Tag: vascular disorders

Posted on

Ten-year analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial

J Neurosurg 132:771–776, 2020

The authors present the 10-year results of the Barrow Ruptured Aneurysm Trial (BRAT) for saccular aneurysms. The 1-, 3-, and 6-year results of the trial have been previously reported, as have the 6-year results with respect to saccular aneurysms. This final report comparing the safety and efficacy of clipping versus coiling is limited to an analysis of those patients presenting with subarachnoid hemorrhage (SAH) from a ruptured saccular aneurysm.

METHODS In the study, 362 patients had saccular aneurysms and were randomized equally to the clipping and the coiling cohorts (181 each). The primary outcome analysis was based on the assigned treatment group; poor outcome was defined as a modified Rankin Scale (mRS) score > 2 and was independently adjudicated. The extent of aneurysm obliteration was adjudicated by a nontreating neuroradiologist.

RESULTS There was no statistically significant difference in poor outcome (mRS score > 2) or deaths between these 2 treatment arms during the 10 years of follow-up. Of 178 clip-assigned patients with saccular aneurysms, 1 (< 1%) was crossed over to coiling, and 64 (36%) of the 178 coil-assigned patients were crossed over to clipping. After the initial hospitalization, 2 of 241 (0.8%) clipped saccular aneurysms and 23 of 115 (20%) coiled saccular aneurysms required retreatment (p < 0.001). At the 10-year follow-up, 93% (50/54) of the clipped aneurysms were completely obliterated, compared with only 22% (5/23) of the coiled aneurysms (p < 0.001). Two patients had documented rebleeding, both died, and both were in the assigned and treated coiled cohort (2/83); no patient in the clipped cohort (0/175) died (p = 0.04). In 1 of these 2 patients, the hemorrhage was not from the target aneurysm but from an incidental basilar artery aneurysm, which was coiled at the same time.

CONCLUSIONS There was no significant difference in clinical outcomes between the 2 assigned treatment groups as measured by mRS outcomes or deaths. Clinical outcomes in the patients with posterior circulation aneurysms were better in the coiling group at 1 year, but after 1 year this difference was no longer statistically significant. Rates of complete aneurysm obliteration and rates of retreatment favored patients who actually underwent clipping compared with those who underwent coiling. Clinical trial registration no.: NCT01593267 (clinicaltrials.gov)

Posted on

Angiographically occult intracranial aneurysms found during microsurgical aneurysm clipping of known aneurysms

J Neurosurg 132:434–441, 2020

During the microsurgical clipping of known aneurysms, angiographically occult (AO) aneurysms are sometimes found and treated simultaneously to prevent their growth and protect the patient from future rupture or reoperation. The authors analyzed the incidence, treatment, and outcomes associated with AO aneurysms to determine whether limited surgical exploration around the known aneurysm was safe and justified given the known limitations of diagnostic angiography.

METHODS An AO aneurysm was defined as a saccular aneurysm detected using the operative microscope during dissection of a known aneurysm, and not detected on preoperative catheter angiography. A prospective database was retrospectively reviewed to identify patients with AO aneurysms treated microsurgically over a 20-year period.

RESULTS One hundred fifteen AO aneurysms (4.0%) were identified during 2867 distinct craniotomies for aneurysm clipping. The most common locations for AO aneurysms were the middle cerebral artery (60 aneurysms, 54.1%) and the anterior cerebral artery (20 aneurysms, 18.0%). Fifty-six AO aneurysms (50.5%) were located on the same artery as the known saccular aneurysm. Most AO aneurysms (95.5%) were clipped and there was no attributed morbidity. The most common causes of failed angiographic detection were superimposition of a large aneurysm (type 1, 30.6%), a small aneurysm (type 2, 18.9%), or an adjacent normal artery (type 3, 36.9%). Multivariate analysis identified multiple known aneurysms (odds ratio [OR] 3.45, 95% confidence interval [CI] 2.16–5.49, p < 0.0001) and young age (OR 0.981, 95% CI 0.965–0.997, p = 0.0226) as independent predictors of AO aneurysms.

CONCLUSIONS Meticulous inspection of common aneurysm sites within the surgical field will identify AO aneurysms during microsurgical dissection of another known aneurysm. Simultaneous identification and treatment of these additional undiagnosed aneurysms can spare patients later rupture or reoperation, particularly in those with multiple known aneurysms and a history of subarachnoid hemorrhage. Limited microsurgical exploration around a known aneurysm can be performed safely without additional morbidity.

Posted on

Embolization of brain arteriovenous malformations with intent to cure: a systematic review

J Neurosurg 132:388–399, 2020

Endovascular embolization has been established as an adjuvant treatment strategy for brain arteriovenous malformations (AVMs). A growing body of literature has discussed curative embolization for select lesions. The transition of endovascular embolization from an adjunctive to a definitive treatment modality remains controversial. Here, the authors reviewed the literature to assess the lesional characteristics, technical factors, and angiographic and clinical outcomes of endovascular embolization of AVMs with intent to cure.

METHODS Electronic databases—Ovid MEDLINE, Ovid Embase, and PubMed—were searched for studies in which there was evidence of AVMs treated using endovascular embolization with intent to cure. The primary outcomes of interest were angiographic obliteration immediately postembolization and at follow-up. The secondary outcomes of interest were complication rates. Descriptive statistics were used to calculate rates and means.

RESULTS Fifteen studies with 597 patients and 598 AVMs treated with intent-to-cure embolization were included in this analysis. Thirty-four percent of AVMs were Spetzler-Martin grade III. Complete obliteration immediately postembolization was reported in 58.3% of AVMs that had complete treatment and in 45.8% of AVMs in the entire patient cohort. The overall clinical complication rate was 24.1%. The most common complication was hemorrhage, occurring in 9.7% of patients. Procedure-related mortality was 1.5%.

CONCLUSIONS While endovascular embolization with intent to cure can be an option for select AVMs, the reported complication rates appear to be increased compared with those in studies in which adjunctive embolization was the goal. Given the high complication rate related to a primary embolization approach, the risks and benefits of such a treatment strategy should be discussed among a multidisciplinary team. Curative embolization of AVMs should be considered an unanticipated benefit of such therapy rather than a goal.

 

Posted on

Stereotactic radiosurgery for arteriovenous malformations of the basal ganglia and thalamus: an international multicenter study

J Neurosurg 132:122–131, 2020

Arteriovenous malformations (AVMs) of the basal ganglia (BG) and thalamus are associated with elevated risks of both hemorrhage if left untreated and neurological morbidity after resection. Therefore, stereotactic radiosurgery (SRS) has become a mainstay in the management of these lesions, although its safety and efficacy remain incompletely understood. The aim of this retrospective multicenter cohort study was to evaluate the outcomes of SRS for BG and thalamic AVMs and determine predictors of successful endpoints and adverse radiation effects.

METHODS The authors retrospectively reviewed data on patients with BG or thalamic AVMs who had undergone SRS at eight institutions participating in the International Gamma Knife Research Foundation (IGKRF) from 1987 to 2014. Favorable outcome was defined as AVM obliteration, no post-SRS hemorrhage, and no permanently symptomatic radiation- induced changes (RICs). Multivariable models were developed to identify independent predictors of outcome.

RESULTS The study cohort comprised 363 patients with BG or thalamic AVMs. The mean AVM volume and SRS margin dose were 3.8 cm3 and 20.7 Gy, respectively. The mean follow-up duration was 86.5 months. Favorable outcome was achieved in 58.5% of patients, including obliteration in 64.8%, with rates of post-SRS hemorrhage and permanent RIC in 11.3% and 5.6% of patients, respectively. Independent predictors of favorable outcome were no prior AVM embolization (p = 0.011), a higher margin dose (p = 0.008), and fewer isocenters (p = 0.044).

CONCLUSIONS SRS is the preferred intervention for the majority of BG and thalamic AVMs. Patients with morphologically compact AVMs that have not been previously embolized are more likely to have a favorable outcome, which may be related to the use of a higher margin dose.

 

Posted on

Cavernous sinus aneurysms: risk of growth over time and risk factors

J Neurosurg 132:22–26, 2020

Cavernous internal carotid artery (ICA) aneurysms are frequently diagnosed incidentally and the benign natural history of these lesions is well known, but there is limited information assessing the risk of growth in untreated patients. The authors sought to assess and analyze risk factors in patients with cavernous ICA aneurysms and compare them to those of patients with intracranial berry aneurysms in other locations.

METHODS Data from consecutive patients who were diagnosed with a cavernous ICA aneurysm were retrospectively reviewed. The authors evaluated patients for the incidence of cavernous ICA aneurysm growth and rupture. In addition, the authors analyzed risk factors for cavernous ICA aneurysm growth and compared them to risk factors in a population of patients diagnosed with intracranial berry aneurysms in locations other than the cavernous ICA during the same period.

RESULTS In 194 patients with 208 cavernous ICA aneurysms, the authors found a high risk of aneurysm growth (19.2% per patient-year) in patients with large/giant aneurysms. Size was significantly associated with higher risk of growth. Compared to patients with intracranial berry aneurysms in other locations, patients with cavernous ICA aneurysms were significantly more likely to be female and have a lower incidence of hypertension.

CONCLUSIONS Aneurysms of the cavernous ICA are benign lesions with a negligible risk of rupture but a definite risk of growth. Aneurysm size was found to be associated with aneurysm growth, which can be associated with new onset of symptoms. Serial follow-up imaging of a cavernous ICA aneurysm might be indicated to monitor for asymptomatic growth, especially in patients with larger lesions.

 

Posted on

Flow diversion treatment of complex bifurcation aneurysms beyond the circle of Willis: complications, aneurysm sac occlusion, reabsorption, recurrence, and jailed branch modification at follow-up

J Neurosurg 131:1751–1762, 2019

The purpose of this study is to present the authors’ medium-term results, with special emphasis on complications, occlusion rate of the aneurysm sac (digital subtraction angiography [DSA] and MRI), and the fate of cortical branches and perforating arteries covered (“jailed”) by the flow diverter (FD) stent.

METHODS Between January 2010 and September 2017, 29 patients (14 female) with 30 aneurysms were treated with an FD stent. Twenty-one aneurysms were at the middle cerebral artery bifurcation, 8 were in the anterior communicating artery region, and 1 was a pericallosal artery bifurcation. Thirty-five cortical branches were covered. A single FD stent was used in all patients. Symptomatic and asymptomatic periprocedural and delayed complications were reported. DSA and MRI controls were analyzed to evaluate modification of the aneurysm sac and jailed branches.

RESULTS Permanent morbidity was 3.4% (1/29), due to a jailed branch occlusion, with a modified Rankin Scale (mRS) score of 2 at the last follow-up. Mortality and permanent complication with poor prognosis (mRS score > 2) rates were 0%. The mean follow-up time for DSA and MRI (mean ± SD) was 21 ± 14.5 months (range 3–66 months) and 19 ± 16 months (range 3–41 months), respectively. The mean time to aneurysm sac occlusion (available for 24 patients), including stable remodeling, was 11.8 ± 6 months (median 13, range 3–27 months). The overall occlusion rate was 82.1% (23/28), and it was 91.7% (22/24) in the group of patients with at least 2 DSA control sequences. One recanalization occurred at 41 months posttreatment. At the time of publication, at the latest follow-up, 7 (20%) of 35 covered branches were occluded, 18 (51.4%) showed a decreased caliber, and the remaining 10 (28.5%) were unchanged. MRI T2-weighted sequences showed complete sac reabsorption in 7/29 aneurysms (24.1%), and the remaining lesions were either smaller (55.2%) or unchanged (17.2%). MRI revealed asymptomatic and symptomatic ischemic events in perforator territories in 7/28 (25%) and 4/28 (14.3%) patients, respectively, which were reversible within 24 hours.

CONCLUSIONS Flow diversion of bifurcation aneurysms is feasible, with low rates of permanent morbidity and mortality and high occlusion rates; however, recurrence may occur. Caliber reduction and asymptomatic occlusion of covered cortical branches as well as silent perforator stroke are common. Ischemic complications may occur with no identified predictable factors. MRI controls should be required in all patients to evaluate silent ischemic lesions and aneurysm sac reabsorption over time.

Posted on

Quantitative versus qualitative blood amount assessment as a predictor for shunt-dependent hydrocephalus following aneurysmal subarachnoid hemorrhage

J Neurosurg 131:1743–1750, 2019

Reliable tools are lacking to predict shunt-dependent hydrocephalus (SDHC) development after aneurysmal subarachnoid hemorrhage (aSAH). Quantitative volumetric measurement of hemorrhagic blood is a good predictor of SDHC but might be impractical in the clinical setting. Qualitative assessment performed using scales such as the modified Fisher scale (mFisher) and the original Graeb scale (oGraeb) is easier to conduct but provides limited predictive power. In between, the modified Graeb scale (mGraeb) keeps the simplicity of the qualitative scales yet adds assessment of acute hydrocephalus, which might improve SDHC-predicting capabilities. In this study the authors investigated the likely capabilities of the mGraeb and compared them with previously validated methods. This research also aimed to define a tailored mGraeb cutoff point for SDHC prediction.

METHODS The authors performed retrospective analysis of patients admitted to their institution with the diagnosis of aSAH between May 2013 and April 2016. Out of 168 patients, 78 were included for analysis after the application of predefined exclusion criteria. Univariate and multivariate analyses were conducted to evaluate the use of all 4 methods (quantitative volumetric assessment and the mFisher, oGraeb, and mGraeb scales) to predict the likelihood of SDHC development based on clinical data and blood amount assessment on initial CT scans.

RESULTS The mGraeb scale was demonstrated to be the most robust predictor of SDHC, with an area under the curve (AUC) of 0.848 (95% CI 0.763–0.933). According to the AUC results, the performance of the mGraeb scale was significantly better than that of the oGraeb scale (c 2 = 4.49; p = 0.034) and mFisher scale (c 2 = 7.21; p = 0.007). No statistical difference was found between the AUCs of the mGraeb and the quantitative volumetric measurement models (c = 12.76; p = 0.23), but mGraeb proved to be the simplest model since it showed the lowest Akaike information criterion (66.4), the lowest Bayesian information criterion (71.2), and the highest R 2 Nagelkerke coefficient (39.7%). The initial mGraeb showed more than 85% specificity for predicting the development of SDHC in patients presenting with a score of 12 or more points.

CONCLUSIONS According to the authors’ data, the mGraeb scale is the simplest model that correlates well with SDHC development. Due to limited scientific evidence of treatments aimed at SDHC prevention, we propose an mGraeb score higher than 12 to identify patients at risk with high specificity. This mGraeb cutoff point might also serve as a useful prognostic tool since patients with SDHC after aSAH have worse functional outcomes.

Posted on

Endoscope- versus microscope-integrated near-infrared indocyanine green videoangiography in aneurysm surgery

J Neurosurg 131:1413–1422, 2019

The quality of surgical treatment of intracranial aneurysms is determined by complete aneurysm occlusion while preserving blood flow in the parent, branching, and perforating arteries. For a few years, there has been a nearly noninvasive and cost-effective technique for intraoperative flow evaluation: microscope-integrated indocyanine green videoangiography (mICG-VA). This method allows for real-time information about blood flow in the aneurysm and the involved vessels, but its limitations are seen in the evaluation of structures located in the depth of the surgical field, especially through small craniotomies. To compensate for these drawbacks, an endoscope-integrated ICG-VA (eICG-VA) was developed. The objective of the present study was to assess the use of eICG-VA in comparison with mICG-VA for intraoperative blood flow evaluation.

METHODS In the period between January 2011 and January 2015, 216 patients with a total of 248 intracranial saccular aneurysms were surgically treated in the Department of Neurosurgery of Saarland University Medical Center in Homburg/Saar, Germany. During 95 surgeries in 88 patients with a total of 108 aneurysms, intraoperative evaluation was performed with both eICG-VA and mICG-VA. After clipping, evaluation of complete aneurysm occlusion and flow in the parent, branching, and perforating arteries was performed using both methods. Intraoperative applicability of each technique was compared with the other and with postoperative digital subtraction angiography as a standard evaluation technique.

RESULTS Evaluation of completeness of aneurysm occlusion and of flow in the parent, branching, and perforating arteries was more successful with eICG-VA than with mICG-VA, especially for aneurysm neck assessment (88.9% vs 69.4%). For 63.9% of the aneurysms (n = 69), both methods were equivalent, but in 30.6% of the cases (n = 33), the eICG-VA provided better results for evaluating the post-clipping situation. In 4.6% of these aneurysms (n = 5), the information given by the additional endoscope considerably changed the surgical procedure. Thus, one residual aneurysm (0.9%), two neck remnants (1.9%), and two branch occlusions (1.9%) could be prevented. Nevertheless, two incomplete aneurysm occlusions (1.9%) and six neck remnants (5.6%) were revealed by postoperative digital subtraction angiography.

CONCLUSIONS Endoscope-integrated ICG-VA seems to be an improvement that might increase the quality of aneurysm surgery by providing additional information. It offers higher illumination, magnification, and an extended viewing angle. Its main advantage is its ability to assess deep-seated aneurysms, especially through small craniotomies, but further studies are required.

Posted on

Management of recurrent intracranial aneurysms after coil embolization: a novel classification scheme based on angiography

J Neurosurg 131:1455–1461, 2019

Recurrent aneurysms after coil embolization remain a challenging issue. The goal of the present study was to report the authors’ experience with recurrent aneurysms after coil embolization and to discuss the radiographic classification scheme and recommended management strategy.

METHODS Aneurysm treatments from a single institution over a 6-year period were retrospectively reviewed. Ninetyseven aneurysms that recurred after initial coiling were managed during the study period. Recurrent aneurysms were classified into the following 5 types based on their angiographic characteristics: I, pure recanalization inside the aneurysm sac; II, pure coil compaction without aneurysm growth; III, new aneurysm neck formed without coil compaction; IV, new aneurysm neck formed with coil compaction; and V, newly formed aneurysm neck and sac.

RESULTS Aneurysm recurrences resulted in rehemorrhages in 6 cases (6.2%) of type III–V aneurysms, but in none of type I–II aneurysms. There was a significantly higher proportion of ophthalmic artery aneurysms and complex internal carotid artery aneurysms presenting as types I and II than presented as the other 3 types (63.3% vs 16.4%, p < 0.001). In contrast, for posterior communicating artery aneurysms and anterior communicating artery aneurysms, a higher proportion of type III–V aneurysms was observed than for the other 2 types, but without a significant difference in the multivariate model (56.7% vs 23.3%). In addition, giant (> 25 mm) aneurysms were more common among type I and II lesions than among type III and IV aneurysms (36.7% vs 9.0%, p = 0.001), which exhibited a higher proportion of small (< 10 mm) lesions (65.7% vs 13.3%, p < 0.001). A single reembolization procedure was sufficient to occlude 80.0% of type I recurrences and 83.3% of type II recurrences from coil compaction but only 65.6% of type III–V recurrences from aneurysm regrowth.

CONCLUSIONS Aneurysm size and location represent the determining factors of the angiographic recurrence types. Type I and II recurrences were safely treated by reembolization, whereas type III–V recurrences may be best managed surgically when technically feasible.

Posted on

Riskier-than-expected occlusive treatment of ruptured posterior communicating artery aneurysms

J Neurosurg 131:1269–1277, 2019

Occlusive treatment of posterior communicating artery (PCoA) aneurysms has been seen as a fairly uncomplicated procedure. The objective here was to determine the radiological and clinical outcome of patients after PCoA aneurysm rupture and treatment and to evaluate the risk factors for impaired outcome.

METHODS In a retrospective clinical follow-up study, data were collected from 620 consecutive patients who had been treated for ruptured PCoA aneurysms at a single center between 1980 and 2014. The follow-up was a minimum of 1 year after treatment or until death.

RESULTS Of the 620 patients, 83% were treated with microsurgical clipping, 8% with endovascular coiling, 2% with the two procedures combined, 1% with indirect surgical methods, and 6% with conservative methods. The most common procedural complications were treatment-related brain infarctions (15%). The occurrence of artery occlusions (10% microsurgical, 8% endovascular) was higher than expected. Most patients made a good recovery at 1 year after aneurysmal subarachnoid hemorrhage (modified Rankin Scale [mRS] score 0–2: 386 patients [62%]). A fairly small proportion of patients were left severely disabled (mRS score 4–5: 27 patients [4%]). Among all patients, 20% died during the 1st year. Independent risk factors for an unfavorable outcome, according to the multivariable analysis, were poor preoperative clinical condition, intracerebral or subdural hematoma due to aneurysm rupture, age over 65 years, artery occlusion on postoperative angiography, occlusive treatment–related ischemia, delayed cerebral vasospasm, and hydrocephalus requiring a shunt.

CONCLUSIONS Even though most patients made a good recovery after PCoA aneurysm rupture and treatment during the 1st year, the occlusive treatment–related complications were higher than expected and caused morbidity even among initially good-grade patients. Occlusive treatment of ruptured PCoA aneurysms seems to be a high-risk procedure, even in a high-volume neurovascular center.

Posted on

Circumferential wall enhancement in evolving intracranial aneurysms on magnetic resonance vessel wall imaging

J Neurosurg 131:1262–1268, 2019

Recent MR vessel wall imaging studies have indicated intracranial aneurysms in the active state could show circumferential enhancement along the aneurysm wall (CEAW). While ruptured aneurysms frequently show CEAW, CEAW in unruptured aneurysms at the evolving state (i.e., growing or symptomatic) has not been studied in detail. The authors quantitatively assessed the degree of CEAW in evolving unruptured aneurysms by comparing it separately to that in stable unruptured and ruptured aneurysms.

METHODS A quantitative analysis of CEAW was performed in 26 consecutive evolving aneurysms using MR vessel wall imaging. Three-dimensional T1-weighted fast spin echo sequences were obtained before and after contrast media injection, and the contrast ratio of the aneurysm wall against the pituitary stalk (CR stalk ) was calculated as the indicator of CEAW. Aneurysm characteristics of evolving aneurysms were compared with those of 69 stable unruptured and 67 ruptured aneurysms.

RESULTS The CR stalk values in evolving aneurysms were significantly higher than those in stable aneurysms (0.54 vs 0.34, p < 0.0001), and lower than those in ruptured aneurysms (0.54 vs 0.83, p < 0.0002). In multivariable analysis, CR stalk remained significant when comparing evolving with stable aneurysms (odds ratio [OR] 12.23, 95% confidence interval [CI] 3.53–42.41), and with ruptured aneurysms (OR 0.083, 95% CI 0.022–0.310).

CONCLUSIONS The CEAW in evolving aneurysms was higher than those in stable aneurysms, and lower than those in ruptured aneurysms. The degree of CEAW may indicate the process leading to rupture of intracranial aneurysms, which can be useful additional information to determine an indication for surgical treatment of unruptured aneurysms.

Posted on

Giant intracranial aneurysms of the posterior circulation and their relation to the brainstem: analysis of risk factors for neurological deficits

J Neurosurg 131:403–409, 2019

Giant posterior circulation aneurysms (GPCirAs) usually cause substantial mass effect on the brainstem, which may lead to neurological deficits. So far, there has been no systematic investigation of factors associated with such deficits in GPCirA. The authors aim to examine the risk factors for cranial nerve deficit (CND), motor deficit, and disability in patients with GPCirA.

METHODS Using MR images obtained in 30 patients with unruptured GPCirA, the authors examined GPCirA volume, presence of hydrocephalus or partial thrombosis (PT) of the aneurysm, and the degree of brainstem displacement mea- sured by the distance between the McRae line and the tip of the GPCirA (∆MT). They evaluated associations between these factors and neurological deficits.

RESULTS Thirty GPCirAs in 30 patients were included. The prevalence of CNDs was 50%. Patients with CNDs signifi- cantly differed from those without CNDs in terms of age (mean 51.0 years [SD 15.0 years] vs 69.0 years [SD 21.0 years], p = 0.01) and in ∆MT (median 50.7 mm [IQR 39.2–53.9 mm] vs 39.0 mm [IQR 32.3–45.9 mm], p = 0.02). The prevalence of motor deficits was 33.3%. Patients with motor deficits showed a larger ∆MT (median 50.5 mm [IQR 40.8–54.6 mm]) compared with those without (∆MT: median 39.1 mm [IQR 32.8–50.5 mm], p = 0.04). GPCirA volume was larger in patients with poor modified Rankin Scale (mRS) scores (median 14.9 cm3 [IQR 8.6–18.7 cm3]) than in those with mRS scores of 0–2 (median 6.8 cm3 [IQR 4.4–11.7 cm3], p = 0.03). After adjusting for patient age and the occurrence of hydro- cephalus or PT, the authors found that higher degrees of disability were significantly associated with aneurysm volume (OR 1.13, 95% CI 1.0–1.3; p = 0.04), but not with ∆MT. The occurrence of CND or motor deficit was not associated with any of the examined variables. There was no correlation between GPCirA volume and ∆MT (rs = 0.01, p = 0.96). The prevalence of neurological deficits did not differ between GPCirA at the basilar apex, the basilar trunk, the vertebrobasi- lar junction, or the vertebral artery.

CONCLUSIONS In this study, the neurological condition of the patients was associated only with GPCirA volume and not with the degree of brainstem displacement, the occurrence of PT or hydrocephalus, or the exact location of the GPCirA. These findings highlight the clinical relevance of GPCirA volume and suggest that factors such as brainstem displacement or PT should play less of a role when finding arguments for or against treatment of GPCirA.

 

Posted on

Endoscopic clipping of intraventricular aneurysms using the “wet-field” technique

J Neurosurg 131:104–108, 2019

Intraventricular hemorrhage and intracerebral aneurysms are relatively frequent complications associated with moy- amoya disease. Prevention of aneurysm rerupture is important because it significantly decreases the morbidity and mortality rates. Aneurysms arising distal to collateral flow are sometimes observed in patients with intraventricular hem- orrhage; however, the treatment of these aneurysms remains challenging because of their deep-seated location in the brain and accompanying narrow surgical corridor.

The authors describe a neuroendoscopic aneurysm clipping technique performed in 2 cases using a small-diameter tubular retractor for intraventricular aneurysms of the distal lateral posterior choroidal artery. In this technique, the surgical field was continuously irrigated with artificial CSF to keep the ventricle size intact, and aneurysm clipping was performed through a tubular retractor that was introduced with neuronavigational guidance. The patients’ postoperative courses were uneventful, and CT angiography revealed complete clipping of the aneurysms and patent parent arteries.

Endoscopic clipping using a tubular retractor is an effective and less invasive alternative for treating intraventricular aneurysms. The wet-field endoscopic technique is performed in an aqueous field and maintains an intact ventricle size, allowing for a clear surgical view and a wider, enhanced surgical field.

 

Posted on

Surgical or endovascular management of ruptured intracranial aneurysms: an agreement study

J Neurosurg 131:25–31, 2019

Ruptured intracranial aneurysms (RIAs) can be managed surgically or endovascularly. In this study, the authors aimed to measure the interobserver agreement in selecting the best management option for various patients with an RIA.

METHODS The authors constructed an electronic portfolio of 42 cases of RIA in which an angiographic image along with a brief clinical vignette for each patient were displayed. Undisclosed to the responders was that the RIAs had been categorized as International Subarachnoid Aneurysm Trial (ISAT) (small, anterior-circulation, non–middle cerebral artery location, n = 18) and non-ISAT (n = 22) aneurysms; the non-ISAT group also included 2 basilar apex aneurysms for which a high number of endovascular choices was expected. The portfolio was sent to 132 clinicians who manage pa- tients with RIAs and circulated to members of an American surgical association. Judges were asked to choose between surgical and endovascular management, to indicate their level of confidence in the choice of treatment on a quantitative 0–10 scale, and to determine whether they would include the patient in a randomized trial in which both treatments are compared. Eleven clinicians were asked to respond twice at least 1 month apart. Responses were analyzed using kappa statistics.

RESULTS Eighty-five clinicians (58 cerebrovascular surgeons, 21 interventional neuroradiologists, and 6 interventional neurologists) answered the questionnaire. Overall, endovascular management was chosen more frequently (n = 2136 [59.8%] of 3570 answers). The proportions of decisions to clip were significantly higher for non-ISAT (50.8%) than for ISAT (26.2%) aneurysms (p = 0.0003). Interjudge agreement was only fair (kappa 0.210, 95% CI 0.158–0.276) for all cases and judges, despite high confidence levels (mean score > 8 for all cases). Agreement was no better within sub- groups of clinicians with the same specialty, years of experience, or location of practice or across capability groups (ability to clip or coil, or both). When agreement was defined as > 80% of responders choosing the same option, agreement occurred for only 7 of 40 cases, all of which were ISAT aneurysms, for which coiling was preferred.

CONCLUSIONS Agreement between clinicians regarding the best management option was infrequent but centered around coiling for some ISAT aneurysms. Surgical clipping was chosen more frequently for non-ISAT aneurysms than for ISAT aneurysms. Patients with such an aneurysm might be candidates for inclusion in randomized trials.

Posted on

Cavernous angiomas: deconstructing a neurosurgical disease

J Neurosurg 131:1–13, 2019

Cavernous angioma (CA) is also known as cavernoma, cavernous hemangioma, and cerebral cavernous malformation (CCM) (National Library of Medicine Medical Subject heading unique ID D006392). In its sporadic form, CA occurs as a solitary hemorrhagic vascular lesion or as clustered lesions associated with a developmental venous anomaly. In its autosomal dominant familial form (Online Mendelian Inheritance in Man #116860), CA is caused by a heterozygous germ-line loss-of-function mutation in one of three genes—CCM1/KRIT1, CCM2/Malcavernin, and CCM3/PDCD10—causing multifocal lesions throughout the brain and spinal cord.

In this paper, the authors review the cardinal features of CA’s disease pathology and clinical radiological features. They summarize key aspects of CA’s natural history and broad elements of evidence-based management guidelines, including surgery. The authors also discuss evidence of similar genetic defects in sporadic and familial lesions, consequences of CCM gene loss in different tissues at various stages of development, and implications regarding the pathobiology of CAs.

The concept of CA with symptomatic hemorrhage (CASH) is presented as well as its relevance to clinical care and research in the field. Pathobiological mechanisms related to CA include inflammation and immune-mediated processes, angiogenesis and vascular permeability, microbiome driven factors, and lesional anticoagulant domains. These mechanisms have motivated the development of imaging and plasma biomarkers of relevant disease behavior and promising therapeutic targets.

The spectrum of discoveries about CA and their implications endorse CA as a paradigm for deconstructing a neurosurgical disease.

 

Posted on

Assessment of the endoscopic endonasal approach to the basilar apex region for aneurysm clipping

J Neurosurg 130:1937–1948, 2019

The expanded endoscopic endonasal approach (EEA) has shown promising results in treatment of midline skull base lesions. Several case reports exist on the utilization of the EEA for treatment of aneurysms. However, a comparison of this approach with the classic transcranial orbitozygomatic approach to the basilar apex (BAX) region is missing. The present study summarizes the results of a series of cadaveric surgical simulations for assessment of the EEA to the BAX region for aneurysm clipping and its comparison with the transcranial orbitozygomatic approach as one of the most common approaches used to treat BAX aneurysms.

METHODS Fifteen cadaveric specimens underwent bilateral orbitozygomatic craniotomies as well as an EEA (first without a pituitary transposition [PT] and then with a PT) to expose the BAX. The following variables were measured, recorded, and compared between the orbitozygomatic approach and the EEA: 1) number of perforating arteries counted on bilateral posterior cerebral arteries (PCAs); 2) exposure and clipping lengths of the PCAs, superior cerebellar arteries (SCAs), and proximal basilar artery; and 3) surgical area of exposure in the BAX region.

RESULTS Except for the proximal basilar artery exposure and clipping, the orbitozygomatic approach provided statistically significantly greater values for vascular exposure and control in the BAX region (i.e., exposure and clipping of ipsilateral and contralateral SCAs and PCAs). The EEA with PT was significantly better in exposing and clipping bilateral PCAs compared to EEA without a PT, but not in terms of other measured variables. The surgical area of exposure and PCA perforator counts were not significantly different between the 3 approaches. The EEA provided better exposure and control if the BAX was located ≥ 4 mm inferior to the dorsum sellae.

CONCLUSIONS For BAX aneurysms located in the retrosellar area, PT is usually required to obtain improved exposure and control for the bilateral PCAs. However, the transcranial approach is generally superior to both endoscopic approaches for accessing the BAX region. Considering the superior exposure of the proximal basilar artery obtained with the EEA, it could be a viable option when surgical treatment is considered for a low-lying BAX or mid–basilar trunk aneurysms (≥ 4 mm inferior to dorsum sellae).

 

Posted on

Prospective validation of a molecular prognostication panel for clival chordoma

J Neurosurg 130:1528–1537, 2019

There are currently no reliable means to predict the wide variability in behavior of clival chordoma so as to guide clinical decision-making and patient education. Furthermore, there is no method of predicting a tumor’s response to radiation therapy.

METHODS A molecular prognostication panel, consisting of fluorescence in situ hybridization (FISH) of the chromosomal loci 1p36 and 9p21, as well as immunohistochemistry for Ki-67, was prospectively evaluated in 105 clival chordoma samples from November 2007 to April 2016. The results were correlated with overall progression-free survival after surgery (PFSS), as well as progression-free survival after radiotherapy (PFSR).

RESULTS Although Ki-67 and the percentages of tumor cells with 1q25 hyperploidy, 1p36 deletions, and homozygous 9p21 deletions were all found to be predictive of PFSS and PFSR in univariate analyses, only 1p36 deletions and homozygous 9p21 deletions were shown to be independently predictive in a multivariate analysis. Using a prognostication calculator formulated by a separate multivariate Cox model, two 1p36 deletion strata (0%–15% and > 15% deleted tumor cells) and three 9p21 homozygous deletion strata (0%–3%, 4%–24%, and ≥ 25% deleted tumor cells) accounted for a range of cumulative hazard ratios of 1 to 56.1 for PFSS and 1 to 75.6 for PFSR.

CONCLUSIONS Homozygous 9p21 deletions and 1p36 deletions are independent prognostic factors in clival chordoma and can account for a wide spectrum of overall PFSS and PFSR. This panel can be used to guide management after resection of clival chordomas.

 

Posted on

Microsurgical treatment of unruptured middle cerebral artery aneurysms

J Neurosurg 130:1498–1504, 2019

Advances in endovascular therapy for the treatment of middle cerebral artery (MCA) aneurysms have led to scrutiny of its benefits compared with microsurgical repair. To provide information regarding complication rates and outcomes, the authors reviewed the results of a large series of unruptured MCA aneurysms treated with open microsurgery.

METHODS The authors included all patients who underwent surgical repair of an unruptured MCA aneurysm between 1997 and 2015. All surgical procedures, including clipping, wrapping, bypass, and parent artery occlusion, were performed by a single neurosurgeon. Aneurysm occlusion was assessed using intraoperative digital subtraction angiography (DSA) or DSA and indocyanine green videoangiography in all cases. Postoperatively, all patients were monitored in a neurointensive care unit overnight. Clinical follow-up was scheduled for 2–4 weeks after surgery, and angiographic follow-up was performed in those patients with subtotally occluded aneurysms at 1, 2, and 5 years postoperation.

RESULTS The authors treated 750 unruptured MCA aneurysms in 716 patients: 649 (86.5%) aneurysms were small, 75 (10.0%) were large, and 26 (3.5%) were giant. Most aneurysms (n = 677, 90%) were treated by primary clip reconstruction. The surgical morbidity rate was 2.8%, and the mortality rate was 0%. Complete angiographic aneurysm occlusion was achieved in 92.0% of aneurysms. At final follow-up, 713 patients had a modified Rankin Scale (mRS) score of 0, 2 patients had an mRS score of 2 or 3, and 1 had an mRS score of 4.

CONCLUSIONS In high-volume centers, microsurgical management of MCA aneurysms can be performed with very low morbidity rates. Currently, microsurgical repair appears to be a highly effective method of treating MCA aneurysms.

Posted on

Comparison of flow diversion with clipping and coiling for the treatment of paraclinoid aneurysms in 115 patients

J Neurosurg 130:1505–1512, 2019

Paraclinoid aneurysms represent approximately 5% of intracranial aneurysms (Drake et al. [1968]). Visual impairment, which occurs in 16%–40% of patients, is among the most common presentations of these aneurysms (Day [1990], Lai and Morgan [2013], Sahlein et al. [2015], and Silva et al. [2017]). Flow-diverting stents, such as the Pipeline Embolization Device (PED), are increasingly used to treat these aneurysms, in part because of their theoretical reduction of mass effect (Fiorella et al. [2009]). Limited data on paraclinoid aneurysms treated with a PED exist, and few studies have compared outcomes of patients after PED placement with those of patients after clipping or coiling.

METHODS The authors performed a retrospective analysis of 115 patients with an aneurysm of the cavernous to ophthalmic segments of the internal carotid artery treated with clipping, coiling, or PED deployment between January 2011 and March 2017. Postoperative complications were defined as new neurological deficit, aneurysm rupture, recanalization, or other any operative complication that required reintervention.

RESULTS A total of 125 paraclinoid aneurysms in 115 patients were treated, including 70 with PED placement, 23 with coiling, and 32 with clipping. Eighteen (14%) aneurysms were ruptured. The mean aneurysm size was 8.2 mm, and the mean follow-up duration was 18.4 months. Most aneurysms were discovered incidentally, but visual impairment, which occurred in 21 (18%) patients, was the most common presenting symptom. Among these patients, 15 (71%) experienced improvement in their visual symptoms after treatment, including 14 (93%) of these 15 patients who were treated with PED deployment. Complete angiographic occlusion was achieved in 89% of the patients. Complications were seen in 17 (15%) patients, including 10 (16%) after PED placement, 2 (9%) after coiling, and 5 (17%) after clipping. Patients with incomplete aneurysm occlusion had a higher rate of procedural complications than those with complete occlusion (p = 0.02). The rate of postoperative visual improvement was significantly higher among patients treated with PED deployment than in those treated with coiling (p = 0.01). The significant predictors of procedural complications were incomplete occlusion (p = 0.03), hypertension, (p = 0.04), and diabetes (p = 0.03).

CONCLUSIONS In a large series in which patient outcomes after treatment of paraclinoid aneurysms were compared, the authors found a high rate of aneurysm occlusion and a comparable rate of procedural complications among patients treated with PED placement compared with the rates among those who underwent clipping or coiling. For patients who presented with visual symptoms, those treated with PED placement had the highest rate of visual improvement. The results of this study suggest that the PED is an effective and safe modality for treating paraclinoid aneurysms, especially for patients who present with visual symptoms.

Posted on

Spot sign as a predictor of rebleeding after endoscopic surgery for intracerebral hemorrhage

J Neurosurg 130:1485–1490, 2019

In patients with spontaneous intracerebral hemorrhage (sICH), postoperative recurrent hemorrhage (PRH) is one of the most severe complications after endoscopic evacuation of hematoma (EEH). However, no predictors of this complication have been identified. In the present study, the authors retrospectively investigated whether PRH can be preoperatively predicted by the presence of the spot sign on CT scans.

METHODS In total, 143 patients with sICH were treated by EEH between June 2009 and March 2017, and 127 patients who underwent preoperative CT angiography were included in this study. Significant correlations of PRH with the patients’ baseline, clinical, and radiographic characteristics, including the spot sign, were evaluated using multivariable logistic regression models.

RESULTS The incidence of and risk factors for PRH were assessed in 127 patients with available data. PRH occurred in 9 (7.1%) patients. Five (21.7%) cases of PRH were observed among 23 patients with the spot sign, whereas only 4 (3.8%) cases of PRH occurred among 104 patients without the spot sign. The spot sign was the only independent predictor of PRH (OR 5.81, 95% CI 1.26–26.88; p = 0.02). The following factors were not independently associated with PRH: age, hypertension, poor consciousness, antihemostatic factors (thrombocytopenia, coagulopathy, and use of antithrombotic drugs), the location and size of the sICH, other radiographic findings (black hole sign and blend sign), surgical duration and procedures, and early surgery.

CONCLUSIONS The spot sign is likely to be a strong predictor of PRH after EEH among patients with sICH. Complete and careful control of bleeding in the operative field should be ensured when surgically treating such patients. New surgical strategies and procedures might be needed to improve these patients’ outcomes.

 

Proudly powered by WordPress