Aneurysm Obliteration Research Articles

Analysis of Wide-Neck Aneurysms in the Barrow Ruptured Aneurysm Trial.

Ruptured wide-neck aneurysms (WNAs) are difficult to treat and few publications have compared clipping to coiling. To determine, using Barrow Ruptured Aneurysm Trial (BRAT) data: (1) How many aneurysms had a wide neck? (2) Did wide-neck status influence treatment? (3) How did clipping compare to coiling for WNAs? A post hoc analysis was conducted of saccular WNAs in the BRAT. A WNA was defined as maximum neck width≥4 mm or maximum aneurysm dome-diameter-to-neck-width ratio<2. Both intent-to-treat and as-treated analyses were performed. Of the 327 patients analyzed, 177 (54.1%) had a WNA. WNAs were more likely to occur in older patients (P=.03) with worse presenting clinical grade (P=.02), were more likely to arise from the middle cerebral artery, basilar tip, or internal carotid artery other than the junction with the posterior communicating artery (P=.001) and were associated with worse clinical outcomes at all time points (P≤.01). WNAs were equally distributed in assigned treatment groups (clip 56.6% vs coil 51.8%; P=.38), but were overrepresented in the actual clipping group (clip 62.4% vs coil 37.6%, P<.001). Most patients (76.7%) in the coil-to-clip crossover group had a WNA. Comparing clipping to coiling, there was no difference in clinical outcomes at any time point in either analysis (P≥.33). The aneurysm obliteration rate was lower (P<.001) and the retreatment rate higher (P<.001) in the actual coiling group. Wide-neck status significantly impacted treatment strategy in the BRAT, favoring clipping. Clipping and coiling of ruptured WNAs resulted in statistically similar long-term clinical outcomes. 10.1093/neuros/nyy439 Video Abstract 10.1093.neuros.nyy439 5850292551001.

Impact of perioperative aneurysm rebleeding after subarachnoid hemorrhage.

Aneurysm rebleeding is a major cause of death and morbidity in patients with aneurysmal subarachnoid hemorrhage (SAH). Recognizing the predictors of rebleeding might help to identify patients who will benefit from acute management. This study was performed to investigate the predictors of aneurysm rebleeding and their impact on clinical outcomes in the preoperative, intraoperative, and postoperative periods. The incidence of rebleeding, demographic data, and clinical data from 4933 patients with aneurysmal SAH beginning in the year 2000 were retrospectively analyzed in the Nagasaki SAH Registry Study. The authors performed multiple logistic regression analyses to identify the risk factors contributing to rebleeding and outcome after SAH. Preoperative rebleeding occurred in 7.2% of patients. Patient age (p = 0.01), multiple aneurysms (p < 0.01), aneurysm size (p < 0.0001), and heart disease (p = 0.03) were significantly associated with preoperative rebleeding. Conversely, intraoperative rebleeding occurred in 11.2% of patients. Aneurysm location (anterior communicating artery [ACoA]), family history (p = 0.02), preoperative rebleeding (p < 0.01), and clipping/coiling (p < 0.0001) were significantly associated with intraoperative rebleeding. Interaction analysis showed that clipping significantly affected intraoperative rebleeding at the ACoA (OR 4.00; 95% CI 1.82-8.80; p < 0.001). Postoperative rebleeding occurred in 2.4% of patients. Coiling/clipping (p < 0.0001) and intraoperative rebleeding (p < 0.01) were significantly associated with postoperative rebleeding. Rebleeding in all time periods examined significantly contributed to the clinical outcome after SAH. Aneurysm rebleeding after SAH has specific characteristics in the preoperative, intraoperative, and postoperative periods, and all of these characteristics contribute to the clinical outcome. The ACoA has a higher risk of intraoperative rebleeding, and endovascular coiling could be a good candidate in terms of techniques for preventing intraoperative rebleeding, although complete aneurysm obliteration should be accomplished.

Clip-wrapping of ruptured blood blister-like aneurysms of the internal carotid artery.

To evaluate the safety and validity of microsurgical Gore-Tex clip-wrapping for ruptured blood blister-like aneurysms (BBAs) of the internal carotid artery (ICA). Single-surgeon series. Retrospective study. Data analyzed were patient age, sex, Hunt and Hess grade (H&H), Fisher grade, time from rupture to hospitalization, aneurysm size and location, collateral capacity of the circle of Willis, time from hospitalization to aneurysm repair, aneurysm obliteration, complications, and modified Rankin scale (mRS) at follow-up. Six patients (2 males, 4 females) with ICA BBAs underwent clip-wrapping between 2011 and 2016. Median age was 50.0years (range 31.7-54.0). H&H was grade 1 or 2 in 5 patients and grade 4 in 1 patient. All aneurysms were small (≤ 0.3cm), without relation to vessel bifurcations, and located anteromedially, anterolaterally, and superomedially on the ICA trunk. Right side was most frequent (66%). All aneurysms could be clip-wrapped without intraoperative ruptures and all parent arteries could be preserved in the acute phase. Clip-wrapping completely eliminated the BBAs in five patients, whereas one patient underwent additional stent-assisted coiling. There were no re-ruptures, delayed infarctions, or deaths postoperatively. After a median follow-up of 57months (range 20-90), outcome was favorable (mRS score 0-2) in all patients without radiographic signs of recurrences. Using the Gore-Tex clip-wrapping technique for ruptured ICA BBAs, the aneurysm could be treated without intraoperative ruptures or parent artery sacrifice in the acute phase. The outcomes were similar to other SAH patients and on follow-up, there were no aneurysm recurrences, indicating a durable long-term outcome.

Flow diversion covering the M1 origin as a last resort

IntroductionInternal carotid artery termination (ICAT) and proximal A1 aneurysms can be challenging for open surgical clipping or endovascular coiling. Treatment with flow diversion covering the middle cerebral artery (MCA), an...

Morphometric Comparison of the Pterional Trans-sylvian and the Pretemporal Transclinoidal Approaches to Posterior Communicating Artery Aneurysms: Anatomical Study

Abstract INTRODUCTION Due to the advent of endovascular techniques, modern series of surgically treated posterior communicating (Pcom) aneurysms have shown a tendency towards higher complexity and more technical difficulties. The pretemporal approach was described as a valuable extension to the pterional approach in treating basilar apex aneurysms. Its use for clipping of ruptured Pcom aneurysms was associated with decreased ischemic complications. However, its anatomical advantages for Pcom aneurysm surgery have not been previously analyzed. METHODS Six cadaveric heads (12 sides) underwent a sequential dissection, starting with a pterional craniotomy, and then extended to a pretemporal transclinoidal approach. In each step, the following variables were measured, taking the origin of Pcom as a focal point: (1) exposed length of the internal carotid artery (ICA) proximal to the Pcom artery, (2) exposed angular circumference of ICA at the origin of Pcom, (3) deep working area between the optic nerve and tentorium/oculomotor nerve, (4) superficial working area, (5) depth of the exposure and the (6) fronto-temporal (superior posterolateral), and (7) orbito-sphenoidal (inferior anterolateral) angles of exposure. Clinical case examples are used to illustrate the advantages of the pretemporal approach. RESULTS Compared to the pterional craniotomy, the pretemporal transclinoidal approach increased the exposed length of the proximal ICA from 3.3 to 11.7 mm (P = .0001), and its circumference from 5.1 to 7.8 mm (P = .0003), allowing a 210-degree view of the ICA (vs 137.9). The deep and superficial working areas also significantly widened from 53.7 to 92.4 mm2 (P = .0048) and 252.8 to 418.2 mm2 (P = .0001), respectively; while the depth of the exposure was equivalent. The frontotemporal and the sphenosylvian angles increased on average by 17 (P = .0006) and 10 (P = .0037) degrees, respectively. The clinical case examples demonstrate the visual, technical and strategic advantages of the pretemporal approach as a consequence of its anatomical exposure. CONCLUSION The pretemporal approach can be useful for complex Pcom aneurysms by providing easier proximal control, wider working space, aneurysm visualization, and more versatile clipping angles. The enhanced exposure potentially results in a higher rate of complete aneurysm obliteration and complication avoidance.

Role of Computational Fluid Dynamics for Predicting Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage: Study Protocol for a Multicenter Prospective Study.

Delayed cerebral ischemia (DCI) is a significant cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH). Recently, we reported the possibility that computational fluid dynamics (CFD) could predict DCI in terms of the cross-sectional area and flow velocity of the ipsilateral extracranial internal carotid and distal parent arteries in a single-center retrospective study. This is a multicenter, prospective, cohort study. Patients with aneurysmal SAH will undergo CFD analyses using preoperative three-dimensional computed tomography angiography, and we will investigate hemodynamic features of cerebral arteries in an acute stage of SAH. Primary outcome measures will be CFD features in patients with subsequent occurrence of DCI. Secondary outcome measures will be CFD features in patients with subsequent occurrence of cerebral vasospasm and cerebral infarction and the relationships with eventual modified Rankin scale score at 3months. The present protocol for a multicenter prospective study is expected to provide a novel diagnostic method to predict DCI before aneurysmal obliteration in an acute stage of SAH.

A Retrospective Analysis of Treatment Outcomes of 40 Incidental Cavernous Carotid Aneurysms

The management of cavernous carotid aneurysms (CCAs) poses a significant dilemma to the treating surgeon. Asymptomatic CCAs usually are managed conservatively with clinical and radiologic follow-up. Large size, intradural extension, sphenoid bone erosion, and increasing size on follow-up are usual indications for treating asymptomatic CCAs. However, there are no clear-cut guidelines in literature. We share our experience of 40 asymptomatic CCAs treated by endovascular and surgical methods. All the asymptomatic CCAs treated between January 2014 and December 2018 were analyzed retrospectively. Patient demographics, aneurysm characteristics, postprocedural complications, and clinical and radiologic follow-up data were obtained from records. Outcome was evaluated in terms of aneurysm obliteration and maintained cerebral perfusion, postoperative complications, recurrence, and clinically significant complications during follow-up. Endovascular coiling, balloon-assisted coiling, and stent-assisted coiling were performed in 27 (75%), 5 (13.9%), and 4 (11.1%), respectively. Raymond-Roy occlusion classification grade I occlusion was achieved in 88.9% of cases. No immediate or delayed complications were noted. Coil compaction was seen in 4 (11.1%) patients. In the surgery group, all patient underwent high-flow bypass with radial artery graft. Aneurysm exclusion with good graft patency was achieved in all 4 cases without any permanent morbidity or mortality. The current study demonstrates excellent outcomes of asymptomatic CCAs after treatment. In view of the technical advancements of both surgical and endovascular methods, consideration for treatment should be given to asymptomatic CCAs. Each aneurysm should be individually assessed by experts for choosing the best endovascular or surgical treatment option.

Management of tracheostomized patients after poor grade subarachnoid hemorrhage: Disease related and pulmonary risk factors for failed and delayed decannulation

ObjectiveTracheostomy is often indicated in patients with spontaneous subarachnoid hemorrhage (sSAH). Decannulation is a major goal of neurorehabilitation, but cannot be achieved in all patients. The aim of this study was to describe the course of decannulation and to identify associated risk factors in a single-center collective. Patients and methodsWe retrospectively reviewed 87 sSAH patients with WFNS (World Federation of Neurosurgical Societies) grade III-IV, who received tracheostomy. Decannulation events and the time from tracheostomy to decannulation were recorded in a 200-days follow-up. Variables analyzed were: age, sex, WFNS grade, Fisher grade, the presence of intracerebral or intraventricular hematoma, acute hydrocephalus, aneurysm location, aneurysm obliteration (surgical vs. endovascular), treatment related complications, decompressive craniectomy, symptomatic cerebral vasospasm, vasospasm-related infarction and timing of tracheostomy. Further risk factors analyzed were preexisting chronic lung disease and pneumonia. Functional outcome was assessed by the modified Rankin Scale (mRS). ResultsThe rate of successful decannulation was 84% after a median of 47 days. A higher WFNS grade and pneumonia were associated with both a prolonged time to decannulation (TTD) and decannulation failure (DF). Older age (> 60 years) and necessity for decompressive craniectomy were only associated with prolonged TTD. Outcome analysis revealed that patients with DF show a significantly (p < 0.01) higher rate of unfavorable outcome (mRS 3–6). ConclusionSuccessful decannulation is possible in the majority of sSAH patients and particularly, in all patients with WFNS grade III. WFNS grading, age, the necessity for decompressive craniectomy and pneumonia are significantly associated with the TTD. WFNS grade and pneumonia are significantly associated with DF. The mean cannulation time of sSAH patients is shorter in relation to stroke patients.

Letter by Malhotra and Wu Regarding Article, “Computed Tomography Angiography Versus Digital Subtraction Angiography for Postclipping Aneurysm Obliteration Detection: A Meta-Analysis”

Letter by Malhotra and Wu Regarding Article, “Computed Tomography Angiography Versus Digital Subtraction Angiography for Postclipping Aneurysm Obliteration Detection: A Meta-Analysis”

Flow diversion for small caliber vessel aneurysms: efficacy, safety, and functional outcome.

Flow-diverting stents had gained prominence among neurointerventionalists. Aneurysms originating from distal vessels, particularly dissecting or fusiform, pose more technical challenges. The aim of the following single center large series was to report the safety, efficacy, and functional outcome of flow diversion for aneurysms originating from small caliber vessel and compare to proximal vessels group. A retrospective chart review of a prospectively maintained database for subjects treated with flow diversion from 2010-2019. A total of 598 aneurysms were treated during a period extending from 2010-2019 (87.8% large caliber group versus 12.20% small caliber group); 84.28% (N.=504) were females and the average age was 55.5 years. Ischemic stroke occurred at a rate of 2.99% with a non-significant difference between both groups. Delayed aneurysmal rupture and distal intraparenchymal bleed occurred at a rate of 3.70% with a non-significant difference between both groups. Complete aneurysms occlusion was seen at a rate of 75.3% with a non-significant difference between both groups. Morbidity rate occurred at a rate of 5.8% with non-significant difference between both groups. Multivariate logistic regression showed that small vessel was an independent predictor of aneurysm obliteration with a 2.6-fold-higher likelihood. Flow-diverting stents are being used to treat diverse types of aneurysms and in various locations, in distal small caliber vessels where other treatment options pose a considerable risk. Small caliber group had similar complication and occlusion rates compared to proximal vessel group.

Paediatric intracranial aneurysms: a British institutional review.

Paediatric intracranial aneurysms are rare, with a differing natural history and thought to account for only up to 7% of all intracranial aneurysms. There is much uncertainty that surrounds the prevalence of unruptured intracranial aneurysms and it is estimated to be anywhere between 2 and 90 per 1000. This is the largest British single-centre analysis of paediatric intracranial aneurysms. We present the patient course from their initial presentations to the outcome of treatment and evaluate a serial assessment of adequacy of aneurysmal obliteration radiologically. Twenty-two paediatric cases were identified that required treatment. The median age of presentation was 11.3years (mean 9.9, range 0 to 15.9), 68% (15/22) were male and 77% (17/22) were ruptured on presentation. The majority of aneurysms were located at the anterior circulation (77% (17/22)). The overall median aneurysm size (n = 21) was 7.4mm (mean 5mm, range 2.5-19mm). Twenty patients survived the acute phase and 80% (16/20) underwent coil embolisation and the other patients' surgical clipping. The overall outcomes were available for the 20 patients; on discharge, 90% (18/20) had a favourable clinical outcome (GOS score of 3-5). Treatment-specific clinical favourable outcomes were 88% (14/16) for coil embolisation against 100% (4/4) after surgical clipping. Of the two patients that died in the acute phase, one had sickle cell anaemia. Aneurysm aetiology was unknown in all other cases. None of the patients had a family history of aneurysms. Paediatric intracranial aneurysms while rare should be considered a differential diagnosis of children presenting with unexplained loss of consciousness with or without focal neurological deficit and/or headache. There is a two to one preponderance for males with a larger proportion of aneurysms within the posterior circulation (25%). Coil embolisation is the preferred method of securing a paediatric intracranial aneurysm.

Risk Factors and Preoperative Risk Scoring System for Shunt-Dependent Hydrocephalus Following Aneurysmal Subarachnoid Hemorrhage.

ObjectiveShunt-dependent hydrocephalus (SdHCP) is a well-known complication of aneurysmal subarachnoid hemorrhage (SAH). The risk factors for SdHCP have been widely investigated, but few risk scoring systems have been established to predict SdHCP. This study was performed to investigate the risk factors for SdHCP and devise a risk scoring system for use before aneurysm obliteration. MethodsWe reviewed the data of 301 consecutive patients who underwent aneurysm obliteration following SAH from September 2007 to December 2016. The exclusion criteria for this study were previous aneurysm obliteration, previous major cerebral infarction, the presence of a cavum septum pellucidum, a midline shift of >10 mm on initial computed tomography (CT), and in-hospital mortality. We finally recruited 254 patients and analyzed the following data according to the presence or absence of SdHCP : age, sex, history of hypertension and diabetes mellitus, Hunt-Hess grade, Fisher grade, aneurysm size and location, type of treatment, bicaudate index on initial CT, intraventricular hemorrhage, cerebrospinal fluid drainage, vasospasm, and modified Rankin scale score at discharge. ResultsIn the multivariate analysis, acute HCP (bicaudate index of ≥0.2) (odds ratio [OR], 6.749; 95% confidence interval [CI], 2.843–16.021; p=0.000), Fisher grade of 4 (OR, 4.108; 95% CI, 1.044–16.169; p=0.043), and an age of ≥50 years (OR, 3.938; 95% CI, 1.375–11.275; p=0.011) were significantly associated with the occurrence of SdHCP. The risk scoring system using above parameters of acute HCP, Fisher grade, and age (AFA score) assigned 1 point to each (total score of 0–3 points). SdHCP occurred in 4.3% of patients with a score of 0, 8.5% with a score of 1, 25.5% with a score of 2, and 61.7% with a score of 3 (p=0.000). In the receiver operating characteristic curve analysis, the area under the curve (AUC) for the risk scoring system was 0.820 (p=0.080; 95% CI, 0.750–0.890). In the internal validation of the risk scoring system, the score reliably predicted SdHCP (AUC, 0.895; p=0.000; 95% CI, 0.847–0.943). ConclusionOur results suggest that the herein-described AFA score is a useful tool for predicting SdHCP before aneurysm obliteration. Prospective validation is needed.

Evaluating the safety and technical effectiveness of a newly developed intravascular ’flow isolator' stent for the treatment of intracranial aneurysms: study protocol for a first-in-human single-arm multiple-site clinical trial in Japan

IntroductionWide-neck or large intracranial aneurysms are difficult to cure by conventional surgical or endovascular procedures. A flow diverter (FD) is an implantable, stent-like, fine-mesh medical device for the treatment of...

Transclival clipping for giant vertebral artery aneurysm: A case report

Abstract Background Endovascular treatment often achieves complete obliteration of VA giant aneurysm; however, retreatment may be required because of late recanalization. We report a case of giant VA aneurysm that showed regrowth after endovascular treatment and was treated with VA clipping using the endoscopic endonasal transclival approach. Case description A 47-year-old man with chief complaint of ataxia underwent endovascular treatment of giant VA aneurysm. One year later, he needed additional treatment to regrowth of the aneurysm. We were not able to accomplish aneurysmectomy via the transcondylar fossa approach because of difficulty in achieving hemostasis and ended with partial thrombectomy. Digital subtraction angiography (DSA) performed after 4 months revealed coil compaction and distal flow due to recanalization. Right VA elongation and position of anterior spinal artery (ASA), these factors made possible for us to perform transclival approach to VA. Despite the limited indications for its use, endonasal endoscopic transclival clipping may be effective in limited anatomical cases. Conclusion We report the use of endonasal endoscopic transclival clipping for giant VA aneurysm. This endonasal endoscopic treatment may be an optional alternative in only limited cases depending upon the anatomical location of the lesion because of limitations of vascular control and the inability to visualize the field in the presence of major bleeding. For treatment of progressive giant VA aneurysm, it is very important to avoid optimistic strategy for giant VA aneurysm initially.

Outcomes and Complications After the Use of the Pipeline Embolization Device in the Treatment of Intracranial Aneurysms of the Posterior Circulation: A Systematic Review and Meta-Analysis

The use of the Pipeline embolization device (PED) for posterior circulation aneurysms is controversial. The aim of this study was to explore the safety and efficacy of PED for these aneurysms in a meta-analysis. Meta-regression was used to identify predictors for incomplete aneurysm occlusion and procedure-related complications. PubMed, Web of Science, and OVID databases were searched to identify all published references evaluating the treatment effect of PED for posterior circulation aneurysms. Only studies written in English that reported original data and included >10 cases were considered for inclusion. Patient demographics, aneurysm characteristics, angiographic outcomes, and clinical outcomes were extracted. A random-effects model was adopted to pool the obliteration rates and complication rates across selected studies. Finally, we conducted meta-regression analysis to identify predictors of angiographic outcomes. 12 studies including 358 patients with 365 aneurysms were included. The pooled complete aneurysm obliteration rate was 82% (95% confidence interval 73%-90%), and pooled procedure-related complication rate was 18% (95% confidence interval 14%-22%). Increasing age predicted incomplete obliteration of aneurysms after PED treatment in these patients (P= 0.01). PED is an alternative to treat intracranial aneurysms of the posterior circulation, achieving high complete occlusion rates, but it is less effective in elderly patients. The risk of procedure-related complications is not negligible. Further larger, long-term follow-up studies are needed before definitive conclusions can be drawn.

Exploring the Feasibility of Pipeline Embolization Device Compared With Stent-Assisted Coiling to Treat Non-saccular, Unruptured, Intradural Vertebral Artery Aneurysms.

Object: The pipeline embolization device (PED) has been used to treat non-saccular, unruptured, intradural vertebral artery aneurysms at some institutions. However, there is an absence of large controlled studies validating the feasibility of this treatment. This study aimed to explore the therapeutic feasibility of PED by comparing PED treatment with controlled stent-assisted coiling (SAC).Materials and Methods: Thirty-two PED procedures were matched in a 1:2 manner with 64 SAC procedures based on patient age, sex, aneurysm size, and aneurysm location. Technical factors, procedural complications, angiographic results, and clinical outcomes were analyzed and compared.Results: There was no statistically significant difference in technical factors and procedural complications between the two groups (PED vs. SAC, 9.4 vs. 4.7%, P = 0.397). In multivariate analysis, smoking and therapeutic modality were identified as independent predictors of occlusion. Smoking was a risk factor for aneurysm obliteration [hazard ratio (HR) 0.53; 95% confidence interval (CI), 0.31–0.89; P = 0.018]. Aneurysms treated with PED were more likely to achieve obliteration over time compared with aneurysms treated with SAC (HR 2.97; 95% CI, 1.79–4.93; P < 0.001). The rate of favorable clinical outcomes (modified Rankin Scale (mRS), 0–2) was similar between the two groups (PED vs. SAC, 100 vs. 96.9%, P = 0.551). In the SAC group, one patient had neurological deficit with an mRS of four at the latest follow-up. There was no mortality in either group.Conclusions: The PED and SAC groups showed similar technical factors, procedural complications, angiographic results, and favorable clinical outcomes. Aneurysms treated with PED were more prone to obliteration over time than aneurysms treated with SAC. These outcomes suggest, based on short-term follow-up, PED is a safe and feasible strategy for the treatment of non-saccular, unruptured, intradural vertebral artery aneurysms.

Surgical and Endovascular Comprehensive Treatment Outcomes of Unruptured Intracranial Aneurysms: Reduction of Treatment Bias

Determining the risks of treatment of unruptured intracranial aneurysms is critical in the decision-making process of management. Most studies have reported the results for endovascular or surgical management. Our objective was to better delineate the risk estimates for unruptured intracranial aneurysms treated with surgical or endovascular techniques in a comprehensive fashion, according to the patients' risk profiles. Data were gathered from 553 patients with 658 unruptured intracranial aneurysms treated at a single institution from 2014 to 2017. The decision to treat was determined by a projected morbidity that was lower than the natural history rupture risk. Data on aneurysm size, location, patient age, and outcome at the last clinical visit (modified Rankin scale scores) were collected and analyzed retrospectively. The mean patient age was 59 years, and the mean lesion size was 7.3 mm. Microsurgical clipping was used in 251 lesions (38.2%), endovascular coiling in 70 (10.6%), stent-assisted coiling in 89 (13.5%), and a pipeline embolization device in 248 (37.7%). Complications from the procedures or during hospital admission occurred 66 lesions (10% of the total). Of these 66 complications, 28 (4.32% of the total) were non-neurological, treated, and resolved without permanent morbidity. Neurologic complications occurred in 38 procedures (5.7% of the total). Of these, 7 (1%) resulted in a permanent poor outcome (modified Rankin scale score, 3-6). Aneurysmal obliteration using endovascular and surgical approaches in a comprehensive fashion has low treatment risks for unruptured aneurysms. The nomograms generated are useful in the discussion with patients and families regarding the risks of total institutional treatment of unruptured aneurysms.

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

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. 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. 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. 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).

The 25th anniversary of the retrograde suction decompression technique (Dallas technique) for the surgical management of paraclinoid aneurysms: historical background, systematic review, and pooled analysis of the literature.

Paraclinoid internal carotid artery (ICA) aneurysms frequently require temporary occlusion to facilitate safe clipping. Brisk retrograde flow through the ophthalmic artery and cavernous ICA branches make simple trapping inadequate to soften the aneurysm. The retrograde suction decompression (RSD), or Dallas RSD, technique was described in 1990 in an attempt to overcome some of those treatment limitations. A frequent criticism of the RSD technique is an allegedly high risk of cervical ICA dissection. An endovascular modification was introduced in 1991 (endovascular RSD) but no studies have compared the 2 RSD variations. The authors performed a systematic review of MEDLINE/PubMed and Web of Science and identified all studies from 1990-2016 in which either Dallas RSD or endovascular RSD was used for treatment of paraclinoid aneurysms. A pooled analysis of the data was completed to identify important demographic and treatment-specific variables. The primary outcome measure was defined as successful aneurysm obliteration. Secondary outcome variables were divided into overall and RSD-specific morbidity and mortality rates. Twenty-six RSD studies met the inclusion criteria (525 patients, 78.9% female). The mean patient age was 53.5 years. Most aneurysms were unruptured (56.6%) and giant (49%). The most common presentations were subarachnoid hemorrhage (43.6%) and vision changes (25.3%). The aneurysm obliteration rate was 95%. The mean temporary occlusion time was 12.7 minutes. Transient or permanent morbidity was seen in 19.9% of the patients. The RSD-specific complication rate was low (1.3%). The overall mortality rate was 4.2%, with 2 deaths (0.4%) attributable to the RSD technique itself. Good or fair outcome were reported in 90.7% of the patients.Aneurysm obliteration rates were similar in the 2 subgroups (Dallas RSD 94.3%, endovascular RSD 96.3%, p = 0.33). Despite a higher frequency of complex (giant or ruptured) aneurysms, Dallas RSD was associated with lower RSD-related morbidity (0.6% vs 2.9%, p = 0.03), compared with the endovascular RSD subgroup. There was a trend toward higher mortality in the endovascular RSD subgroup (6.4% vs 3.1%, p = 0.08). The proportion of patients with poor neurological outcome at last follow-up was significantly higher in the endovascular RSD group (15.4% vs 7.2%, p < 0.01). The treatment of paraclinoid ICA aneurysms using the RSD technique is associated with high aneurysm obliteration rates, good long-term neurological outcome, and low RSD-related morbidity and mortality. Review of the RSD literature showed no evidence of a higher complication rate associated with the Dallas technique compared with similar endovascular methods. On a subgroup analysis of Dallas RSD and endovascular RSD, both groups achieved similar obliteration rates, but a lower RSD-related morbidity was seen in the Dallas technique subgroup. Twenty-five years after its initial publication, RSD remains a useful neurosurgical technique for the management of large and giant paraclinoid aneurysms.

Pediatric Intracranial Aneurysms: Favorable Outcomes Despite Rareness and Complexity

Pediatric intracranial aneurysms (IAs) are rare and differ from their adult counterparts in terms of their aneurysmal characteristics, presentation, treatment, and outcomes. Their treatment is often more difficult and complex compared with that of adults. However, studies outlining the clinical effect of pediatric IAs remain sparse. We retrospectively reviewed the data from patients aged ≤18 years admitted to our hospital from 2000 to 2017 with a diagnosis of IAs. From the sample of 8207 patients with an IA diagnosis, 26 patients with 33 IAs were involved. Our cohort included 17 males and 9 females, with a mean age of 12.5 years. The mean follow-up duration was 4 years and 3 months. Seven patients (26.92%) were assumed to have a traumatic origin for their IAs. Ruptured aneurysms were more common than unruptured ones (61.53% vs. 38.46%). Complex features were observed in 14 aneurysms (42.42%). Initially, microsurgical and endovascular treatment were both performed in 10 patients (38.46%). A good recovery was obtained in 16 patients (61.54%) as determined by the Glasgow outcome scale scores at the 6-month follow-up visits. The complete obliteration of aneurysms was observed in 17 patients (65.38%). Endovascular treatment was the initial treatment in 3 patients with incomplete obliteration. The treatment of pediatric IAs is challenging and technically demanding owing to their discrete nature compared with adult IAs and the need for greater surgical skills. We found a male predominance, with internal carotid artery bifurcation as the most frequent location of the aneurysms. Despite the greater incidence of ruptured and complex aneurysm cases, many patients had experienced a good recovery at the 6-month follow-up examinations.