaluation was performed at 0, 3, and 6 months. Clinical grades were classified as described in Markwalder et al. Surgical and clinical outcomes were evaluated with the brain expansion rate and modified Rankin Scale (mRS). Brain expansion rate was calculated as the ratio between post- and pre-operative hematoma thickness. Recurrence was defined as the occurrence of symptoms and hematoma on CT within 6 months.

Results This study included 130 patients over 2 years. Among the variable parameters, young age (<75), iso-density of hematoma on CT, and short duration from symptom to surgery were correlated with good brain expansion. Patients with good brain expansion had fewer recurrences. In terms of mRS, young age, iso-density, and good clinical grade were correlated with good functional outcomes.

Conclusions Clinicians should be more aware of general conditions and medical problems, especially in elderly patients. Membranectomy should be considered in patients with a long duration of symptoms or hypo-dense hematomas to promote good brain expansion and good mRS scores.

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Surgical Clipping of Very Small Unruptured Intracranial Aneurysms

very small aneurysms

Neurosurgery 78:47–52, 2016

Treatment of very small unruptured intracranial aneurysms (VSUIAs, defined as ≤3 mm) can be indicated in selected circumstances. The feasibility and outcomes of endovascular therapy for VSUIAs have been recently published; however, the efficacy and complication rate of surgical clipping has not been reported in any large series to date.

OBJECTIVE: We conducted a multicenter study to examine surgical outcomes for VSUIAs.

METHODS: All consecutive patients undergoing surgery for a VSUIA in 4 neurosurgical centers between October 2001 and December 2012 were retrospectively analyzed.

RESULTS: In the study, 183 patients (128 women, mean age 51.3 years) were treated with 190 procedures for a total of 228 aneurysms. Most were anterior circulation aneurysms (n = 215). The majority were directly clipped (n = 222, 97.4%), with coagulation or wrapping in the remainder. After 1 reoperation for incomplete clipping, postoperative imaging of 225 aneurysms confirmed complete occlusion in 221 (98.2%), 1 neck remnant (0.44%), and 3 partial occlusions (1.3%). Mortality was 0%. Early postoperative neurological deficit developed in 12 patients (6.6%); posterior circulation location was a significant risk factor for early neurological deficit (P < .001). Middle cerebral artery aneurysms had the lowest rate of postoperative deficits at 1.5% (P = .023). After the initial 30-day perioperative period, all deficits related to treatment of posterior circulation aneurysms recovered; overall neurological morbidity decreased to 2.7% with no mortality.

CONCLUSION: VSUIA clipping is highly effective and is associated with a low morbidity rate. For VSUIAs selected for treatment, our data support surgical clipping as the modality of choice.

KEY WORDS:

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Aneurysm location and clipping versus coiling for development of secondary normal-pressure hydrocephalus after aneurysmal subarachnoid hemorrhage

Hydrocephalus

J Neurosurg 123:1555–1561, 2015

The present study aimed to investigate aneurysm locations and treatments for ruptured cerebral aneurysms associated with secondary normal-pressure hydrocephalus (sNPH) after subarachnoid hemorrhage (SAH) by using comprehensive data from the Japanese Stroke DataBank.

Methods Among 101,165 patients with acute stroke registered between 2000 and 2013, 4693 patients (1482 men, 3211 women) were registered as having had an SAH caused by a ruptured saccular aneurysm. Of them, 1448 patients (438 men and 1010 women; mean age 61.9 ± 13.4 years) who were confirmed to have or not have coexisting acute hydrocephalus and sNPH were included for statistical analyses. Locations of the ruptured aneurysms were subcategorized into 1 of the following 4 groups: middle cerebral artery (MCA; n = 354), anterior communicating artery and anterior cerebral artery (ACA; n = 496), internal carotid artery (ICA; n = 402), and posterior circulation (n = 130). Locations of 66 of the ruptured aneurysms were unknown/unrecorded. Treatments included craniotomy and clipping alone in 1073 patients, endovascular coil embolization alone in 285 patients, and a combination of coiling and clipping in 17 patients. The age-adjusted and multivariate odds ratios from logistic regression analyses were calculated after stratification using the Fisher CT scale to investigate the effects of the hematoma volume of SAH.

Results Acute hydrocephalus was confirmed in 593 patients, and 521 patients developed sNPH. Patients with a ruptured ACA aneurysm had twice the risk for sNPH over those with a ruptured MCA aneurysm. Those with an ACA aneurysm with Fisher Grade 3 SAH had a 9-fold-higher risk for sNPH than those with an MCA aneurysm with Fisher Grade 1 or 2 SAH. Patients with a ruptured posterior circulation aneurysm did not have any significant risk for sNPH. Clipping of the ruptured aneurysm resulted in twice the risk for sNPH over coil embolization alone.

Conclusions Patients with low-grade SAH caused by a ruptured MCA aneurysm had a low risk for the development of sNPH. In contrast, patients with high-grade SAH caused by a ruptured ACA aneurysm had a higher risk for sNPH. Endovascular coiling might confer a lower risk of developing sNPH than microsurgical clipping.

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Safety and Efficacy of Surgical Resection of Unruptured Low-grade Arteriovenous Malformations From the Modern Decade

AVM-before

Neurosurgery 77:948–953, 2015

Recent studies have questioned the utility of surgical resection of unruptured brain arteriovenous malformations (bAVMs).

OBJECTIVE: We performed an assessment of outcomes and complications of surgical resection of low-grade bAVMs (Spetzler-Martin grade I or II) at a single high-volume neurosurgical center.

METHODS: We reviewed all unruptured low-grade bAVMs treated with surgery (with or without preoperative embolization) between January 2004 and January 2014. Stroke rate, mortality, and clinical and radiographic outcomes were examined.

RESULTS: Of 95 patients treated surgically, 85 (25 grade I, 60 grade II) met inclusion criteria, and all achieved radiographic cure postoperatively. Ten patients (11.8%) were lost to follow-up; the mean follow-up of the remaining 85 was 3.3 years. Three patients (3.5%) with grade II bAVMs experienced a stroke; no patients died. Although 20 patients (23.5%) had temporary postoperative neurological deficit, only 3 (3.5%) had new clinical impairment (modified Rankin Scale score $2) at last follow-up. Eight of the 13 patients (61.5%) with preexisting clinical impairment had improved modified Rankin Scale scores of 0 or 1; and 17 of 30 patients (56.7%) with preoperative seizures were seizure-free without antiepileptic medication postoperatively. No significant differences existed in stroke rate or clinical outcome between grades I and II patients at follow-up (Fisher exact test, P = .55 and P . .99, respectively).

CONCLUSION: Surgical resection of low-grade unruptured bAVMs is safe, with a high rate of improvement in functional status and seizure reduction. Although transient postoperative neurological deficit was observed in some patients, permanent treatment- related neurological morbidity was rare.

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Resolution of Oculomotor Nerve Palsy Secondary to Posterior Communicating Artery Aneurysms- Comparison of Clipping and Coiling

Advanced Technical Skills Are Required for Microsurgical Clipping of Posterior Communicating Artery Aneurysms in the Endovascular Era-0

Neurosurgery 77:931–939, 2015

Previous studies have attempted to determine the best treatment for oculomotor nerve palsy (ONP) secondary to posterior communicating artery (PCoA) aneurysms, but have been limited by small sample sizes and limited treatment.

OBJECTIVE: To analyze the treatment of ONP secondary to PCoA with both coiling and clipping in ruptured and unruptured aneurysms.

METHODS: Data from 2 large academic centers was retrospectively collected over 22 years, yielding a total of 93 patients with ONP secondary to PCoA aneurysms. These patients were combined with 321 patients from the literature review for large data analyses. Onset symptoms, recovery, and time to resolution were evaluated with respect to treatment and aneurysm rupture status.

RESULTS: For all patients presenting with ONP (n = 414) 56.6% of those treated with microsurgical clipping made a full recovery vs 41.5% of those treated with endovascular coil embolization (P = .02). Of patients with a complete ONP (n = 229), full recovery occurred in 47.3% of those treated with clipping but in only 20% of those undergoing coiling (P = .01). For patients presenting with ruptured aneurysms (n = 130), full recovery occurred in 70.9% compared with 49.3% coiled patients (P = .01). Additionally, although patients with full ONP recovery had a median time to treatment of 4 days, those without full ONP recovery had a median time to treatment of 7 days (P = .01).

CONCLUSION: Patients with ONP secondary to PCoA aneurysms treated with clipping showed higher rates of full ONP resolution than patients treated with coil embolization. Larger prospective studies are needed to determine the true potential of recovery associated with each treatment.

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Prognostic Value of the Amount of Bleeding After Aneurysmal Subarachnoid Hemorrhage: A Quantitative Volumetric Study

SAH

Neurosurgery 77:898–907, 2015

Quantitative estimation of the hemorrhage volume associated with aneurysm rupture is a new tool of assessing prognosis.

OBJECTIVE: To determine the prognostic value of the quantitative estimation of the amount of bleeding after aneurysmal subarachnoid hemorrhage, as well the relative importance of this factor related to other prognostic indicators, and to establish a possible cut-off value of volume of bleeding related to poor outcome.

METHODS: A prospective cohort of 206 patients consecutively admitted with the diagnosis of aneurysmal subarachnoid hemorrhage to Hospital 12 de Octubre were included in the study. Subarachnoid, intraventricular, intracerebral, and total bleeding volumes were calculated using analytic software. For assessing factors related to prognosis, univariate and multivariate analysis (logistic regression) were performed. The relative importance of factors in determining prognosis was established by calculating their proportion of explained variation. Maximum Youden index was calculated to determine the optimal cut point for subarachnoid and total bleeding volume.

RESULTS: Variables independently related to prognosis were clinical grade at admission, age, and the different bleeding volumes. The proportion of variance explained is higher for subarachnoid bleeding. The optimal cut point related to poor prognosis is a volume of 20 mL both for subarachnoid and total bleeding.

CONCLUSION: Volumetric measurement of subarachnoid or total bleeding volume are both independent prognostic factors in patients with aneurysmal subarachnoid hemorrhage. A volume of more than 20 mL of blood in the initial noncontrast computed tomography is related to a clear increase in poor outcome risk.

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In-Pipeline Stenosis: Incidence, Predictors, and Clinical Outcomes

In-Pipeline Stenosis- Incidence, Predictors, and Clinical Outcomes

Neurosurgery 77:875–879, 2015

The Pipeline Embolization Device is a widely utilized flow diverter in the treatment of intracranial aneurysms.

OBJECTIVE: To assess the incidence, clinical significance, predictors, and outcomes of in-Pipeline stenosis (IPS).

METHODS: Angiographic studies in 139 patients treated between 2011 and 2013 were independently reviewed by 2 authors for the presence of IPS. Multivariable logistic regression analysis was conducted to determine predictors of IPS.

RESULTS: A total of 21 (15.8%) patients demonstrated some degree of IPS during the follow-up period at a mean time point of 6.7 months (range, 3-24 months). The stenosis was mild (,50%) in 11 patients, moderate (50%-75%) in 5, and severe (.75%) in 6. None were symptomatic or required further intervention. Sixteen of these 22 patients (73%) had IPS detected within 6 months. IPS was noted in 7.6% (1/13) of patients with posterior circulation aneurysms vs 16.7% (21/126) of those with anterior circulation aneurysms (P = .03). The rate of IPS was 60% (3/5) in patients who did not receive aspirin vs only 14.2% (19/134) in those who received aspirin (P = .02). In multivariable analysis, no aspirin therapy (odds ratio, 10.0; 95% confidence interval, 1.4-67.7; P = .02) and internal carotid artery aneurysm location (odds ratio, 3.1; 95% confidence interval, 1.1-8.8; P = .03) were strong independent predictors of IPS.

CONCLUSION: IPS is a common, early, and mostly benign complication. Patients with internal carotid artery aneurysms are more likely to develop IPS. Aspirin plays a key role in preventing IPS. The results of this study further support the safety of flow diverters.

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Extended endoscopic endonasal transclival clipping of posterior circulation aneurysms

Extended endoscopic endonasal transclival clipping of posterior circulation aneurysms

Acta Neurochir (2015) 157:2077–2085

Transcranial clipping of most posterior circulation aneurysms is one of the most difficult procedures, with high morbidity, and endovascular coiling is an alternative with less risk, but is not devoid of complications and not suitable for all aneurysms. Here we describe four cases of posterior circulation aneurysms clipped via the extended endoscopic endonasal transclival route. To the best of our knowledge, this is the first report of basilar top and posterior cerebral artery aneurysms being clipped endonasally.

Methods and results Four patients with posterior circulation aneurysms underwent extended endoscopic endonasal transclival clipping of the aneurysm. The age range was 35– 70 years. There were two males and two females. Three of the four patients presented after the rupture of aneurysms, and the other patient presented with sudden-onset left hemiparesis probably due to thromboembolism from a large unruptured left posterior cerebral artery (PCA) aneurysm. On evaluation with four-vessel digital subtraction angiography (DSA), two patients had a basilar apex aneurysm, one had a basilar trunk aneurysm, and the other had a PCA (P1) aneurysm. Postoperatively, two patients had good recovery. One patient with a PCA aneurysm and another with a basilar apex aneurysm had fresh postoperative deficits. One patient developed postoperative CSF rhinorrhea.

Conclusion Endoscopic extended transnasal surgery is an expanding field in neurosurgery with a steep learning curve. With improvement in techniques and instrumentation the use of this approach for clipping posterior circulation aneurysms can become an effective alternative in the treatment of aneurysms.

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Seizure Outcomes in Patients With Surgically Treated Cerebral Arteriovenous Malformations

ICG and AVM

Neurosurgery 77:762–768, 2015

Epilepsy is the second most common symptom in cerebral arteriovenous malformation (AVM) patients. The consecutive reduction of life quality is a clinically underrated problem because treatment usually focuses on the prevention of intracerebral hemorrhage.

OBJECTIVE: To evaluate postoperative seizure outcome with the aim of more accurate counseling for postoperative seizure outcome.

METHODS: From 1985 to 2012, 293 patients with an AVM were surgically treated by J.S. One hundred twenty-six patients with preoperative seizures or epilepsy could be identified; 103 of 126 had a follow-up of at least 12 months and were included in the analysis. The different epilepsy subtypes were categorized (sporadic seizures, chronic epilepsy, drug-resistant epilepsy [DRE]). Preoperative workup and surgical technique were evaluated. Seizure outcome was analyzed by using International League Against Epilepsy classification.

RESULTS: Sporadic seizures were identified in 41% of patients (chronic epilepsy and DRE were identified in 36% and 23%, respectively). Detailed preoperative epileptological workup was done in 13%. Seizure freedom was achieved in 77% (79% at 5 years, 84% at 10 years). Outcome was significantly poorer in DRE cases. More extensive resection was performed in 11 cases with longstanding symptoms (.24 months) and resulted in better seizure outcome as well as the short duration of preoperative seizure history.

CONCLUSION: Patients presenting with AVM-associated epilepsy have a favorable seizure outcome after surgical treatment. Long-standing epilepsy and the progress into DRE markedly deteriorate the chances to obtain seizure freedom and should be considered an early factor in establishing the indication for AVM removal.

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Morphological aspects of blister aneurysms and nuances for surgical treatment

blister aneurysms

J Neurosurg 123:1156–1165, 2015

Blister aneurysms of the supraclinoid part of the internal carotid artery (ICA) are known for their high morbidity and mortality rates related to treatment, regardless of whether the treatment is surgical or endovascular. However, this grim prognosis is based on results that indiscriminately group all blister aneurysms together without taking into account the heterogeneous appearance of these lesions. The goal of this study was 2-fold: to determine whether different blister aneurysm morphologies present different pitfalls, which would then require different surgical strategies, as well as to determine whether there are identifiable subgroups of these types of aneurysms based on morphology.

Methods The authors reviewed the charts, cerebral catheter angiograms, surgical reports, and intraoperative videos of all ICA blister aneurysms treated surgically at the Centre Hospitalier de l’Université de Montréal from 2005 to 2012 to investigate whether there was a relationship between morphology and pitfalls, and whether different surgical strategies had been used according to these pitfalls. During this review process the authors noted 4 distinct morphological aspects. These 4 aspects led to a review of the English and French literature on blister aneurysms in which imaging was available, to determine whether other cases could also be classified into the same 4 subgroups based on these morphological aspects.

Results The retrospective review of the authors’ series of 10 patients allowed a division into 4 distinct subtypes: Type I (classic), Type II (berry-like), Type III (longitudinal), and Type IV (circumferential). These subtypes may at times be progressive stages in the arterial anomaly, and could represent a continuum. Each subtype described in this paper presented its own pitfalls and required specific surgical adaptations. Upon reviewing the literature the authors retained 35 studies involving a total of 61 cases of blister aneurysms, and all cases were able to be classified into 1 of these 4 distinct subtypes.

Conclusions Although they share some common characteristics, blister aneurysms may be divided into distinct subtypes, suggestive of a continuum. Such a classification with a detailed description of each type of blister aneurysm would allow for better recognition to anticipate complications during intervention and better assess the different treatment strategies according to the subtypes.

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Application of intraoperative motor evoked potential monitoring during giant internal carotid artery aneurysm surgery using prolonged temporary occlusion

Application of intraoperative motor evoked potential monitoring during giant internal carotid artery aneurysm surgery using prolonged temporary occlusion

Acta Neurochir (2015) 157:1833–1840

Clipping and bypass surgery are common therapeutic options for the management of giant internal carotid artery (ICA) aneurysms. However, potential ischemic risks may be exaggerated by prolonged temporary occlusion (PTO) during the surgery. Monitoring motor-evoked potentials (MEPs) is a sensitive technique for detecting potential ischemia intraoperatively. This preliminary study was designed to evaluate the effectiveness of applying MEP monitoring during giant ICA aneurysm surgery using PTO.

Methods From July 2009 to July 2012, 11 patients with giant ICA aneurysms who could not pass the preoperative hemodynamic evaluations were enrolled in this study. MEP monitoring was utilized intraoperatively in all cases. Clipping was performed if there were no significant MEP changes under PTO. A variant extracranial-to-intracranial (EC-IC) bypass was performed if there was reproducible loss of MEP signals after PTO or unclippable anatomic features.

Results Five patients underwent clipping alone and six underwent bypass. There were no significant differences in baseline clinical data between the two groups. The overall percentage of patients with good outcomes (Glasgow Outcome Score≥4) improved from 72.7 % (8/11) postoperatively to 90.9 % (10/11) after 26.0±9.5 months of follow-up. There were no significant differences between the clipping and bypass groups regarding short- and long-term outcomes (p=0.545 and p=1.000).

Conclusions MEP monitoring is useful for evaluating the safety of PTO, surgical strategy, and outcomes of giant ICA aneurysm surgery. Direct clipping during safe PTO under intraoperative MEP monitoring is applicable for giant ICA aneurysms. Its use achieved favorable outcomes by indicating the need for bypass surgery.

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Temporal lobe epilepsy and cavernous malformations: surgical strategies and long-term outcomes

Temporal lobe epilepsy and cavernous malformations- surgical strategies and long-term outcomes

Acta Neurochir (2015) 157:1887–1895

Cerebral cavernous malformations (CCM) of the temporal lobe often present with seizures. Surgical resection of these lesions can offer durable seizure control. There is, however, no universally accepted methodology for assessing and surgically treating these patients. We propose an algorithm to maximize positive surgical outcomes (seizure control) while minimizing post-surgical neurological deficit.

Methods A retrospective review of 34 patients who underwent epilepsy surgery for radiographically proven temporal lobe CCM was conducted. Patients underwent a relatively standard work-up for seizure localization. In patients with mesial temporal lobe epilepsy (MTLE), a complete resection of the epileptogenic zone was performed including amygdalo-hippocampectomy in addition to a lesionectomy if not contraindicated by pre-operative work-up. Patients with neocortical epilepsy underwent intraoperative electrocorticography (ECoG)-guided lesionectomy.

Results Seizure-free rate for mesial and neocortical (anterior, lateral, and basal) location was 90 vs. 83 %, respectively. Complete resection of the lesion, irrespective of location, was statistically significant for seizure control (p=0.018). There was no difference in seizure control based on disease duration or location (p>0.05). Patients with mesial temporal CCM who presented with MTLE were presumed to also have mesial temporal sclerosis (MTS), or dual pathology. These patients underwent routine resection of the mesial structures. Interestingly, patients who had MTLE and basal (neocortical) lesions who underwent a mesial resection for suspected MTS were found not to have dual pathology.

Conclusions Patients with temporal lobe CCM should be offered resection for durable seizure control, prevention of secondary epileptogenic foci, and elimination of hemorrhage risk. The preoperative work-up should follow a team approach. Surgical intervention should include complete lesionectomy in all cases. Intra or extra-operative ECoG for neocortical lesions may be beneficial. Management of mesial temporal CCMs (archicortex) should consider resection of a well-defined epileptogenic zone (including mesial structures) due to high probability of pathologically proven MTS. The use of this treatment algorithm is useful for the education and treatment of these patients.

Keywords Epilepsy , Cavernous malformation, Temporal lobe , Pathology

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Cost Comparison of Surgical and Endovascular Treatment of Unruptured Giant Intracranial Aneurysms

Virtual planning of different possible approaches for the surgical treatment of a giant carotid-ophthalmic aneurysm

Neurosurgery 77:733–743, 2015

Giant intracranial aneurysms (GIAs), which are defined as intracranial aneurysms (IAs) with a diameter of $25 mm, are most likely associated with the highest treatment costs of all IAs. However, the treatment costs of unruptured GIAs have so far not been reported. OBJECTIVE: To examine direct costs of endovascular and surgical treatment of unruptured GIAs.

METHODS: We retrospectively examined 55 patients with unruptured GIAs treated surgically (37 patients) or endovascularly (18 patients) between April 2004 and March 2014. We analyzed the costs of all hospital stays, interventions, and imaging with a median follow-up of 46 months.

RESULTS: There was no difference in the costs of hospital stay between surgical and endovascular treatment groups ($10 565 vs $14 992; P = .37). Imaging costs were significantly higher in the surgical group than in the endovascular treatment group ($2890 vs $1612; P < .01), as were the costs of the intervention room and personnel involved in the intervention ($5566 vs $1520; P < .01). Implants used per patient were more expensive in the endovascular group than in the surgical treatment group ($20885 vs $167). The total direct treatment costs were higher in the endovascular group ($52325) than in the surgical treatment group ($20619; P < .01). Treatment costs were associated with the type of treatment and GIA location but not with patient age, sex, or GIA size.

CONCLUSION: Endovascular GIA treatment produced higher direct costs than surgical GIA treatment mainly due to higher implant costs. Reducing endovascular implant costs may be the most effective tool to decrease direct costs of GIA treatment.

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