Tag: Unruptured cerebral aneurysm

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Keyhole strategy aiming at minimizing hospital stay for surgical clipping of unruptured middle cerebral artery aneurysms

J Neurosurg 130:1359–1366, 2019

Aneurysms of the middle cerebral artery (MCA) are still most often treated by clipping through standard craniotomy, but a longer hospital stay is one of the main drawbacks of this treatment. The authors developed a pterional keyhole clipping strategy for unruptured MCA aneurysms with the intention of minimizing hospital stay. In this paper, they report on their experience with this approach and analyze the long-term neurological and radiological outcomes.

METHODS A total of 160 relatively small unruptured MCA aneurysms (mean 6.4 mm) were clipped through the pterional keyhole approach (19–30 mm, mean 24.6 mm) in 149 patients (aged 34–79 years, mean 62 years). Neurological and cognitive function were examined by several scales, including the modified Rankin Scale (mRS) and Mini–Mental State Examination (MMSE). Patients’ level of depression was assessed using the Beck Depression Inventory and Hamilton Depression Scale. The state of clipping was assessed at 1 year and then every few years after the operation.

RESULTS The mean duration of postoperative hospitalization was 2.3 ± 3.4 days; in 31.3% of the cases, the patients were discharged on the day after the operation (overnight hospital stay) and in 93.2% within 3 days. Of the patients younger than 60 years, 40.4% required only an overnight stay. Complete aneurysm neck clipping was confirmed in 157 cases (98.1%). None of the completely clipped aneurysms showed any recurrence during the mean follow-up period of 5.0 years. The mean length of clinical follow-up was 5.4 years. After 2 (1.3%) of the surgical procedures, the patients showed persistent neurological deficits, defined as mRS score 1, but the overall operative morbidity based on the International Study of Unruptured Intracranial Aneurysms (ISUIA) definition (mRS score ≥ 2 or MMSE score < 24) was 0% at the last examination. Depression scores were significantly improved after surgery, and in 85.6% of the cases the patients were satisfied with their cosmetic results.

CONCLUSIONS Pterional keyhole clipping is less invasive than clipping via standard craniotomy, minimizes hospital stay, and achieves durable treatment for relatively small unruptured MCA aneurysms.

 

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Outcomes of Elective Cerebral Aneurysm Treatment Performed by Attending Neurosurgeons after Night Work

Neurosurgery 82:329–334, 2018

The association between long work hours and outcomes among attending surgeons remains an issue of debate.

OBJECTIVE: To investigate whether operating emergently the night before an elective case was associated with inferior outcomes among attending neurosurgeons.

METHODS:We executed a cohort study with unruptured cerebral aneurysm patients,who underwent endovascular coiling or surgical clipping from 2009 to 2013 and were registered in the Statewide Planning and Research Cooperative Systemdatabase. We investigated the association of treatment by surgeons performing emergency procedures the night before with outcomes of elective cerebral aneurysm treatment using an instrumental variable analysis.  RESULTS:Overall, 4700 patients underwent treatment for unruptured cerebral aneurysms. Therewas no difference in inpatient mortality (adjusted difference, –0.7%; 95% confidence interval [CI], –1.4% to 0.02%), discharge to a facility (adjusted difference, –0.1%; 95% CI, –1.2% to 1.2%), or length of stay (adjusted difference, –0.58; 95% CI, –1.66 to 0.50) between patients undergoing elective cerebral aneurysm treatment by surgeons who performed emergency procedures the night before, and those who did not.

CONCLUSION: Using a comprehensive patient cohort in New York State for elective treatment of unruptured cerebral aneurysms, we did not identify an association of treatment by surgeons performing emergency procedures the night before, with mortality, discharge to a facility, or length of stay. Our study had 80% power to detect differences inmortality (our primary outcome), as small as 4.1%. The results of the present study do not support the argument for regulation of attending work hours.

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A new comorbidities index for risk stratification for treatment of unruptured cerebral aneurysms

Aneurysm surgery

J Neurosurg 125:713–719, 2016

Comorbidities have an impact on risk stratification for outcomes in analyses of large patient databases. Although the Charlson Comorbidity Index (CCI) and the Elixhauser Comorbidity Index (ECI) are the most commonly used comorbidity indexes, these have not been validated for patients with unruptured cerebral aneurysms; therefore, the authors created a comorbidity index specific to these patients.

Methods The authors extracted all records involving unruptured cerebral aneurysms treated with clipping, coiling, or both from the Nationwide Inpatient Sample (2002–2010). They assessed the effect of 37 variables on poor outcome and used the results to create a risk score for these patients. The authors used a validation data set and bootstrapping to evaluate the new index and compared it to CCI and ECI in prediction of poor outcome, mortality, length of stay, and hospital charges.

Results The index assigns integer values (-2 to 7) to 20 comorbidities: neurological disorder, renal insufficiency, gastrointestinal bleeding, paralysis, acute myocardial infarction, electrolyte disorder, weight loss, metastatic cancer, drug abuse, arrhythmia, coagulopathy, cerebrovascular accident, psychosis, alcoholism, perivascular disease, valvular disease, tobacco use, hypothyroidism, depression, and hypercholesterolemia. Values are summed to determine a patient’s risk score. The new index was better at predicting poor outcome than CCI or ECI (area under the receiver operating characteristic curve [AUC] 0.814 [95% CI 0.798–0.830], vs 0.694 and 0.712, respectively, for the other indices), and it was also better at predicting mortality (AUC 0.775 [95% CI 0.754–0.792], vs 0.635 and 0.657, respectively, for CCI and ECI).

Conclusions This new comorbidity index outperforms the CCI and ECI in predicting poor outcome, mortality, length of stay, and total charges for patients with unruptured cerebral aneurysm. Reevaluation of other patient cohorts is warranted to determine the impact of more accurate patient stratification.

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Microembolism after endovascular coiling of unruptured cerebral aneurysms: incidence and risk factors

Microembolism after endovascular coiling of unruptured cerebral aneurysms

J Neurosurg 124:777–783, 2016

The incidence and risk factors of microembolic lesions on MR diffusion-weighted imaging (DWI) were analyzed after the endovascular coiling of unruptured intracranial aneurysms (UIAs).

Methods Data obtained from 271 consecutive patients (70 men and 201 women; median age 57 years; range 23–79 years) who presented with UIA for coil embolization between July 2011 and June 2013 were analyzed. Two independent reviewers examined the DWI and apparent diffusion coefficient maps obtained the following day for the presence of restrictive diffusion spots and counted the number of spots. Multivariate analysis was then performed to identify independent risk factors for developing microembolism following the coiling of an aneurysm.

Results Microembolic lesions were noted in 101 of 271 patients (37.3%). The results of the multivariate analysis showed that the following factors significantly influenced the risk for microembolism: age, diabetes, previous history of ischemic stroke, high-signal FLAIR lesions in the white matter, multiple aneurysms, and the insertion of an Enterprise stent (all ORs > 1.0 and all p values < 0.05). Previously known risk factors such as prolonged procedure duration, aneurysm size, and decreased antiplatelet function did not show any significant influence.

Conclusions The incidence of microembolism after endovascular coiling of UIA was not low. Lesions occurred more frequently in patients with vascular status associated with old age, diabetes, and previous stroke. Aneurysm multiplicity and the type of stent used for treatment also influenced lesion occurrence.

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Incidence of growth and rupture of unruptured intracranial aneurysms followed by serial MRA

Incidence of growth and rupture of unruptured intracranial aneurysms followed by serial MRA

Acta Neurochir (2013) 155:211–216

The natural history, including growth and rupture, of unruptured intracranial aneurysms (UIAs) remains unknown. Here, we present the results of serial magnetic resonance angiography (MRA) follow-up study in 111 patients with 136 UIAs.

Method A total of 111 patients with 136 UIAs were followed annually over the past 12 years, using 1.5-Tesla MRA. Follow-up was ended when UIAs were treated surgically, or the patients died of subarachnoid hemorrhage or other causes. Various factors influencing aneurysm rupture or growth were examined statistically.

Results Aneurysm rupture and growth occurred in six and 13 of the 111 patients, respectively. Annual rupture rate was 1.8 % per year and annual growth rate was 3.9 % per year. Aneurysm size was the sole factor influencing rupture(H.R. 1.214, 95 % CI, 1.078–1.368) and multiplicity was the sole factor influencing aneurysm growth (H.R. 5.174, 95 % CI 1.81–14.80).

Conclusions Serial MRA study showed that the incidence of UIA growth was twice as high as that of UIA rupture. As four patients showed aneurysm rupture or growth within 1 year, further investigations are necessary to determine the optimum interval of radiological investigation and to identify which UIAs grow or rupture within a short time.

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Preoperative Evaluation of Unruptured Cerebral Aneurysms by Fast Imaging Employing Steady- State Acquisition Image

Neurosurgery 69:412–420, 2011 DOI: 10.1227/NEU.0b013e318213431e

In aneurysm surgery, understanding the microanatomy around the aneurysm such as perforating arteries and cranial nerves is mandatory.

OBJECTIVE: To assess the usefulness in determining the microanatomy around the cerebral aneurysms by the use of fast imaging employing steady-state acquisition (FIESTA) images of magnetic resonance imaging preoperatively, in addition to computed tomography and digital subtraction angiography.

METHODS: Between October 2006 and June 2009, 123 patients with 140 unruptured cerebral aneurysms were treated in our institution. Eighty-two patients were assessed with FIESTA by the operators on the workstation of the magnetic resonance image before surgical clipping of the aneurysms. The small vessels and cranial nerves were confirmed intraoperatively before or after obliteration of the aneurysms.

RESULTS: Sensitivities and specificities of FIESTA imaging were 100% in detecting hypothalamic artery around anterior communicating artery aneurysms, oculomotor nerve attachment to the posterior communicating artery aneurysm domes, and anterior choroidal artery adhesion to the posterior communicating artery aneurysms. This technique was also useful for predicting adhesion between the aneurysm and adjacent main trunks or perforators. Although the specificity was 100%, sensitivity was 56% in detecting vessel adhesion around the middle cerebral aneurysms. This technique can provide limited information in large aneurysms or aneurysms located in minimal cerebrospinal fluid space. The overall outcomes of the patients included 120 excellent recoveries, 1 moderate deficit, 1 severe deficit, and 1 persistent vegetative state according to the Glasgow Outcome Scale.

CONCLUSION: By giving information on the minute anatomical structure around the aneurysm, FIESTA can contribute to thorough preoperative evaluations of cerebral aneurysms.

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