Month: August 2013

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Flow-Diverter Devices for Intracranial Aneurysms

Flow-Diverter Devices for Intracranial Aneurysms

Neurosurgery 73:193–200, 2013

Although the introduction of flow-diverter devices (FDDs) has aroused great enthusiasm, the level of evidence supporting their use has not been systematically evaluated.

OBJECTIVE: To report a systematic review of medical literature up to May 2012 on FDDs to assess the morbidity, case fatality rate, and efficacy of FDDs for intracranial aneurysms.

METHODS: The literature was searched by using MEDLINE, Embase, and all Evidence- Based Medicine in the OVID database. Eligibility criteria were studies including at least 10 patients, reporting duration of follow-up and number of patients lost to follow-up, and documenting the rate of aneurysm occlusion and death and neurological complications. The endpoints were angiographic success, early and late mortality, and neurological morbidity.

RESULTS: Fifteen studies were analyzed consisting of 897 patients with 1018 aneurysms. The mean value of methodological quality score was 14.4 using the STROBE score. The early mortality rate was 2.8% (95% confidence interval [CI]: 1.7-3.8; I2 = 93.4%) and the late mortality rate was 1.3% (95% CI: 0.2-2.3; I2 = 36.9%). The early neurological morbidity rate was 7.3% (95% CI: 5.7-9; I2 = 91.8%) and the late morbidity rate was 2.6% (95% CI: 1.1-4; I2 = 81.3%). The Egger test for early and late morbidity and aneurysm occlusion was ,0.001.

CONCLUSION: With the available data from the studies, both heterogeneity and publication biases imply that the current clinical use of FDDs is not supported by highquality evidence. In the absence of reliable evidence, the use of FDDs in patients eligible for more conventional treatments should be restricted to controlled clinical trials.

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Complex middle cerebral artery aneurysms. A new classification

Complex MCAA-a new classification

Acta Neurochir (2013) 155:1481–1491

Because of the diversity of aneurysm morphology, complicated arterial anatomy and hemodynamic characteristics, tailored surgical treatments are required for cases of individual complex middle cerebral artery (MCA) aneurysms.

Methods During an 8-year period, 59 complex MCA aneurysms in 58 patients were treated microsurgically in our department. Complex aneurysms were defined as having large (10–24 mm in diameter) or giant (diameter≥25 mm) size or non-saccular morphology (fusiform, dissecting or serpentine).

Results Direct clipping of the aneurysmal necks was achieved in eight patients, while reconstructive clipping was performed in 25 patients. Indirect aneurysm occlusion was performed in 25 cases, including trapping or resecting the aneurysm in four cases, trapping or resecting the aneurysm with extraintracranial (EC) or intra-intracranial (IC) bypass in 21 cases and internal carotid artery (ICA) sacrifice with EC-IC bypass in one case. Forty-eight aneurysms (81.4 %) were completely obliterated. Graft patency was confirmed in 20 of 21 cases (95.2 %) with bypass. A recurrent aneurysm was detected in one case and a re-operation was performed. Two patients with Hunt-Hess grade IV aneurysms died during the perioperative period. Overall, 52 cases (88.1 %) had good outcomes (Glasgow Outcome Scale≥4) during the late follow-up period.

Conclusion The surgical modality and strategy for treating complex MCA aneurysm are decided according to the morphology of the aneurysm, vascular anatomy and the hemodynamic characteristics of each case. Thus, we developed a new classification based on the angioarchitecture. Favorable outcomes can be achieved by treating complex MCA aneurysms with appropriate surgical modalities, strategies and techniques.

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