Microsurgical Clipping Research Articles

Microsurgical Clipping of a Ruptured Basilar Apex Aneurysm: 3-Dimensional Operative Video.

A 59-yr-old woman presented with a sudden onset of headache with neck pain and stiffness, Hunt and Hess grade 2. Brain computed tomography (CT) showed subarachnoid hemorrhage, Fisher Grade 2. Intra-arterial digital subtraction angiography (IADSA) showed a basilar artery apex aneurysm, dome size 9 mm and neck 3 mm, leaning towards the right, and a dominant right artery of Percheron. Endovascular treatment and microsurgical clipping were both explained to the patient, but she decided to undergo microsurgery due to the durability of treatment. She underwent a right frontotemporal craniotomy and orbital osteotomy. We performed optic nerve decompression and intradural anterior clinoidectomy to enhance the exposure. Working through the carotid-oculomotor space, the posterior communicating artery was traced back to the posterior cerebral artery. The basilar artery was temporarily occluded for aneurysm dissection after burst suppression to protect the brain. The aneurysm was irregular, multilobulated, and projecting upward. The dominant thalamoperforate artery (artery of Percheron) was arising from the right P1, and densely adherent to the sac of the aneurysm. After dissection of the artery of Percheron away from the aneurysm, it was completely occluded by a side-curved titanium clip. The patient had right oculomotor nerve paresis and headache postoperatively, but at discharge 2 wk later the headache and paresis had completely resolved. The postoperative IADSA showed total occlusion of the aneurysm with patency of the artery of Percheron. This 3-dimensional video shows the technical nuances of microsurgical clipping of a ruptured basilar apex aneurysm and intraoperative dissection of the artery of Percheron. Informed consent was obtained from the patient prior to the surgery that included videotaping of the procedure and its distribution for educational purposes. All relevant patient identifiers have also been removed from the video and accompanying radiology slides.

Hippocampus subfield volumetry after microsurgical or endovascular treatment of intracranial aneurysms\u2014an explorative study

BackgroundTo study hippocampus subfield volumes in patients after microsurgical clipping (MC) and/or endovascular coiling (EC) of intracranial aneurysms.MethodsHippocampus subfield volumetry was performed using FreeSurfer v6.0 in 51 patients (35 females, mean age 54.9 ± 11.9 years, range 24–78 years). Visual inspection of image and segmentation quality was performed prior to statistical analyses. Multiple regression analysis, controlled for age, sex, and side of treatment, was used to assess the impact of prior MC and history of subarachnoid haemorrhage (SAH) on hippocampus subfield volumes (cornu ammonis (CA)-2/3, CA-4, subiculum). Partial correlation analyses were used to assess effect of multiple treatments on hippocampus subfield volumes.ResultsPrior MC was significantly associated with lower hippocampal subfield volumes in MC patients for right and left CA-2/3 (β = -22.32 [-40.18, -4.45]; p = 0.016 and β = -20.03 [-39.38, -0.68]; p = 0.043) and right CA-4 (β = -17.00 [-33.86, 0.12]; p = 0.048). History of SAH was not significantly associated with hippocampal subfield volumes. We observed a higher disease burden in the MC cohort. The number of aneurysms correlated with right-sided hippocampal subfield volumes while the number of treatment interventions did not.ConclusionIn this explorative study, we found that history of MC was significantly associated with lower volumes in distinct hippocampal subfields, which may be a consequence of a more extensive treatment. This could indicate specific atrophy of CA-2/3 after MC and should motivate hippocampal subfield assessment in larger cohorts.

Clinical Efficacy Between Microsurgical Clipping and Endovascular Coiling in the Treatment of Ruptured Poor-Grade Anterior Circulation Aneurysms

The treatment for patients with poor-grade aneurysms defined as World Federation of Neurosurgical Societies (WFNS) grade IV-V is still unclear and controversial. In this research, we compared the clinical efficacy and safety between clipping and coiling in the treatment of ruptured poor-grade anterior circulation aneurysms. We conducted a retrospective analysis of a hospital database. From January 2013 to May 2018, 94 patients who presented with poor-grade anterior circulation aneurysms were included. Preoperative baseline, postprocedure complications, and outcome (3-month and 6-month modified Rankin Scale scores) were analyzed. Multivariate logistic regression analysis was conducted to identify risk factors of short-term (in-hospital, 30-day) mortality. A total of 21 (22%) patients died during short-term follow-up; there was a greater short-term mortality in coiling group (38% vs. 15%, P= 0.015). The incidence of delayed cerebral ischemia and intracranial infection in the clipping group was significantly greater than the coiling group: (33% vs. 14%, P= 0.045) and (68% vs. 41%, P= 0.016). However, coiling group had a greater rate of shunt-dependent hydrocephalus (21% vs. 6%, P= 0.035). Multivariate logistic regression analysis revealed cerebral vasospasm (odds ratio [OR], 9.22; P < 0.01), admission WFNS grade V (OR, 15.43; P < 0.01), coiling (OR, 5.92; P= 0.013), and postoperative aneurysm rebleeding (OR, 40.04; P= 0.01) would influence the mortality. Patients with ruptured poor-grade anterior circulation aneurysms who undergo microsurgical clipping seem to have a lower short-term mortality. Cerebral vasospasm, WFNS grade V, and postoperative aneurysm rebleeding are associated with short-term mortality.

Prognostic Factors Influencing Outcome in Unruptured Anterior Communicating Artery Aneurysm after Microsurgical Clipping.

Anterior communicating artery (A.com. A) aneurysm projection is an important factor in determining the outcome of aneurysm clipping. The objective of this study was to analyze the outcome of A.com.A aneurysm projection and prognostic factors influencing it and comparing them with Glasgow outcome scale. A retrospective analysis of 47 patients from hospital records who have got admitted in the Banbuntanke Hotokokai Hospital, Nagoya, Japan, from 2014 to 2017, with unruptured A.com.A aneurysm and subsequently operated in the hospital. Demographic factors such as age, sex, and associated with other aneurysms and the morphological characteristics such as aneurysm size, projection, and height were analyzed with postoperative complications and Glasgow outcome scale. Totally 47 cases have been operated in which 26 (55.3%) are female and 21 (44.6%) are male, and the median age is 68 years, 7 (14.89%) patients had middle cerebral artery aneurysm along with A.com.A aneurysm and 1 had internal carotid artery-posterior communicating artery junction aneurysm. Four (8.5%) had chronic subdural hematoma and 1 (2.12%) had epilepsy, 1 (2.12%) case got reoperated, and 1 (2.12%) had hydrocephalus. Moreover, the overall complication rate is 14.89%. For six patients, motor-evoked potential monitoring was used. Forty-six patients had Glasgow outcome scale of 5 and 1 patient had Glasgow outcome scale of 4. There was no mortality in this study. Mean size of the aneurysm was 6.68 mm and the range was 2–25 mm. Mean height was 4.14 mm, 26 (56.52%) A.com.A aneurysm were anteriorly projecting, 9 (19.56%) were superiorly projecting, 8 (17.32%) were inferiorly projecting, and 3 (6.38%) were posteriorly projecting. Morphological parameters such as size, height, and projection were not only highly associated with A.com.A aneurysm rupture and also complications due to clipping of aneurysm.

Microsurgical Clip Placement for a Giant Anterior Communicating Artery Aneurysm With Intraluminal Thrombus: 2-Dimensional Operative Video

Giant brain aneurysms account for approximately 5% of all intracranial aneurysms. Although treatment modalities can vary widely, none is ideal for every patient. Endovascular treatment is usually preferred, especially when the large size of the aneurysm limits visualization of the brain parenchyma and parent vessels that arise from the aneurysm, making surgical clip placement across the neck a difficult task. However, despite the higher chances of morbidity, microsurgery is an effective treatment modality due to lower recurrence rates. Surgically, a wide neck, calcifications, or atheroma are complicating factors to be considered while planning the best treatment. Thus, with an appropriate case selection, a favorable outcome is feasible in most cases. Here, we present the case of a 27-yr-old female who presented with a severe headache for 7 mo and 3 mo of progressive left temporal vision loss, which was confirmed by visual field perimetry using the Humphrey visual field analyzer. Magnetic resonance angiography and digital subtraction cerebral angiography showed an anterior communicating artery complex inferiorly and medially oriented aneurysm measuring 25.4×16.5 mm, with a 3 mm neck. It was fed by the right A1, associated with a hypoplastic left A1, incorporating the proximal right and left A2 segments, with an intraluminal thrombus and causing mass effect on the optic chiasm and hypothalamus. This video demonstrates the microsurgical steps required to perform this operation, through a right orbitozygomatic craniotomy. At a 3-mo follow-up, the patient was neurological intact without complaints. The patient signed the Institutional Consent Form, which allows the use of his/her images and videos for any type of medical publications in conferences and/or scientific articles.

Effect Analysis of Microsurgical Clipping and Endovascular Embolization for the Treatment of Middle Cerebral Artery Aneurysms

To evaluate the safety and effectiveness of microsurgical clipping and endovascular embolization for the treatment of middle cerebral artery aneurysm (MCAA). The clinical data of 482 patients with MCAA treated with microsurgical clipping or endovascular embolization were analyzed retrospectively. According to whether the aneurysms were ruptured, patients were divided into a ruptured group and an unruptured group. Demographics, clinical manifestation, and postoperative complications were recorded. In the microsurgical clipping group (257 patients), there were 114 male and 143 female patients. The mean age was (55 ± 10) years and the mean course of disease was 3 (1, 36) days. The total numbers of MCAA were 274, including 179 ruptured aneurysms and 95 unruptured aneurysms. In the endovascular embolization group (225 patients), there were 98 male and 127 female patients. The mean age was (54 ± 11) years and the mean course of disease was 10 (1, 55) days. The total numbers of MCAA were 234, including 126 ruptured aneurysms and 108 unruptured aneurysms. There was no difference between the incidence of complications in the ruptured and unruptured groups. The outcome of the endovascular embolization group was better than the microsurgical clipping group in ruptured aneurysms (P= 0.000). The recurrence rate of the endovascular embolization group was greater than the microsurgical clipping group in ruptured aneurysms (P= 0.023). Both microsurgical clipping and endovascular embolization were safe and effective methods for the treatment of MCAA, but patients with ruptured MCAAs treated with endovascular embolization were more likely to experience recurrence.

Preoperative Predictors and Prognosticators After Microsurgical Clipping of Poor-Grade Subarachnoid Hemorrhage: A Retrospective Study

Contrary to expectations, some patients with poor-grade subarachnoid hemorrhage (SAH) show favorable outcomes. However, the factors predictive of good prognosis are unclear. The purposes of this study were to identify factors related to poor-grade SAH and to analyze preoperative prognostic factors. We included 186 patients with SAH who underwent surgical clipping or conservative treatment immediately after SAH diagnosis. Physiologic, radiographic, and blood examination data were collected retrospectively. Factors related to poor World Federation of Neurological Societies (WFNS) grade (WFNS IV and V) and poor outcome (modified Rankin Scale scores 3-6) were analyzed. The patients (mean age, 61.6 years) included 134 women (72%). Seventy patients (38.2%) had poor WFNS scores. On multivariate analysis, age ≥70 years (adjusted odds ratio [OR], 3.73), midline shift (OR, 4.89), and the absence of cerebrospinal fluid in the high-convexity cortical sulci (OR, 5.47) and ambient cistern (OR, 4.83) were predictive of poor WFNS scores. Age ≥70 years (OR, 8.36), WFNS grade 5 (OR, 15.35), intracerebral hematoma (OR, 3.32), and Evans index (EI) ≥0.3 (OR, 4.40) were predictive of poor outcome. Body mass index (OR, 0.87), intraventricular hemorrhage (OR, 3.86), glycated hemoglobin level (OR, 2.78), and age ≥70 years (OR, 4.12) were predictive of EI ≥0.3. Poor outcomes correlated with older age, brain-destructive hemorrhage, and EI ≥0.3. The EI reflects both hydrocephalus and the patient's frailty. Radiographic signs of poor-grade SAH were not correlated with poor outcome, suggesting that early decompressive surgery may improve outcome.

Abstract WP128: Preoperative Prediction of the Necessity for Anterior Clinoidectomy during Microsurgical Clipping of Posterior Communicating Artery Aneurysms

Background: Although most posterior communicating artery (PCoA) aneurysms can be clipped easily with excellent results, some require anterior clinoidectomy for safe and complete clipping. Objectives: To review our microsurgical series of ruptured PCoA aneurysms and identify the preoperative predictors for anterior clinoidectomy during microsurgical clipping for PCoA aneurysms Methods: Results from microsurgical clipping of 104 patients with ruptured PCoA aneurysms were retrospectively reviewed. Distances and angles were obtained from computed tomographic angiography and compared between the anterior and non-anterior clinoidectomy groups. Result: Anterior clinoidectomy was required in 19 of the 104 cases (18%). None developed surgical complications due to anterior clinoid process (ACP) resection, including postoperative visual deficit. Univariate and multivariate analyses revealed that the distances from the ACP tip to the aneurysmal proximal neck and from the ACP line to the aneurysmal proximal neck were statistically significant predictive factors for the need of anterior clinoidectomy. Based on a receiver operating characteristic (ROC) analysis, the distances from the ACP tip to the aneurysmal proximal neck &lt; 4.0 mm and from the ACP line to the aneurysmal proximal neck &lt; 2.0 mm were selected as optimal cut-off values for predicting the necessity of anterior clinoidectomy, and the area under the ROC curve values were 0.991 and 0.955, respectively. Conclusion: In case of ruptured PCoA aneurysm surgery, the distances from the ACP tip to the aneurysmal proximal neck and from the ACP line to the aneurysmal proximal neck were both found to be useful predictors of whether anterior clinoidectomy was required.

Microsurgical Clipping of Ruptured Distal Posterior Inferior Cerebellar Artery Aneurysm: 3-Dimensional Operative Video.

The distal posterior inferior cerebellar artery (PICA) is a rare site of aneurysm formation. Only small case series and case reports regarding surgical treatment are found in the literature.The PICA is divided into 5 segments (anterior medullary, lateral medullary, tonsilomedullary, telovelotonsillary, and cortical), and the distal ones represent the most complex, due to anatomic variations. We present a case of a 69-yr-old female patient who has suffered from a sudden and intense occipital headache, associated with nausea and vomiting. CT scan showed intraventricular hemorrhage, and further investigation with MRI and MR Angiography revealed a small distal PICA aneurysm, at the superior part of the medial aspect of the left cerebellar tonsil. Digital angiography has demonstrated the aneurysm at the tonsilomedullary segment of the PICA. In this 3-dimensional video, the authors show the microsurgical clipping of a saccular distal PICA aneurysm in the close relation to a choroidal branch, performed by median suboccipital craniotomy. Step-by-step of the dissection, relevant surrounding anatomy and aneurysm clipping is demonstrated. The patient signed the Institutional Consent Form, which allows the use of his/her images and videos for any type of medical publications in conferences and/or scientific articles.

Surgical Treatment of Recurrent Previously Coiled and/or Stent-Coiled Intracerebral Aneurysms: A Single-Center Experience in a Series of 75 Patients

Endovascular treated cerebral aneurysms have a greater recurrence rate compared with microsurgical clip ligation. Despite recent endovascular advances, microsurgical clip ligation might be the treatment of choice for certain previously endovascular treated recurrent aneurysms. We report on our single-center experience with 76 previously coiled and/or stent-coiled aneurysms. To analyze the surgical and radiologic outcome after clipping of previous endovascular treated recurrent cerebral aneurysms. Patients were retrospectively identified. Demographic data, aneurysm size, location, perioperative coil extraction, occlusion rate, and complication rate were recorded. Patients were divided into a previously coiled-only group (COG) and a previously stent-assisted coiled group (SAC). Seventy-five patients with 76 aneurysms were included. Sixty-nine patients were included in the COG, 7patients in the SAC group. Complete or acceptable near-complete occlusion was obtained in 95% of patients in the COG and 57% in the SAC group. Two patients in the COG (2.9%) died postoperatively of a major stroke. One patient died of rehemorrhage after wrapping of an aneurysm. Minor complications occurred in 8.7%. In the SAC group, the mortality was 0%, with 1 major stroke (14.2%), 1 minor stroke (14.2%), and 1 cranial nerve palsy (14.2%). Intraoperative coil extraction and previous stent-assisted coiling were significant predictors of complication rate (P= 0.025 and P= 0.0036 respectively). Previous stent-assisted coiling was a significant predictor of incomplete occlusion (P= 0.036). Microsurgical clipping of previously endovascular treated recurrent aneurysms is an effective treatment with high obliteration rates. Previously stent-assisted coiling and intraoperative coil extraction are predictors of worse outcome and incomplete occlusion.

Microsurgical Clipping for Previously Coiled Intracranial Aneurysms with Special Reference to Aneurysmal Collapsibility

Microsurgical Clipping for Previously Coiled Intracranial Aneurysms with Special Reference to Aneurysmal Collapsibility

Complications in Patients Undergoing Microsurgical Clipping of Intracranial Aneurysms with Pre-existing Ventriculoperitoneal Shunts Following a Cranial Procedure

Introduction: Patients with ventriculoperitoneal/pleural (VP) shunts occasionally must undergo subsequent craniotomy, craniectomy, or cranioplasty. Due to changes in pressure dynamics following shunt placement, we hypothesized that such patients may have an increased risk of developing symptomatic collections of extra-axial blood, fluid, and/or air postoperatively, leading to longer stays and worse outcomes compared to those undergoing cranial operations without a VP shunt.Methods: From a retrospective cohort of patients who underwent cranial operations for management of cerebral aneurysms in 2005-2014, we identified patients who previously had a VP shunt placed, determined the temporal relationship between shunt placement and cranial operation, and investigated outcomes in those with and without a shunt.Results: Of 818 patients who underwent cranial operations, 28 (3.4%) had a VP shunt. Four of these 28 (14.3%, 95% confidence interval [CI] 4.0%-32.7%) developed postoperative complications, compared to 42 of 790 (5.3%, 95% CI 4.0%-7.1%) without a history of VP shunt (P = .07). In addition, patients with a shunt were more likely to have longer cranial procedures (P = .04), longer hospital stays (P = .05), and more computed tomography scans during their craniotomy-associated admission (P = .002). Multivariate analysis, though not significant, demonstrated that the presence of a shunt contributed to the development of complications (odds ratio [OR] 2.24, 95% CI .70-7.13, P = .17). Length of surgery (OR 1.17, 95% CI 1.04-1.31, P = .01) and length of stay (OR 1.04, 95% CI 1.01-1.07, P = .01) were significantly longer in those with a postoperative complication.Conclusion: We found a nonsignificant trend toward increased postoperative complications in patients with a VP shunt who underwent a subsequent cranial operation.

The classification of intracranial aneurysm neck: a single center research experience

BackgroundThere is associating with incidence of unfavorable outcomes compared to microsurgical clippings. We are in order to investigate the outcomes of microsurgical clipping for intracranial aneurysms and determine the ideal clipping methods for different aneurysm subtypes.MethodRetrospectively analyzed the clinical characteristics and follow-up data (completely recorded) of 123 patients with 128 aneurysms were treated. 20 cases were treated as control group from October 2013 to December 2013. Since January 2014, aneurysms were classified base on the 20 cases of aneurysm imaging data. 103 patients were treated as experimental group, the classification of aneurysms previously proposed was used to estimate the way of surgery, and the guiding value of the genotype was verified according to the intraoperative findings. The proposed aneurysm classification is based on the virtual surface of the aneurysm and the parent artery, the aneurysm neck was classified as follows: subtype I, the curved surface of the neck is a single curved surface; subtype II, the neck is hyperboloid; subtype III, neck is a three-curved surface. Aneurysms were divided into further subtypes according to the ratio of the width of the aneurysm neck surface and the length of the artery circumference: subtype A, the ratio of the aneurysm neck surface to the parent artery was not more than 0.5; subtype B, more than 0.5. There are some clamping methods include simple, sliding, interlocking and hybrid.ResultsIn the control group, patients did not undergo a suitable clipping scheme without classification of aneurysm neck (unclassed clipping). While causing the occurrence of occlusion adverse events, including neck residual, Tumor artery stenosis, electrophysiological changes, the lack of blood supply and so on. The experimental[page1image12073600]group was analyzed by using a predetermined clipping scheme (classed clipping), and the use of aneurysms clamps was approximately the same as expected. Compared the preoperative assessment with the actual situation, the consistency of the control group was 50% and the experimental group was 96%. Adverse events of classed clipping is 2%, another is 60%. There is a significant difference between the two groups (P < 0.05).Classed clipping of subject IA and IB are simple (mean 1.2 and 1.3 clips); classed clipping of subject IIA is simple and interlocking(mean 1.2 clips); classed clipping of subject IIB is sliding and hybrid(mean 2.05 clips); classed clipping of subject IIIA and IIIB are hybrid(mean 2.3 clips).ConclusionThere is a higher consistency in surgery through the above classification of preoperative assessment of clipping. There was no adverse event of intracranial aneurysm clipping in the clipping mode selected by the above classification, and satisfactory surgical clipping rate was achieved and no recurrence was found.

Anterior Communicating Artery Complex Aneurysms: Anatomic Characteristics as Predictors of Surgical Outcome in 300 Cases

Anterior communicating artery (ACoA) complex aneurysms are challenging to treat microsurgically. The authors report their experience with microsurgical treatment of ACoA aneurysms and examine the anatomic characteristics of these aneurysms as predictors of outcome. The authors queried their institution's aneurysm database for records of consecutive patients treated for ACoA aneurysms via microsurgical clip ligation. Data included patient demographics and clinical/radiographic presentation characteristics as well as operative techniques. Glasgow Outcome Scale (GOS) scores at hospital discharge and 6-month as well as 1-year follow-up were analyzed. Of 319 ACoA aneurysms that underwent treatment, 259 were ruptured and 60 were unruptured. Average GOS at 1-year follow-up for all patients was 4.6. Average GOS for patients with ruptured aneurysms correlated with Hunt and Hess grade at presentation, presence of frontal hemorrhages, and need for multiple clips during surgery. Notably, 142 (44.5%) of aneurysms originated mainly from the ACoA artery; 12 (3.8%) primarily from the A1 branch; 3 (0.9%) from the A2 branch; and 162 (50.8%) from the A1/A2 junction. Aneurysm projection was superior in 118 (37%), inferior in 106 (33.2%), anterior in 88 (27.6%), and posterior in 7 (2.2%). Patients with aneurysms originating from the A1 segment had worse outcomes. Posteriorly projecting aneurysms were more likely to be unruptured and larger than other aneurysm configurations. The aneurysm's exact location in relation to the adjacent neurovascular structures is potentially predictive of outcomes in the microsurgical treatment of ACoA aneurysms.

Coiling Versus Microsurgical Clipping in the Treatment of Unruptured Middle Cerebral Artery Aneurysms: A Meta-Analysis.

Open microsurgical clipping of unruptured intracranial aneurysms has long been the gold standard, yet advancements in endovascular coiling techniques have begun to challenge the status quo. To compare endovascular coiling with microsurgical clipping among adults with unruptured middle cerebral artery aneurysms (MCAA) by conducting a meta-analysis. A systematic search was conducted from January 2011 to October 2015 to update a previous meta-analysis. All studies that reported unruptured MCAA in adults treated by microsurgical clipping or endovascular coiling were included and cumulatively analyzed. Thirty-seven studies including 3352 patients were included. Using the random-effects model, pooled analysis of 11 studies of microsurgical clipping (626 aneurysms) revealed complete aneurysmal obliteration in 94.2% of cases (95% confidence interval [CI] 87.6%-97.4%). The analysis of 18 studies of endovascular coiling (759 aneurysms) revealed complete obliteration in 53.2% of cases (95% CI: 45.0%-61.1%). Among clipping studies, 22 assessed neurological outcomes (2404 aneurysms), with favorable outcomes in 97.9% (95% CI: 96.8%-98.6%). Among coiling studies, 22 examined neurological outcomes (826 aneurysms), with favorable outcomes in 95.1% (95% CI: 93.1%-96.5%). Results using the fixed-effect models were not materially different. This updated meta-analysis demonstrates that surgical clipping for unruptured MCAA remains highly safe and efficacious. Endovascular treatment for unruptured MCAAs continues to improve in efficacy and safety; yet, it results in lower rates of occlusion.

Anterior Clinoidectomy and Microsurgical Clipping of a Giant Thrombotic Recurrent Ophthalmic Artery Aneurysm Previously Wrapped and Stent Coiled: 2-Dimensional Operative Video.

Anterior Clinoidectomy and Microsurgical Clipping of a Giant Thrombotic Recurrent Ophthalmic Artery Aneurysm Previously Wrapped and Stent Coiled: 2-Dimensional Operative Video.

Nationwide analysis of hospital-to-hospital transfer in patients with aneurysmal subarachnoid hemorrhage requiring aneurysm repair.

Aneurysmal subarachnoid hemorrhage (aSAH) has devastating consequences. The association between higher institutional volumes and improved outcomes for aSAH patients has been studied extensively. However, the literature exploring patterns of transfer in this context is sparse. Expansion of the endovascular workforce has raised concerns about the decentralization of care, reduced institutional volumes, and worsened patient outcomes. In this paper, the authors explored various patient and hospital factors associated with the transfer of aSAH patients by using a nationally representative database. The 2013 and 2014 years of the National Inpatient Sample (NIS) were used to define an observational cohort of patients with ruptured brain aneurysms. The initial search identified patients with SAH (ICD-9-CM 430). Those with concomitant codes suggesting trauma or other intracranial vascular abnormalities were excluded. Finally, the patients who had not undergone a subsequent procedure to repair an intracranial aneurysm were excluded. These criteria yielded a cohort of 4373 patients, 1379 of whom had undergone microsurgical clip ligation and 2994 of whom had undergone endovascular repair. The outcome of interest was transfer status, and the NIS data element TRAN_IN was used to define this state. Multiple explanatory variables were identified, including age, sex, primary payer, median household income by zip code, race, hospital size, hospital control, hospital teaching status, and hospital location. These variables were evaluated using descriptive statistics, bivariate correlation analysis, and multivariable logistic regression modeling to determine their relationship with transfer status. Patients with aSAH who were treated in an urban teaching hospital had higher odds of being a transfer (OR 2.15, 95% CI 1.71-2.72) than the patients in urban nonteaching hospitals. White patients were more likely to be transfer patients than were any of the other racial groups (p < 0.0001). Moreover, patients who lived in the highest-income zip codes were less likely to be transferred than the patients in the lowest income quartile (OR 0.78, 95% CI 0.64-0.95). Repair type (clip vs coil) and primary payer were not associated with transfer status. A relatively high percentage of patients with aSAH are transferred between acute care hospitals. Race and income were associated with transfer status. White patients are more likely to be transferred than other races. Patients from zip codes with the highest income transferred at lower rates than those from the lowest income quartile. Transfer patients were preferentially sent to urban teaching hospitals. The modality of aneurysm treatment was not associated with transfer status.

Microsurgical Clipping of Partially Thrombosed Wide-Necked Saccular Aneurysm From a Dysplastic M1 Segment in a Pediatric Patient: 3-Dimensional Operative Video.

Microsurgical Clipping of Partially Thrombosed Wide-Necked Saccular Aneurysm From a Dysplastic M1 Segment in a Pediatric Patient: 3-Dimensional Operative Video.

Residual Cerebral Aneurysms After Microsurgical Clipping: A New Scale, an Agreement Study, and a Systematic Review of the Literature

The surgical repair of a cerebral aneurysm does not always lead to complete occlusion. A standardized repeatable method of reporting results of surgical clipping is desirable. Our purpose was to systematically review methods of classifying aneurysm remnants, provide a new scale with precise definitions of categories, and perform an agreement study to assess the variability in adjudicating remnants after aneurysm clipping. A systematic review was performed to identify ways to report angiographic results of surgical clipping between 1963 and 2017. Postclipping angiographic results of 43 patients were also independently evaluated by 10 raters of various experience and backgrounds using a new 4-category scale. Agreement between responses were analyzed using κ statistics. The systematic review yielded 63 articles with 37 different nomenclatures using 2-6 categories. The reliability of judging the presence of an aneurysm remnant on catheter angiography was studied only twice, with only 2 raters each time, with contradictory results. Interobserver agreement using the new 4-category scale was moderate (κ= 0.52; 95% confidence interval, 0.43-0.62) for all observers, but improved to substantial (κ= 0.62; 95% confidence interval, 0.47-0.76) when results were dichotomized (grade 0/1 vs. 2/3). Various classification schemes to evaluate angiographic results after surgical clipping exist in the literature, but they lack standardization. Adjudication using fewer, better defined categories may yield more reliable agreement.

Patient Selection and Technical Nuances for Microsurgical Clipping of Carotid-Ophthalmic Aneurysms: 2-Dimensional Operative Video.

Patient Selection and Technical Nuances for Microsurgical Clipping of Carotid-Ophthalmic Aneurysms: 2-Dimensional Operative Video.