Intraoperative Aneurysm Rupture Research Articles

LVIS Jr. stent for treatment of intracranial aneurysms with parent vessel diameter of 2.5 mm or less.

Background and purpose This retrospective study evaluates the safety, effectiveness, and long-term clinical and angiographic follow-up of intracranial aneurysms treated with the Low-Profile Visualized Intraluminal Support Junior (LVIS Jr.) stent and parent vessels of diameter equal to or less than 2.5 mm. Materials and methods We included all patients treated with the LVIS Jr. stent in aneurysms with small parent vessel diameter between March 2015 and July 2017. Periprocedural adverse events, immediate aneurysm occlusion rates, and clinical and angiographic follow-up are reported. Results A total of 35 patients with 35 aneurysms were included. Ten aneurysms were ruptured (28.6%) and 25 were unruptured (71.4%). The parent arteries measured 0.9 mm to 2.5 mm in diameter (mean, 2.2 mm). Intra-procedural thromboembolic complications occurred in four patients (11.4%) and there was an intraoperative aneurysm rupture in one patient (2.8%). Immediate complete aneurysm occlusion was noted in 21 out of 35 patients (60%). Clinical follow-up ranged between one and 25 months (mean, 10.5 months) and magnetic resonance angiography follow-up ranged between four and 24 months (mean, 10.4 months). Complete aneurysm occlusion was achieved in 21 out of 29 patients (72.4%) at last angiographic follow-up (mean, 9.4 months; range four to 23 months). In-stent stenosis occurred in one out of 29 patients (3.4%), who was asymptomatic. Of the four patients with in-stent thrombosis, three patients were treated with "Y configuration" (two patients with middle cerebral artery aneurysms and one patient with an anterior communicating artery aneurysm). Mortality rate was 0%. Neurological morbidity was 2.9%. Conclusions Stenting with the LVIS Jr. stent allowed us to treat complex intracranial aneurysms with parent vessel diameter of 2.5 mm or less with an acceptable safety profile.

Вплив інтраопераційного розриву аневризм головного мозку на результати хірургічного лікування в ранній післяопераційний період

Objective – to study features of clinical neurological manifestations of intraoperative rupture of arterial aneurysms (AA) in the early postoperative period. Materials and methods. A retrospective study of the results of surgical treatment of 69 patients (31 (44.9 %) men and 38 (55.1 %) women) with acute cerebrovascular disorder in the hemorrhagic type was performed, due to the breakdown of brain aneurysm, in which there was an intraoperative rupture of arterial aneurysm. Age of patients from 21 to 65 years, the average age is (42.2 ± 14.2) year. In all cases the disease manifested itself as a clinic of non-traumatic intracranial hemorrhage as a result of the rupture of AA. The primary gap was observed in 57 (82.6 %) patients, repeated – in 12 (17.4 %) patients. The formation of intrahepatic hematoma was observed in 36 (52.2 %) patients. During hospitalization all patients underwent computer tomography of the brain to verify hemorrhage, cerebral edema, ischemic lesions and hydrocephalus expansion of the ventricular system. Diagnosis and determination of the degree of angiospasm were performed using transcranial dopplerography. The diagnosis of cerebral aneurysms was established using cerebral angiography and multispiral computer angiography. Intraoperative doppler screening was used to assess the radicalization of the aneurysm exclusion from the bloodstream. The Hunt-Hess scale, the World Federation of Neurological Surgeon Grading System for Subarachnoid Hemorrhage (WFNS SAH grading scales), Glasgow scale, was used to assess the clinical state of patients. Results. In the acute period 47 (68.12 %) patients were operated, in the subacute and cold period – 22 (31.9 %). In 63 patients, the intraoperative aneurysm rupture occurred during the allocation of aneurysms from arachnoidal adhesions, 2 at the time of aspiration of the intracerebral hematoma, 3 in the approach to aneurysm during to retraction of spatulas, 1 – noncontact aneurysm rupture during the trepanation stage. Temporary occlusion with a clip of an arterial carrier aneurysms as a measure of prevention of intraoperative rupture of brain aneurysms was aplicated in 66 (95.65 %) cases. Persistent neurological disorders arose in 15 (21.74 %) patients. 48 patients were discharge from the hospital in satisfactory condition. Six (8.7 %) patients (3 women and 3 men from 22 to 53 years old) died: 3 – due to the rupture of the aneurysm of anterior cerebral artery-anterior communicating artery on the left, 2 – aneurysms of anterior cerebral artery-anterior communicating artery on the right, 1 – the aneurysms of anterior inferior cerebellar artery on the right. In acute period operated 4 patients, in the distant period – 2. Conclusions. Intraoperative rupture of cerebral aneurysm – the most often intraoperative complications of clipping brain aneurysms, the appearance of which worsens the general condition of the patient, leads to the formation of persistent focal deficiency and increases the likelihood of postoperative lethality. The application of adequate surgical access to the optimal position of the patient on the operating table, induced arterial hypotension, temporary occlusion of the artery carrier aneurysms are reliable methods of preventing the onset of intraoperative ruptures of arterial aneurysms. Surgical tactics with an intraoperative rupture of aneurysm depends on the stage at which the bleeding from aneurysm occurred, its intensity and on anatomic-topographic features of aneurysms and arterial links of blood supply to the brain.

Stent-Assisted Coil Embolization Using Only a Glycoprotein IIb/IIIa Inhibitor (Tirofiban) for Ruptured Wide-Necked Aneurysm Repair.

ObjectiveThe aim of this study was to evaluate the safety and efficacy of stent-assisted coil embolization using only a glycoprotein IIb/IIIa inhibitor (tirofiban).Materials and MethodsWe retrospectively reviewed patients with a subarachnoid hemorrhage due to ruptured wide-necked intracranial aneurysms who were treated by stent-assisted coil embolization. In all patients, the glycoprotein IIb/IIIa inhibitor tirofiban was administered just before stent deployment. Electronic medical records for these patients were reviewed for peri-procedural complications and extra-ventricular drainage catheter related hemorrhage, as well as Glasgow outcome scale (GOS) at discharge, 3 months, and 6 months follow-up were recorded.ResultsFifty-one aneurysms in 50 patients were treated. The mean patient age was 64.9 years. Eighteen patients (36%) received a World Federation of Neurosurgical Societies grade of 4 or 5. The mean aneurysm size was 9.48 mm and mean dome-to-neck ratio was 1.06. No intraoperative aneurysm ruptures occurred, although five (10%) episodes of asymptomatic stent thrombosis did occur. Three patients experienced a delayed thrombo-embolic event and two a delayed hemorrhagic event. Immediate radiologic assessment indicated a complete occlusion in 29 patients, a residual neck in 19, and a residual sac in 3. Four patients (8%) died. Sixteen patients (32%) experienced a poor GOS (< 4). Two aneurysms were recanalized during the follow-up period (mean, 19 months for clinical and 18 months for angiographic follow-up).ConclusionTreatment of ruptured wide-necked intracranial aneurysms via stent-assisted coil embolization with a glycoprotein IIb/IIIa inhibitor alone was found to be relatively safe and efficient.

Surgical Outcome of Very Small Intracranial Aneurysms Utilizing the Double Clip Technique.

To report the outcome of patients with very small intracranial aneurysm (VSIA) undergoing surgical clipping using a double-clip technique. This cross-sectional study was conducted in Namazi Hospital, the main referral neurovascular center in Southern Iran during a 6-year period from September 2010 to March 2016. All patients with VSIAs (≤3 mm) undergoing surgery with double-clip technique were included. This technique reduces the clip slippage. The short- and long-term outcomes determined by Glasgow outcome score (GOS), modified Rankin Scale (MRS), and complications. Operations were performed on 32 VSIAs in 26 patients with a mean ± SD age of 55.7 ± 10.1 years. Middle cerebral artery was the most common location for VSIA (50.0%). There was no neck remnant, and the complete occlusion rate was 100%. The rate of intraoperative aneurysm rupture was 30.8%, and none of the patients experienced rebleeding. The 6-month mortality rate was 0% in ruptured VSIAs and 6.25% in unruptured VSIAs. Most of the patients had favorable outcomes (88.5%), and the overall mortality rate was 11.5%. The rate of permanent neurologic deficit was 10.0% in ruptured and 12.5% in unruptured VSIAs. Multivariate logistic regression analysis revealed no association between baseline and clinical characteristics and outcome in this series. VSIAs are difficult to treat because of their small sizes; therefore, with a double-clip technique, one can reduce complications related to the treatment of small aneurysms.

Clipping treatment of posterior communicating artery aneurysms associated with arteriosclerosis and calcification: A single center study of 136 cases.

It is widely acknowledged that arteriosclerosis and calcification of the parent artery and aneurysm neck make it difficult to clip posterior communicating artery (PCoA) aneurysms. A total of 136 cases of PCoA aneurysms accompanied by arteriosclerosis and calcification were collected and treated with clipping in the present study. Of the 136 patients, 112 were females (82.4%) and 24 were males (17.6%), with ages ranging from 37 to 76 years (mean age, 60.2 years). Rupture of a PCoA aneurysm was identified in 132 cases (97.1%), and there were 4 cases of unruptured PCoA aneurysms (2.9%). According to the severity of arteriosclerosis and calcification, the aneurysms were divided into type I, II or III. The treatment of type I aneurysms achieved the best curative effect. It is difficult to temporarily occlude type II and III aneurysms during surgery, and temporary occlusion failed in almost 50% of cases. Types II and III were prone to intraoperative aneurysm ruptures. A significantly higher rate of intraoperative aneurysm rupture was seen in type III compared with type II cases. Type II and III cases were more likely to be treated using a fenestrated clip for aneurysm clipping compared with type I cases, and fenestrated clips were used significantly more frequently in type III cases compared with type II cases. Arteriosclerosis and calcification were likely to affect the prognosis of patients, particularly in cases with type III arteriosclerosis and calcification of the parent artery and aneurysm neck. Therefore, the stratification of the arteriosclerosis and calcification of the parent artery and aneurysm neck into types I-III can guide the intraoperative aneurysm clipping strategy, aid in choosing the correct clips, and inform predictions of the occurrence of rupture and hemorrhage, as well as the prognosis for aneurysms.

Clinical comparative study between the interhemispheric approach and the pterional approach in craniotomy anterior communicating aneurysm clipping surgery

Objective To retrospectively analyze and compare the intraoperative and postoperative clinical efficacies between the interhemispheric approach and pterional approach in craniotomy anterior communicating aneurysm clipping surgery. Methods A total of 21 cases of anterior communicating artery aneurysms with subarachnoid hemorrhage undergoing surgery of craniotomy clipping from January 2012 to December 2016 in the Department of Neurosurgery of Shengjing Hospital of China Medical University, in which 13 cases were treated by pterional approach and 8 cases were treated by interhemispheric approach. Two kinds of operation approaches were compared in operation time, intraoperative aneurysm rupture rate, intraoperative bleeding volume, average length of stay, incidence rate of postoperative fection, and Glasgow Outcome Scale (GOS). Results There were no significant difference in intraoperative aneurysm rupture rate, intraoperative bleeding volume, inicidence rate of postoperative infection rate, and GOS scores (P>0.05). But the opreration time and average length of stay in interhemispheric approach group were significantly shorter than the pterional approach group (P<0.05). Conclusions Approach of interhemispheric was a safe, effective, and convenient approach for the craniotomy of clipping in anterior communicating artery aneurysm. Key words: Intracranial aneurysm/SU; Forehead/SU; Anterior cerebral artery/PA

Minipterional and Supraorbital Keyhole Craniotomies for Ruptured Anterior Circulation Aneurysms: Experience at Single Center.

Keyhole craniotomy is a type of pterional craniotomy that involves a minimally invasive approach for the treatment of cerebral aneurysms. Currently, the minipterional keyhole craniotomy and supraorbital keyhole craniotomy procedures are frequently performed. We evaluated the feasibility and safety of supraorbital keyhole craniotomies and minipterional keyhole craniotomy for the clipping of ruptured intracranial aneurysms in the anterior cerebral circulation as an alternative to the pterional approach in a consecutive series of 25 patients. The rate of intraoperative aneurysmal rupture was 8% (2/25), and all ruptures were safely controlled. The success solely depends on careful selection of patients and the experience of the surgical team.

Adenosine-assisted neurovascular surgery: initial case series and review of literature.

Cerebral aneurysms in complex anatomical locations and intraoperative rupture of aneurysms are challenging for neurosurgeons and anaesthetists alike. Mechanical and non-mechanical methods to reduce blood flow into aneurysms are well-recognised techniques to facilitate aneurysm exclusion from the circulation. Mechanical methods like temporary clipping of parent arteries, carotid artery ligation and endovascular balloon occlusion are commonly used in clinical practice. However, non-mechanical techniques such as rapid ventricular pacing and adenosine-induced cardiac standstill with hypotension are still emerging strategies. The aim of this study is to report our units' experience in the use of adenosine in aneurysm clipping and arteriovenous malformation (AVM) resection and review the literature. The records of all patients who had adenosine-assisted clipping of intracranial aneurysms and AVM resections in our institute between November 2015 and December 2016 were extracted from prospectively maintained database. The following data were collected: patient demographics, comorbidities, size and location of the aneurysms or AVM, number of boluses and total dose of adenosine administered, duration of cardiac standstill and hypotension (systolic blood pressure<60mmHg), intraoperative and postoperative complications and outcome scores at discharge. Literature search on Embase and PubMed for the terms "adenosine and clipping", "adenosine and aneurysm" and "adenosine and AVM" was performed. Eight aneurysms and two AVMs were identified. While both AVMs were elective procedures, half of the aneurysm clippings were on urgent basis. We used adenosine safely with spontaneous return of rhythm in all cases. Temporary clips to the parent artery were applied for brief periods in 2 patients who had pre-adenosine intraoperative rupture. We did not observe any immediate or late adverse events related to administration of adenosine. From our literature review, a total of ten case series and four case reports were identified. There were no reports on the use of adenosine in AVM resection. Transient adenosine-induced asystole is a safe and effective technique in facilitating surgical treatment of complex aneurysms and AVMs. In addition, adenosine use reduces the need, duration, and associated complications of temporary clip applications to parent arteries.

Translucent Appearance of Middle Cerebral Artery Bifurcation Aneurysms Is Risk Factor for Intraoperative Aneurysm Rupture During Clipping.

The rupture rate of unruptured intracranial aneurysms is influenced by certain angioarchitectural and hemodynamic characteristics. Recently the translucent appearance of aneurysms was described as a possible risk factor for aneurysm rupture. In this study, we investigate the intraoperative rupture risk of surgically clipped unruptured translucent aneurysms (TAs). Clinical and radiologic data of microsurgically treated unruptured middle cerebral artery (MCA) bifurcation aneurysms between 2013 and 2015 were collected and analyzed. Aneurysms were divided into TA as defined as >90% reddish pigmentation appearance of the aneurysm wall or non-TA (NTA) according to the observation under microscope by a single neurosurgeon. Parameters were analyzed using univariate and multivariate statistical analyses. A total of 41 unruptured MCA bifurcation aneurysms were included in the analysis, and 68.2% (28/41) were defined as TA. The univariate analysis showed that aneurysm characteristics (Dmax, Wmax, height, and lower size ratio [SR]) that were small in nature were associated with TAs. TAs were associated with intraoperative rupture (28.6% vs. 0%, P= 0.04). Multivariate logistic regression analysis found that the lower SR is the independent risk factor for TAs. The results demonstrate that a lower SR correlates with TA in the MCA bifurcation and the thinner wall of the TA causes intraoperative rupture more likely. These results provide important information on the fragility of TAs and might influence the treatment decisions in unruptured MCA bifurcation aneurysms with lower SRs.

Flow Diversion for the Treatment of MCA Bifurcation Aneurysms—A Single Centre Experience

Intracranial aneurysms located at the bifurcation of the middle cerebral artery (MCA) can often be challenging for the neurointerventionalist. We aimed to evaluate the efficacy and safety of flow diverting stents (FDS) in the treatment of these aneurysms. We retrospectively reviewed our prospectively maintained database to collect information for all patients with unruptured saccular bifurcation MCA aneurysms treated with FDS between January 2010 and January 2016. In addition to demographic data, we recorded the location, aneurysm characteristics, previous treatments, number and type of FDS, complications, and clinical and angiographic follow-up. Our search identified 13 patients (7 males) with an average age of 61.7 years (47-74 years). All patients had a single bifurcation aneurysm of the MCA, and none of the aneurysms were acutely ruptured. The average fundus size of the saccular aneurysms was 3 mm (range 1.5-10 mm). Follow-up studies were available for 12 patients. Based on the most recent follow-up angiograms, six aneurysms (50%) were totally occluded; five aneurysms (41.7%) showed only a small remnant; and one aneurysm (8.3%) remained unchanged. One patient suffered from an ischemic stroke with resultant permanent hemiparesis (mRS 3). In another case, there was an in-stent thrombosis during the intervention, which resolved upon intra-arterial infusion of Eptifibatide (mRS 0). There were no intra-operative vessel or aneurysm ruptures and no mortalities. Angiography of the covered MCA branches showed no change in the caliber or flow of the vessel in six (50%), a reduction in caliber in five (41.7%), and a complete occlusion in one (8.3%). All caliber changes and occlusions of the vessels were asymptomatic. In our series, 91.7% of treated MCA bifurcation aneurysms were either completely occluded or showed only a small remnant with a good safety profile. Flow diversion of MCA bifurcation aneurysms should be considered as an alternative treatment strategy when microsurgical clipping or alternative endovascular treatment options are not feasible.

Blister Aneurysms of the Internal Carotid Artery: Microsurgical Results and Management Strategy.

Blister aneurysms of the supraclinoid internal carotid artery (ICA) are challenging lesions with high intraoperative rupture rates and significant morbidity. An optimal treatment strategy for these aneurysms has not been established. To analyze treatment strategy, operative techniques, and outcomes in a consecutive 17-year series of ICA blister aneurysms treated microsurgically. Seventeen patients underwent blister aneurysm treatment with direct clipping, bypass and trapping, or clip-reinforced wrapping Twelve aneurysms (71%) were treated with direct surgical clipping. Three patients required bypass: 1 superficial temporal artery to middle cerebral artery bypass, 1 external carotid artery to middle cerebral artery bypass, and 1 ICA to middle cerebral artery bypass. One patient was treated with clip-reinforced wrapping. Initial treatment strategy was enacted 71% of the time. Intraoperative rupture occurred in 7 patients (41%), doubling the rate of a poor outcome (57% vs 30% for patients with and without intraoperative rupture, respectively). Severe vasospasm developed in 9 of 16 patients (56%). Twelve patients (65%) were improved or unchanged after treatment, and 10 patients (59%) had good outcomes (modified Rankin Scale scores of 1 or 2). ICA blister aneurysms can be cautiously explored and treated with direct clipping as the first-line technique in the majority of cases. Complete trapping of the parent artery with temporary clips and placing permanent clip blades along normal arterial walls enables clipping that avoids intraoperative aneurysm rupture. Trapping/bypass is used as the second-line treatment, maintaining a low threshold for bypass with extensive or friable pathology of the carotid wall and in patients with incomplete circles of Willis.

Computed tomography angiography spot sign predicts intraprocedural aneurysm rupture in subarachnoid hemorrhage.

To analyze whether the computed tomography angiography (CTA) spot sign predicts the intraprocedural rupture rate and outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). From a prospective nationwide multicenter registry database, 1023 patients with aneurysmal subarachnoid hemorrhage (aSAH) were analyzed retrospectively. Descriptive statistics and logistic regression analysis were used to compare spot sign-positive and -negative patients with aneurysmal intracerebral hemorrhage (aICH) for baseline characteristics, aneurysmal and ICH imaging characteristics, treatment and admission status as well as outcome at discharge and 1-year follow-up (1YFU) using the modified Rankin Scale (mRS). A total of 218 out of 1023 aSAH patients (21%) presented with aICH including 23/218 (11%) patients with spot sign. Baseline characteristics were comparable between spot sign-positive and -negative patients. There was a higher clip-to-coil ratio in patients with than without aICH (both spot sign positive and negative). Median aICH volume was significantly higher in the spot sign-positive group (50ml, 13-223ml) than in the spot sign-negative group (18ml, 1-416; p < 0.0001). Patients with a spot sign-positive aICH thus were three times as likely as those with spot sign-negative aICH to show an intraoperative aneurysm rupture [odds ratio (OR) 3.04, 95% confidence interval (CI) 1.04-8.92, p = 0.046]. Spot sign-positive aICH patients showed a significantly worse mRS at discharge (p = 0.039) than patients with spot sign-negative aICH (median mRS 5 vs. 4). Logistic regression analysis showed that the spot sign was an aICH volume-dependent predictor for outcome. Both spot sign-positive and -negative aICH patients showed comparable rates of hospital death, death at 1YFU and mRS at 1YFU. In this multicenter data analysis, patients with spot sign-positive aICH showed higher aICH volumes and a higher rate of intraprocedural aneurysm rupture, but comparable long-term outcome to spot sign-negative aICH patients.

Performing concurrent operations in academic vascular neurosurgery does not affect patient outcomes.

OBJECTIVE Concurrent surgeries, also known as "running two rooms" or simultaneous/overlapping operations, have recently come under intense scrutiny. The goal of this study was to evaluate the operative time and outcomes of concurrent versus nonconcurrent vascular neurosurgical procedures. METHODS The authors retrospectively reviewed 1219 procedures performed by 1 vascular neurosurgeon from 2012 to 2015 at the University of California, San Francisco. Data were collected on patient age, sex, severity of illness, risk of mortality, American Society of Anesthesiologists (ASA) status, procedure type, admission type, insurance, transfer source, procedure time, presence of resident or fellow in operating room (OR), number of co-surgeons, estimated blood loss (EBL), concurrent vs nonconcurrent case, severe sepsis, acute respiratory failure, postoperative stroke causing neurological deficit, unplanned return to OR, 30-day mortality, and 30-day unplanned readmission. For aneurysm clipping cases, data were also obtained on intraoperative aneurysm rupture and postoperative residual aneurysm. Chi-square and t-tests were performed to compare concurrent versus nonconcurrent cases, and then mixed-effects models were created to adjust for different procedure types, patient demographics, and clinical indicators between the 2 groups. RESULTS There was a significant difference in procedure type for concurrent (n = 828) versus nonconcurrent (n = 391) cases. Concurrent cases were more likely to be routine/elective admissions (53% vs 35%, p < 0.001) and physician referrals (59% vs 38%, p < 0.001). This difference in patient/case type was also reflected in the lower severity of illness, risk of death, and ASA class in the concurrent versus nonconcurrent cases (p < 0.01). Concurrent cases had significantly longer procedural times (243 vs 213 minutes) and more unplanned 30-day readmissions (5.7% vs 3.1%), but shorter mean length of hospital stay (11.2 vs 13.7 days), higher rates of discharge to home (66% vs 51%), lower 30-day mortality rates (3.1% vs 6.1%), lower rates of acute respiratory failure (4.3% vs 8.2%), and decreased 30-day unplanned returns to the OR (3.3% vs 6.9%; all p < 0.05). Rates of severe sepsis, postoperative stroke, intraoperative aneurysm rupture, and postoperative aneurysm residual were equivalent between the concurrent and nonconcurrent groups (all p values nonsignificant). Mixed-effects models showed that after controlling for procedure type, patient demographics, and clinical indicators, there was no significant difference in acute respiratory failure, severe sepsis, 30-day readmission, postoperative stroke, EBL, length of stay, discharge status, or intraoperative aneurysm rupture between concurrent and nonconcurrent cases. Unplanned return to the OR and 30-day mortality were significantly lower in concurrent cases (odds ratio 0.55, 95% confidence interval 0.31-0.98, p = 0.0431, and odds ratio 0.81, p < 0.001, respectively), but concurrent cases had significantly longer procedure durations (odds ratio 21.73; p < 0.001). CONCLUSIONS Overall, there was a significant difference in the types of concurrent versus nonconcurrent cases, with more routine/elective cases for less sick patients scheduled in an overlapping fashion. After adjusting for patient demographics, procedure type, and clinical indicators, concurrent cases had longer procedure times, but equivalent patient outcomes, as compared with nonconcurrent vascular neurosurgical procedures.

Multiple-stent after coiling technique for the treatment of the dissecting aneurysm of the vertebral artery

Objective To investigate the clinical effect of multiple-stent after coiling technique for the treatment of the dissecting aneurysm of the vertebral artery. Methods From September 2011 to September 2015, the clinical data of 43 patients(43 aneurysms) with vertebral dissecting aneurysms admitted to the Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University were analyzed retrospectively. All patients were embolized with the multiple-stent after coiling technique. The follow-up time ranged from 3 to 18 months (mean, 11.6 months). Results The postoperative immediate angiography results showed that the aneurysms of 15 patients were completely embolized, those of 22 were mostly embolized, and those of 6 were loosely embolized. No intraoperative aneurysm rupture was observed. The symptoms of patients were improved or stable after procedure. The aneurysms of 12 patients had different degrees of recurrence, 6 of them were treated with endovascular treatment again. Conclusion The efficacy of using multiple-stent after coiling technique is good for the treatment of the dissecting aneurysm of the vertebral artery. This method is beneficial to the maximum extent of embolization of the bodies of aneurysms and reduces the reoccurrence of aneurysms. Key words: Intracranial aneurysm; Sents; Endovascular treatment; Dissecting aneurysms of the vertebral artery

Intraoperative rupture in the surgical treatment of patients with intracranial aneurysms

Intraoperative rerupture (IOR) during clipping of cerebral aneurysms is a difficult complication of microneurosurgery. The aim of this study was to evaluate the incidence of IOR and analyze the strategies for controlling profound hemorrhage. A total of 165 patients with unruptured intracranial aneurysms and 46 patients with subarachnoid hemorrhage (SAH) treated surgically between April 2010 and March 2011, were reviewed. The data were collected with regard to age, sex, presence of symptoms, confounding factors and strategy for controlling intraoperative hemorrhage was analyzed in terms of location of aneurysms, timing of rupture and severity of IOR. 211 patients with 228 aneurysms were treated in this series. There were a total of six IORs which represented an IOR rate of 2.84% per patient and 2.63% per aneurysm. The highest ruptures rates occurred in patients with internal carotid artery aneurysms (25%). Surgeries in the group with ruptured aneurysms had a much higher rate of IOR compared with surgeries in the group with unruptured aneurysms. Of the six IOR aneurysms, one occurred during predissection, four during microdissection and one during clipping. One was major IOR, three were moderate and two were minor. Intraoperative rupture of an intracranial aneurysm can be potentially devastating in vascular neurosurgery. Aneurysm location, presence of SAH and surgical experience of the operating surgeon seem to be important factors affecting the incidence of IOR.

Early experience with the new endovascular aneurysm sealing system Nellix: First clinical results after 50 implantations.

In the present study, 50 EVAS procedures were evaluated in regard to primary (survival and technical success) and secondary (device-related complications) events of interest. The single center study was conducted from July 2013 to August 2014 with prospective collection of the clinical data. The clinical results were controlled by CT angiography and contrast-enhanced ultrasound. The technical success was 98% and the 30-day mortality 4%. One (2%) patient died from multisystem organ failure and another patient from an intracranial bleeding, respectively. One patient (2%) suffered from a device-related aneurysm rupture. During early follow-up, one (2%) patient developed an endoleak type II, while three (6%) patients suffered from a partial endograft limb thrombosis. Overall, a secondary intervention was necessary in six (12%) patients. With the Nellix EVAS system, a high primary technical success of 98% was achieved; one (2%) patient developed an endoleak type II which did not require secondary intervention. Those promising results are contrasted by a substantial rate of endograft limb thromboses (8%) and one (2%) intraoperative aneurysm rupture. Further studies are needed to assess the durability of the Nellix stentgraft and the occurrence of device-related complications.

The causes and strategies for intraoperative rupture during clipping the anterior circulation aneurysms

To investigate the causes and strategies for intraoperative rupture during clipping the anterior circulation aneurysms. Nineteen patients with anterior circulation aneurysms ruptured during clipping, who admitted to the Department of Neurosurgery, Henan Provincial People's Hospital from November 2012 to February 2014, were enrolled. Their clinical data were analyzed retrospectively to summarize the causes and strategies for intraoperative rupture. The aneurysms ruptured during predissection in 2 cases (10.5%), during dissection in 11 cases (57.9%) and during clip application in 6 cases (31.6%). There was no residual aneurysm confirmed by postoperative CTA in 17 patients. One case with posterior communicating artery aneurysm cannot be clipped because of the serious avulsion of the aneurysm neck during clipping. The aneurysm was trapped and the patient paralysed on one side after operation. One case died postoperative 8 days because of severe cerebral edema, whose aneurysm ruptured during predissection. The Glasgow Outcome Scale (GOS) of three months after operation showed good recovery in 11, moderate recovery in 5, severe disability in 2, and death in 1 cases, respectively. Adequate preoperative evaluation for the risk factors of intraoperative rupture and excellent microsurgical techniques can prevent intraoperative rupture of intracranial aneurysms. Controlling the bleeding quickly and dissecting and clipping the aneurysm after definitely know the anatomy of the aneurysm and surrounding vasculature could be the keys to deal with intraoperative aneurysm rupture.

Treatment of ruptured middle cerebral artery aneurysms by endovascular approach: a single-center experience

Purpose: The optimal treatment modalities of ruptured middle cerebral artery aneurysm are still controversial. The objective of this study is to analyze the outcomes of patients with ruptured middle cerebral artery aneurysms treated by endovascular coiling. Materials and methods: From October 2011 to October 2015, 67 patients with 71 ruptured middle cerebral artery aneurysms received endovascular coiling in our hospital. We retrospectively reviewed the clinical, radiologic records and outcomes. Results: Of all the 71 aneurysms (67 patients), 42 were treated by coil embolization merely, 27 by stent-assisted coiling and 2 unruptured aneurysms in patients with bilateral middle cerebral artery aneurysms without receiving treatment. Complete occlusion was achieved in 82.6% (57/69) of all the procedures. Each of incomplete and partial occlusion rates was 8.7% (6/69). Intraoperative rupture of aneurysms occurred in two procedures (2.9%). Thrombogenesis occurred in eight procedures (11.6%). Brain infarction occurred in eight patients (11.9%). Post-operative rebleeding occurred in seven patients (10.4%). Sixty-three patients were followed at a mean follow-up of 8.24 ± 7.16 months. The mortality and good outcome rate were 3.2% and 90.5%, respectively. Aneurysm recurrence occurred in 6 (13.3%) of the 45 aneurysms at a mean follow-up of 8.44 ± 7.83 months. Conclusions: Endovascular coiling is effective for patients with ruptured middle cerebral artery aneurysms. Individualized treatment should be assessed by experienced specialist. It is essential to perform randomized large trials to confirm the efficiency of endovascular coiling.

The Impact of Surgical Experience on Major Intraoperative Aneurysm Rupture and Their Consequences on Outcome: A Multivariate Analysis of 538 Microsurgical Clipping Cases.

The incidence and associated mortality of major intraoperative rupture (MIOR) in intracranial aneurysm surgery is diverse. One possible reason is that many studies failed to consider and properly adjust the factor of surgical experience in the context. We conducted this study to clarify the role of surgical experience on MIOR and associated outcome. 538 consecutive intracranial aneurysm surgeries performed on 501 patients were enrolled in this study. Various potential predictors of MIOR were evaluated with stratified analysis and multivariate logistic regression. The impact of surgical experience and MIOR on outcome was further studied in a logistic regression model with adjustment of each other. The outcome was evaluated using the Glasgow Outcome Scale one year after the surgery. Surgical experience and preoperative Glasgow Coma Scale (GCS) were identified as independent predictors of MIOR. Experienced neurovascular surgeons encountered fewer cases of MIOR compared to novice neurosurgeons (MIOR, 18/225, 8.0% vs. 50/313, 16.0%, P = 0.009). Inexperience and MIOR were both associated with a worse outcome. Compared to experienced neurovascular surgeons, inexperienced neurosurgeons had a 1.90-fold risk of poor outcome. On the other hand, MIOR resulted in a 3.21-fold risk of unfavorable outcome compared to those without it. Those MIOR cases managed by experienced neurovascular surgeons had a better prognosis compared with those managed by inexperienced neurosurgeons (poor outcome, 4/18, 22% vs. 30/50, 60%, P = 0.013).

Solitaire AB stent-assisted coil for embolization of wide-necked cerebral aneurysms: an analysis of complications

Objective To investigate the perioperative complications and treatment measures of Solitaire AB stent for embolization of wide-necked cerebral aneurysms. Methods The clinical and imaging data of 116 patients with wide-necked cerebral aneurysms treated by using Solitaire AB stent-assisted embolization at the Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University from February 2010 to February 2014 were analyzed retrospectively. The perioperative complications were observed. Its causes of occurrence were analyzed and the corresponding treatment measures were investigated. Results All stents were successfully implanted in place. The results of immediate DSA examination revealed that 55 of 120 aneurysms were embolized completely. There were 59 residual aneurysm necks, 6 aneurysms were embolized partially. Ten patients had perioperative complications, 3 were intraoperative aneurysm rupture, the bleeding of 2 patients was stopped after emergency packing, and 1 patient died; after having intraparenchymal hemorrhage, 1 patient died of herniation at 5 h after stenting; 4 had thrombotic complications, 3 of them had blood flow recanalization after in-stent thrombolysis, and the efficacy of 1 case was poor and his blood flow was patent after a new Solitaire stent implantation; 2 had stent migration when the stent was not detached during procedure, fortunately, it did not cause significant neurological damage. After procedure, 114 patients were followed up for 3 to 37 months. Twelve patients had aneurysm recurrence and 5 were treated with intervention therapy again. Conclusions Solitaire AB stent-assisted coil embolization for the treatment of wide-necked aneurysms is a mature technique, but there are some complications. Therefore, the surgeons need to have good operative skills and rich experience. At the same time, the perioperative management should be strengthened in order to reduce the occurrence of complications and improve the prognosis of patients. Key words: Intracranial aneurysm; Intraoperative complications; Wide-necked; Stent