Month: August 2012

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Microsurgical Clipping of Posterior Communicating Artery Aneurysms in the Endovascular Era

Neurosurgery 71:285–295, 2012 DOI: 10.1227/NEU.0b013e318256c3eb

Many neurosurgeons feel competent clipping posterior communicating artery (PCoA) aneurysms and include this lesion in their practice. However, endovascular therapy removes simple aneurysms that would have been easiest to clip with the best results. What remains are aneurysms with complex anatomy and technical challenges that are not well described.

OBJECTIVE: A contemporary surgical series with PCoA aneurysms is reviewed to define the patients, microsurgical techniques, and outcomes in current practice. METHODS: A total of 218 patients had 218 PCoA aneurysms that were treated microsurgically during an 11-year period. Complexities influencing aneurysm management included (1) large/giant size; (2) fetal posterior cerebral artery; (3) previous coiling; (4) anterior clinoidectomy; (5) adherence of the anterior choroidal artery (AChA); (6) intraoperative aneurysm rupture; (7) complex clipping; and (8) atherosclerotic calcification.

RESULTS: Simple PCoA aneurysms were encountered in 113 patients (51.8%) and complex aneurysms in 105 (48.2%). Adherent AChA (13.8%) and intraoperative rupture (11.5%) were the most common complexities. Simple aneurysms had favorable outcomes in 86.6% of patients, whereas aneurysms with 1 or multiple complexities had favorable outcomes in 78.2% and 75.0%, respectively. Intraoperative rupture (P , .01), large/giant size (P = .04), and complex clipping (P = .05) were associated with increased neurological worsening.

CONCLUSION: Because endovascular therapy alters the surgical population, neurosurgeons should recalibrate their expectations with this once straightforward aneurysm. The current mix of PCoA aneurysms requires advanced techniques including clinoidectomy, AChA microdissection, complex clipping, and facility with intraoperative rupture. Microsurgery is recommended for recurrent aneurysms after coiling, complex branches, aneurysms causing oculomotor nerve palsy, multiple aneurysms, and patients with hematomas.

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Predictors of meningioma consistency: A study in 243 consecutive cases

Acta Neurochir (2012) 154:1383–1389 DOI 10.1007/s00701-012-1427-9

Meningioma is a common neoplasm primarily arising in the central nervous system. Its consistency is considered to be one of the critical prognostic factors for determining surgical resectability. The present study endeavored to investigate predictive factors associated with the tumor consistency.

Methods Two hundred and forty-three consecutive participants who underwent resective surgery of meningioma were examined. The authors designed an objective grading system for meningioma consistency and utilized it for assessing consistency among all cases. We focused on the relationship between preoperative tumor characteristics on neuroimaging studies and the consistency.

Results The tumor attributes on T2-weighted image (T2WI) and fluid attenuated inversion recovery (FLAIR) image were significantly correlated with the tumor consistency (p=0.004 and 0.045, respectively). The hypointense tumors on both MRI sequences tended to be hard, whereas the tumors showing hypersignal intensity were associated with soft consistency. There was no correlation between the consistency and age, gender, duration of neurologic symptoms, tumor location, size, calcification, cystic portion, en plague appearance, tumor-brain contact interface expressed by cerebrospinal fluid (CSF) cleft, perilesional vasogenic edema, bony status, features on T1-weighted image (T1WI) and pattern of contrast enhancement. In multiple logistic regression analysis, the tumor characteristics on T2WI and FLAIR image were independent factors significantly correlated with the tumor consistency (p=0.005 and 0.041, respectively). The tumor consistency was also correlated with operative radicalness as evaluated by the Simpson criteria.

Conclusions Signal intensity on T2WI and FLAIR image can be used for insinuating meningioma consistency. Presurgical prediction of the consistency is highly valuable in operative planning, particularly in arduous cases.

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Long-term Results of Enterprise Stent-Assisted Coiling of Cerebral Aneurysms

Neurosurgery 71:239–244, 2012 DOI: 10.1227/NEU.0b013e3182571953

The Enterprise Vascular Reconstruction Device and Delivery System (Cordis; the Enterprise stent) was approved for use in conjunction with coiling of wide-necked aneurysms in 2007. No published long-term aneurysm occlusion or complication data exist for the Enterprise system.

OBJECTIVE: We compiled data on consecutive patients treated with Enterprise stent-assisted coiling of aneurysms from 9 high-volume neurointerventional centers.

METHODS: A 9 center registry was created to evaluate large volume data on the delayed safety and efficacy of the Enterprise stent system. Pooled data were compiled for consecutive patients undergoing Enterprise stent-assisted coiling at each institution prior to May 2009.

RESULTS: Two-hundred twenty-nine patients with 229 aneurysms, 32 of which were ruptured aneurysms, were included in the study. Mean clinical and angiographic follow-up was 619.6 ± 26.4 days and 655.7 ± 25.2 days, respectively. Mean aneurysm size was 9.2 ± 0.4 mm. Fifty-nine percent of patients demonstrated 100% coil obliteration and 81% had 90% or higher occlusion at last follow-up angiography. A total of 19 patients (8.3%) underwent retreatment of their aneurysms during the follow-up period. Angiographic in-stent stenosis was seen in 3.4% and thromboembolic events occurred in 4.4%. Overall, 90% of patients who underwent Enterprise-assisted coiling had a modified Rankin Scale score of 2 or less at last follow-up. A poor modified Rankin Scale score was strongly associated with rupture status (P < .001).

CONCLUSION: Although this study is limited by its retrospective nature, the Enterprise stent system appears to be an effective, safe, and durable treatment for intracranial aneurysms when used in conjunction with coiling.

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