Category: Vascular

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Intracranial-intracranial arterial by-pass for complex aneurysms

Neurosurgery 65:670–683, 2009 DOI: 10.1227/01.NEU.0000348557.11968.F1

OBJECTIVE: Bypass surgery for brain aneurysms is evolving from extracranial-intracranial
(EC-IC) to intracranial-intracranial (IC-IC) bypasses that reanastomose parent arteries,
revascularize efferent branches with in situ donor arteries or reimplantation, and reconstruct bifurcated anatomy with grafts that are entirely intracranial. We compared results with these newer IC-IC bypasses to conventional EC-IC bypasses.
METHODS: During a 10-year period, 82 patients underwent bypass surgery as part of their aneurysm management. A quarter of the patients presented with ruptured aneurysms and two-thirds presented with compressive symptoms from unruptured aneurysms. Most aneurysms (82%) had non-saccular morphology and 56% were giant sized. Common locations included the cavernous internal carotid artery (23%), middle cerebral artery (20%), and posteroinferior cerebellar artery (12%).
RESULTS: Forty-seven patients (57%) received EC-IC bypasses and 35 patients (43%)received IC-IC bypasses, including 9 in situ bypasses, 6 reimplantations, 11 reanastomoses, and 9 intracranial grafts. Aneurysm obliteration rates were comparable in ECIC and IC-IC bypass groups (97.9% and 97.1%, respectively), as were bypass patency rates (94% and 89%, respectively). Three patients died (surgical mortality, 3.7%), and 4 patients were permanently worse as a result of bypass occlusions (neurological morbidity,4.9%). At late follow-up (mean duration, 41 months), good outcomes (Glasgow Outcome Scale score 5 or 4) were measured in 68 patients (90%) overall, and were similar in EC-IC and IC-IC bypass groups (91% and 89%, respectively). Changes in Glasgow Outcome Scale score were slightly more favorable with IC-IC bypass (6% worse or dead after IC-IC bypass versus 14% with EC-IC bypass).
CONCLUSION: IC-IC bypasses compare favorably to EC-IC bypasses in terms of aneurysm obliteration rates, bypass patency rates, and neurological outcomes. IC-IC bypasses can be more technically challenging to perform, but they do not require harvest of extracranial donor arteries, spare patients a neck incision, shorten interposition grafts, are protected inside the cranium, use caliber-matched donor and recipient arteries, and are not associated with ischemic complications during temporary arterial occlusions. IC-IC bypass can replace conventional EC-IC bypass with more anatomic reconstructions for selected aneurysms involving the middle cerebral artery, posteroinferior cerebellar artery, anterior cerebral artery, and basilar apex.

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Aneurysmal subarachnoid hemorrhage diagnosis with computed tomographic angiography and OsiriX

Acta Neurochir DOI 10.1007/s00701-009-0508-x

Purpose Recent advances in computed tomographic angiography (CTA) have resulted in its replacing digital subtraction angiography (DSA). However, CTA requires a powerful workstation and experienced technicians for image postprocessing. OsiriX, a free open-source medical imaging software with powerful three-dimensional (3D) capability, enables neurosurgeons to perform 3D rendering without extensive training. In this study, we examined the sensitivity and specificity of CTA with OsiriX as the primary diagnostic tool for intracranial aneurysms.

Method From May 2006 to March 2009, 121 patients with spontaneous subarachnoid hemorrhage (SAH) underwent CTA. The CTA source images were 3D rendered by neurosurgeons using OsiriX. All the possible locations for aneurysms were carefully reviewed. DSA was performed on every patient in any of the following conditions: for negative CTA findings, after surgical clipping of aneurysms or before transarterial embolization of aneurysms.

Results Of the 121 patients, 8 were excluded because DSA data were not available. In the remaining 113 patients, 20 patients had negative CTA findings. CTA with OsiriX detected 106 aneurysms in 93 patients, of which 103 were confirmed by DSA or postoperative DSA; 3 infundibular dilated pouches of small arteries were mistaken for aneurysms. Two anterior communicating artery aneurysms (1.5 mm and 1 mm) were missed by CTA from among all 113 patients. The sensitivity and specificity of CTA for detecting aneurysms on a per-patient basis were 98.9% and 100%, respectively. The sensitivity and specificity of CTA for detecting aneurysms on a per-aneurysm basis for detecting aneurysms were 98.1% and 86.3%, respectively.

Conclusion CTA with OsiriX enables accurate detection of intracranial aneurysms. Cerebral DSA should be reserved for those patients with negative CTA findings.

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Reduced Platelet Activity Is Associated With More Intraventricular Hemorrhage

Neurosurgery: October 2009 – Volume 65 – Issue 4 – p 684-688. doi:10.1227/01.NEU.0000351769.39990.16

Intraventricular hemorrhage (IVH) is a serious complication of intracerebralhemorrhage (ICH). We hypothesized that antiplatelet medication use and platelet activity would be associated with more IVH.

METHODS: We prospectively identified patients with spontaneous ICH and measured platelet activity on admission with the VerifyNow-Aspirin assay (Accumetrics, San Diego,CA). IVH volume was quantified with the Graeb scale, divided into categories of 0 (noIVH), 1 to 2 (minimal IVH), 3 to 5 (moderate IVH), and 6 and above (severe IVH). Antiplatelet medications were prospectively recorded. We used ordinal regression to measure the effect of platelet activity after correcting for ICH location and ICH volume. Outcomes were measured at 14 days or discharge with the National Institutes of HealthStroke Scale and modified Rankin Scale (mRS) and at 28 days and 3 months with the mRS.

RESULTS: In our cohort of 73 patients, 36 had no IVH, 11 had minimal IVH, 10 hadmoderate IVH, and 16 had severe IVH. Aspirin and clopidogrel (P = 0.03 for both) were associated with less platelet activity. More IVH was related to reduced platelet activity (P =0.01) after correction for ICH volume and location without contribution from aspirin or clopidogrel use. IVH was associated with worse National Institutes of Health Stroke Scalescore (P = 0.002) and mRS score (P = 0.001) at 14 days and with mRS scores at 28 days (P= 0.02) and 3 months (P = 0.008).

CONCLUSION: Reduced platelet activity was related to more IVH as a complication of ICH. The relationship of platelet activity to IVH deserves further study.

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Vertebral artery ostial stent placement for atherosclerotic stenosis in 72 consecutive patients

Neuroradiology (2008) 51:531–539 DOI 10.1007/s00234-009-0531-x

The study’s purpose is to report the technical and clinical outcomes of a patient cohort that underwent vertebral artery ostium stent placement for atherosclerotic stenosis.

Methods  We retrospectively analyzed a prospectively collected database of neurointerventional procedures performed at a single center from 1999 to 2005. Outcome measures included recurrent transient neurological deficits (TNDs), stroke, and death. Kaplan–Meier analysis was used to estimate stroke- and/or death-free survival at 12 months. Cox proportional hazard was used to identify risk factors for recurrent vertebrobasilar ischemic events.

Results  Seventy-two patients with 77 treated vertebral ostial lesions were included. The 30-day stroke and/or death rate was 5.2% (n = 4), although no event was directly related to the vertebral ostium stent placement. Three procedure-related strokes were secondary to attempted stent placement at other sites (one carotid artery and two basilar arteries), and the one death was secondary to the presenting stroke severity. The mean clinical follow-up time available for 66 patients was 9 months. There were 14 TNDs (21%), two strokes (3%), and two deaths (3%) recorded in the follow-up. Recurrent vertebrobasilar ischemic events occurred in nine patients (seven TNDs and two strokes). No recurrent stroke and/or deaths were related to the treated vertebral ostium. Stroke- and/or death-free survival rate (including periprocedural stroke and/or death) was 89 ± 5% at 12 months. No vascular risk factor was significantly associated with recurrent vertebrobasilar ischemic events.

Conclusions  Vertebral artery ostium stent placement can be safely and effectively performed with a low rate of recurrent stroke in the territory of the treated vessel. Patients who also underwent attempted treatment of a tandem intracranial stenosis appeared to be at highest risk for periprocedure stroke.

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Lessons learned by personal failures in aneurysm surgery: what went wrong, and why?

Knut Wester

Acta Neurochir (2009) 151:1013–1024


Purpose To analyse the intraoperative complications of a single neurosurgeon, with emphasis on devastating intraoperative incidents, and how they possibly could have been avoided.
Methods All the patients operated upon by the author between 1986 and 2002, i.e. 252 patients with 270 craniotomies for 294 aneurysms, were included. All intraoperative events that possibly could have influenced the clinical outcome were recorded prospectively.
Results A total of 16 cases (6.3% of all the patients) with serious intraoperative incidents were identified. In 11 cases (3.6% of all aneurysms), an intraoperative rupture occurred that was judged to have had mild to severe consequences for the patient. In another four patients (1.6% of all patients), all with unruptured, large aneurysms (>15 mm) of the carotid or middle cerebral arteries, a major vessel occlusion occurred inadvertently. In one patient with a large, unruptured MCA aneurysm, a clip slipped after the closure of the wound, causing a fatal intracerebral haemorrhage. These events had a severe impact on the clinical outcome. In retrospect, most of these incidents could, and should have, been avoided.

Conclusions It is recommended to start the training of new aneurysm surgeons on patients with small, supratentorial, unruptured aneurysms, followed by ruptured aneurysms in all other supratentorial locations than the anterior communicating artery (ACOM), which is the supratentorial location that should be the last step in the training of independent aneurysm surgeons.

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Long-Term Outcome of Patients With Multiple Cerebral Cavernous Malformations

Neurosurgery: September 2009 – Volume 65 – Issue 3 – p 450-455

Multiple cerebral cavernous malformations (MCCMs) typically occur in patients with a family history of these lesions. Literature on MCCMs is scarce, and little is known about their natural history.

Of 264 consecutive patients with cerebral cavernomas treated at the Department of Neurosurgery, Helsinki University Central Hospital, in the past 27 years, 33 patients had MCCMs. Lesions were categorized according to the Zabramski classification scale. Follow-up questionnaires were sent to all patients. Outcome was assessed using the Glasgow Outcome Scale, and amelioration of epilepsy was assessed using the Engel scale. All clinical data were analyzed retrospectively.

The mean age of patients at diagnosis was 44 years. Sex presentation was almost equal. Nine percent of all patients had a family history of the disease. Patients presented with epilepsy, acute headache, and focal neurological deficits. MCCMs were incidental findings in 2 patients. Altogether, 416 cavernomas were found: 70% supratentorial and 30% infratentorial. Fifteen patients had symptomatic hemorrhage before admission to our department. Surgery was performed on 18 patients. In most cases, the largest cavernoma was removed. Postoperatively, 1 patient experienced temporary hemiparesis, and another developed permanent motor dysphasia. No mortalities occurred. The mean follow-up time was 7.7 years. Twenty-six patients (79%) were in good condition. Among patients with epilepsy who underwent lesionectomy, 70% had an Engel class I outcome. On follow-up magnetic resonance imaging, 52 de novo cavernomas were found.

Surgical treatment of patients with MCCMs is safe. An extirpation of the clinically active cavernoma prevents further bleedings and improves outcome of epilepsy.

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Risk of Retreatment for Aneurysm Recurrence or Residual After Initial Treatment By Endovascular Coiling

Neurosurgery: August 2009 – Volume 65 – Issue 2 – p 311-315

Endovascular treatment of intracranial aneurysms is less invasive than surgical repair but poses a higher risk for aneurysm recurrence, which may necessitate retreatment, thus adding to the long-term risk. Cerebrovascular neurosurgeons from 8 institutions in the United States and Puerto Rico collaborated to assess the risk of retreatment for residual or recurrent aneurysms after the initial endovascular coiling.

Data were prospectively recorded for 311 patients with coiled intracranial aneurysms who underwent 352 retreatment procedures after angiographic or clinical recurrence (hemorrhage after initial coiling). Results analyzed included procedural complications and procedure-related morbidity. Morbidity was classified as major (modified Rankin scale score > 3) or minor, and temporary (<30 days) or permanent (>30 days).

Retreatment mortality was 0.85% per procedure and 0.96% per patient. Treatment-related rates were 0.32% per patient (0.28% per procedure) for permanent or temporary major disability; 1.29% for permanent minor disability (1.14% per procedure); and 1.61% for temporary minor disability (1.42% per procedure). Total risk for death or permanent major disability was 1.28% per patient and 1.13% per procedure.

Retreatment poses a low risk for patients with recurrences of intracranial aneurysms after initial coiling; this risk is smaller than that posed by the initial endovascular therapy. The risk of disability associated with retreatment for aneurysm recurrence after coiling must be considered prospectively in the choice of treatment but with the recognition that its effects are low in the overall management risk.

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Endovascular treatment of brain arteriovenous malformations using onyx: Results of a prospective, multicenter study

Journal of Neuroradiology (36) 3: 147 – 152 (01/06/2009)

Background and purpose. – To evaluate the safety and efficacy of onyx for embolization of brain arteriovenous malformations (BAVM). Methods. – A prospective, multicenter study was conducted in France to evaluate embolization of BAVM with onyx. From May 2003 to March 2005, 50 patients (26 females, 24 mates; mean age: 34.8 years, range: 16-64 years) were included. Clinical. Presentation was haemorrhage in 22 patients (44.0%), seizures in 16 patients (32.0%), headaches in six patients (12.0%) and progressive neurological. Deficit in two cases (4.0%). Four patients were asymptomatic (8.0%). Results. – One hundred and forty-nine sessions of embolization were performed: one to eight sessions/patient with a mean of 3.0 sessions. One hundred and sixteen sessions (77.9%) were performed with onyx, 20 sessions (13.4%) with glue and 13 sessions (8.7%) with onyx and glue. Symptomatic acute postembolization haemorrhage (APEH) was observed in four cases (8.0% per patient). At 1 month, morbidity and mortality related to the treatment were of 8% and 2%, respectively. Complete BAVM occlusion was obtained in 8.3% of cases. In the remaining cases, occlusion rate was between 99 and 80% in 56.3% of patients, 79 and 60% in 16.7%, and less than 60 in 18.7%. In case of incomplete occlusion, complementary treatment was performed by radiosurgery. Conclusion. – Onyx is suitable for BAVM embolization with acceptable morbidity and mortality.

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