Surgery For Unruptured Aneurysms Research Articles

Preservation of the middle meningeal artery during unruptured aneurysm surgery: an independent risk factor for postoperative chronic subdural hematoma.

Although microsurgical clipping for unruptured aneurysms has become safer and more efficient with modern neurosurgical advances, postoperative chronic subdural hematoma (CSDH) persists as an underrecognized complication. This study investigated the association between preservation of the anterior branch of the middle meningeal artery (MMA) during surgery and CSDH development. We retrospectively reviewed 120 patients who underwent clipping for unruptured aneurysms at Kyungpook National University Chilgok Hospital between May 2020 and July 2023. We evaluated the patients on the basis of surgical approach-lateral supraorbital (LSO) or standard pterional craniotomy-and the status of the MMA postoperatively. We employed pre-and post-operative MR angiography to assess MMA preservation and used follow-up computed tomography scans to monitor CSDH development. Of the 120 patients, 22 (18.3%) developed CSDH. Univariate analysis revealed that male sex, advanced age, and MMA preservation are risk factors for postoperative CSDH. Multivariate analysis supported these findings, indicating a significant association with the development of CSDH. MMA preservation was reported in 65 patients, of whom 60 and 5 underwent LSO and pterional craniotomy, respectively. Preservation of the anterior branch of the MMA during unruptured aneurysm surgery is a risk factor for postoperative CSDH development. Advanced age and male sex also contribute to the increased risk. These findings highlight the need for further investigation into surgical techniques that could mitigate postoperative CSDH development.

Applications of enhanced recovery after surgery protocols for unruptured anterior circulation aneurysms in tertiary-level healthcare institutions: a national study.

Enhanced recovery after surgery (ERAS) protocols are standardized perioperative care that reduce patients' stress response during hospitalization and improve hospitalization time, complication rates, costs, and readmission rates. This study aimed to investigate the application rate of protocols for elective craniotomy in the surgery of unruptured anterior circulation aneurysms (AnCAs) at tertiary-level healthcare (TLH) institutions in Türkiye and its effect on the outcomes of the patients. An electronic survey was sent to all Turkish TLH institutions (n = 127) between May and June 2023. The number of institutions participating in the survey was 38 (30%). The institutions were subdivided according to three main factors: institution type (university hospital [UH] vs training and research hospital [TRH]), annual case volume (low [≤ 20 aneurysms] vs high [> 20 aneurysms]), and institution accreditation status (accredited vs nonaccredited). Overall, 55.3% (n = 21) of the institutions participating in the study were UHs. The rates of those that were accredited and had a high case volume were 55.3% (n = 21) and 31.6% (n = 12), respectively. It was determined that the accredited clinics applied preoperative protocols at a higher rate (p = 0.050), and the length of stay in the postoperative period was shorter in the clinics that used the intraoperative protocols (p = 0.014). The length of stay in the postoperative period is lower in TLH institutions in Türkiye that highly implement intraoperative protocols. Furthermore, this is the first study in the literature evaluating protocols for elective craniotomy in unruptured AnCAs.

Association between De Ritis ratio and intraoperative blood transfusion in patients undergoing surgical clipping of unruptured intracranial aneurysms: a single center, retrospective, propensity score-matched study.

Although elective surgery for unruptured intracranial aneurysms (UIA) has increased, few studies have evaluated the risk factors for transfusion during UIA surgery. We evaluated the association between the preoperative De Ritis ratio (aspartate transaminase/alanine transaminase) and the incidence of intraoperative transfusion in patients who had undergone surgical UIA clipping. Patients who underwent surgical clipping of UIA were stratified into two groups according to the preoperative De Ritis ratio cutoff levels (< 1.54 and ≥ 1.54), and the propensity score (PS)-matching analysis was performed to compare the incidence of intraoperative transfusion. Logistic regression analyses were performed to determine the risk factors for intraoperative transfusion. Net reclassification improvement (NRI) and integrated discrimination improvement (IDI) analyses were performed to verify the improvement in the intraoperative transfusion predictive model upon addition of the De Ritis ratio. Intraoperative transfusion incidence was 15.4% (77/502). We observed significant differences in the incidence of intraoperative transfusion (16.2% vs. 39.7%, P = 0.004) between the groups after matching. In the logistic regression analyses, the De Ritis ratio ≥ 1.54 was an independent risk factor for transfusion (odds ratio [OR]: 3.04, 95% CI [1.53, 6.03], P = 0.002). Preoperative hemoglobin (Hb) value was a risk factor for transfusion (OR: 0.33, 95% CI [0.24, 0.47], P < 0.001). NRI and IDI analyses showed that the De Ritis ratio improved the intraoperative blood transfusion predictive models (P = 0.031 and P = 0.049, respectively). De Ritis ratio maybe a significant risk factor for intraoperative transfusion in UIA surgery.

Hyaluronidase Injection to Reduce Periorbital Edema after Surgery for Unruptured Intracranial Aneurysms

Background: In the era of endovascular treatment for intracranial aneurysms, microsurgical treatment might necessitate the minimization of postoperative discomforts such as headache, nausea, vomiting, and edema. The current study aimed to evaluate the effectiveness of hyaluronidase on the reduction of periorbital edema after clipping surgery for unruptured intracranial aneurysms. Methods: From July 2016 to March 2018, the patients who underwent elective surgery for unruptured intracranial aneurysms were included. A mixture of 4500 IU hyaluronidase was injected subcutaneously on the sectional plane of the scalp incision. The photographs of patients’ faces were obtained on postoperative day 1, 3, and 7. The degree of periorbital edema was judged on the grading system based on the vertical palpebral aperture. The thickness of the scalp, temporalis muscle, and soft tissue was measured on a preoperative computed tomography (CT) scan, and other variables (e.g., intraoperative input and output, serum albumin level) were Results: A total of 60 patients were included in this study, and a hyaluronidase mixture was injected in 30 patients. The periorbital edema tended to resolve in 7 days after surgery, but notable differences between the two groups was observed at day three after surgery in this study. On the ordinal logistic regression analysis on the grade of periorbital edema, hyaluronidase injection is significantly associated with the reduction of periorbital edema throughout the postoperative period. (p value &lt; 0.05)Conclusion: Hyaluronidase injection might be helpful in reducing periorbital edema after surgery for unruptured intracranial aneurysms.

Effects of superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis on the cerebrospinal fluid gas tensions and pH in hemodynamically compromised patients.

This study was aimed to directly measure cerebrospinal fluid (CSF) gas tensions and pH before and after STA-MCA anastomosis for occlusive carotid artery diseases to investigate its direct effects on the ischemic brain. This study included 9 patients who underwent STA-MCA anastomosis on the basis of CBF studies. About 1mL of CSF was collected before and after bypass procedures, and CSF pH, CSF PO2, and CSF PCO2 were measured with a blood gas analyzer. As the controls, the CSF was collected from 6 patients during surgery for unruptured cerebral aneurysm. CSF PO2 and CSF PCO2 were expressed as the ratio to PaO2 and PaCO2, respectively. Before bypass procedure, CSF PO2/PaO2 was 0.88 ± 0.16, being lower than the controls (1.10 ± 0.09; P = 0.005). CSF PCO2/PaCO2 was 0.93 ± 0.13, being higher than the controls (0.84 ± 0.06; P = 0.039). Ipsilateral-to-contralateral CBF ratio had a positive correlation with CSF PO2/PaO2 (P = 0.0028) but a negative correlation with the CSF PCO2/PaCO2 (P = 0.0045). STA-MCA anastomosis increased CSF pH from 7.402 ± 0.133 to 7.504 ± 0.126 (P = 0.0011) and CSF PO2/PaO2 from 0.88 ± 0.16 to 1.05 ± 0.26 (P = 0.018) but decreased CSF PCO2/PaCO2 from 0.93 ± 0.13 to 0.70 ± 0.17 (P = 0.0006). The severity of cerebral ischemia before surgery is intensely reflected in the gas tensions and pH of the CSF. STA-MCA anastomosis carries dramatic effects on CSF gas tensions and pH in hemodynamically compromised patients. CSF would be a valuable surrogate biomarker to monitor the severity of cerebral ischemia.

Possible Delayed Foreign Body Reactions against Titanium Clips and Coating Materials after Unruptured Cerebral Aneurysm Surgery.

Delayed foreign body reactions to either or both clipping and coating materials have been reported in several small series; however, studies in the titanium clip era are scarce. This study aims to survey the contemporary status of such reactions to titanium clips and coating materials. Among patients who received a total of 2327 unruptured cerebral aneurysmal surgeries, 12 developed delayed intraparenchymal reactions during outpatient magnetic resonance imaging (MRI) follow-up. A retrospective investigation was conducted. The patients' average age was 58.6 (45-73) years, and 11 were women. The aneurysms were located in the middle cerebral artery (n = 7), internal carotid artery (n = 4), or anterior communicating artery (AComA, n = 1). In 10 patients, additional coating with tiny cotton fragments was applied to the residual neck after clipping with titanium clips; however, only the clipping with titanium clips was performed in the remaining two. The median time from surgery to diagnosis was 4.5 (0.3-60) months. Seven (58.3%) patients were asymptomatic, and three developed neurological deficits. MRI findings were characterized by a solid- or rim-enhancing lobulated mass adjacent to the clip with surrounding parenchymal edema. In 11 patients, the lesions reduced in size or disappeared; however, in one patient, an AComA aneurysm was exacerbated, necessitating its removal along with optic nerve decompression. In conclusion, cotton material is a strongly suspected cause of delayed foreign body reactions, and although extremely rare, titanium clips alone may also induce such a reaction. The prognosis is relatively good with steroid therapy; however, caution is required when the aneurysm is close to the optic nerve, as in AComA aneurysms.

Has intraoperative neuromonitoring changed the surgery for unruptured middle cerebral artery aneurysms? A retrospective comparative study

Intraoperative neurophysiological monitoring (IONM) represents one of the available technologies able to assess ischemia and aimed to improve surgical outcome reducing the treatment related morbidity in surgery for intracranial aneurysms. Many studies analyzing the impact of IONM are poised by the heterogeneity bias affecting the cohorts. We report our experience with IONM for surgery of unruptured middle cerebral artery (MCA) aneurysm in order to highlight its influence on functional and radiological outcome and surgical strategy. We retrospectively reviewed all MCA unruptured aneurysms treated between January 2013 and June 2021 by our institutional neurovascular team. Patients were divided into 2 groups according to the use of IONM. A total of 153 patients were included in the study, 52 operated on without IONM and 101 with IONM. The groups did not differ preoperatively regarding clinical status and aneurysm characteristics. Patients operated with IONM had better functional outcomes at discharge as well as at follow-up (p= 0.048, p=0.041) due to lower symptomatic ischemia and better radiological outcome due to lower rate of unexpected aneurysmal remnants (p= 0.0173). The introduction of IONM changed the use of temporary clipping (TeC), increasing its average duration (p= 0.01) improving the safety of dissecting and clipping the aneurysm. IONM in surgery for unruptured MCA aneurysm could improve the efficacy and safety of clipping strategy in the way it showed a role in changing the use of TeC and was associated to the reduction of unexpected aneurysmal remnants’ rate and improvement in both short- and long-term patient’s outcome.

567 Drivers of 30-day Readmission, Drivers of 30-day Readmission, Reoperation, and Length of Stay Following Clipping Surgery of Unruptured Aneurysms in Elderly: A National Surgical Quality Improvement Program (NSQIP) Study

INTRODUCTION: Elderly population is increasing worldwide with a consistent increase in the incidence of aneurysms. There are limited data evaluating the rate and predictors of reoperation and readmission after microsurgical clipping of unruptured aneurysms in elderly. METHODS: Data on elderly patients (≥65 years) who underwent surgical clipping of an unruptured aneurysm between 2016 and 2020 were extracted from the prospective National Surgical Quality Improvement Program registry (NSQIP). Multivariable logistic regression evaluated the independent predictors of nonroutine hospital discharge, length of stay (LOS), 30-day reoperation, and readmission. Shapley additive explanations (SHAP) were calculated for feature importance using the best-performing model. RESULTS: A total of 367 elderly patients underwent surgical clipping for both ruptured (N = 142) and unruptured aneurysms (N = 225). Among the 225 unruptured cases, 11.6% (N=26) were readmitted and 6.2% (N = 14) were reoperated after 30 days. The mean LOS is 6.53 days (± 7.15). Most patients were discharged home (N = 160; 71.1%). Morbidity and morbidity probabilities were 2.15% and 3.8%, respectively. Male sex; preoperative BUN; preoperative creatinine and preoperative platelet count (p &lt; 0.05) are more likely to predict 30-day readmission. Male sex, history of cancer , and history of COPD (p &lt; 0.05) are more likely to predict reoperation. LOS was predicted with simple aneurysm , history of sepsis; history of COPD; elective surgery; operative time and days till the operation (p &lt; 0.05). Machine learning using SHAP showed that BUN, platelet count, and sex had the highest impact on readmission; WBC, hematocrit, and sodium levels had the highest impact on reoperation; while operative time and history of sepsis had the highest impact on LOS. CONCLUSIONS: Our predictive model validates risk stratification of outcomes of patients undergoing microsurgical clipping of unruptured cerebral aneurysms in the elderly.

Necessity of mandatory postoperative intensive care unit management after clipping surgery for unruptured intracranial aneurysms

ObjectiveMany neurosurgeons routinely perform postoperative intensive care unit (ICU) management after clipping of unruptured intracranial aneurysms (UIAs). However, whether routine postoperative ICU care is necessary remains a clinical question. Therefore, we investigated which factors acted as risk factors that actually required ICU care after microsurgical clipping of unruptured aneurysms. MethodsWe included a total of 532 patients who underwent clipping surgery for UIA between January 2020 and December 2020. The patients were divided into two groups: those who really required ICU care (41 patients, 7.7%) and those who did not (491 patients, 92.3%). A backward stepwise logistic regression model was used to identify factors that were independently associated with ICU care requirement. ResultsThe mean hospital stay duration and the operation time were significantly longer in the ICU requirement group than in the no ICU requirement group (9.9 ± 10.7 vs. 6.3 ± 3.7 days, p = 0.041), (259.9 ± 128.4 vs. 210.5 ± 46.1 min, p = 0.019). The transfusion rate was significantly higher (p = 0.024) in the ICU requirement group. Multivariable logistic regression analysis identified male sex (odds ratio [OR], 2.34; 95% confidence interval [CI], 1.15–4.76; p = 0.0195), operation time (OR, 1.01; 95% CI, 1.00–1.01; p = 0.0022), and transfusion (OR, 2.35; 95% CI, 1.00–5.51; p = 0.0500) as independent risk factors for requiring ICU care after clipping. ConclusionsPostoperative ICU management may not be mandatory after clipping surgery for UIAs. Our results suggest that postoperative ICU management may be more required in the male sex, patients with longer operation times, and those who received a transfusion.

Endovascular treatment of «mirror» aneurysms of the middle cerebral artery

Objective ‒ to analyze the results of endovascular treatment of the «mirror» MCA aneurysms.Materials and methods. A retrospective analysis of the 172 patients with multiple cerebral aneurysms, who were treated between the period from April 2016 to February 2022 at Scientific and Practical Center of Endovascular Neuroradiology of the National Academy of Medical Sciences of Ukraine was conducted. «Mirror» MCA aneurysms were found in 20 (11.6 %) patients. Twenty patients had 54 aneurysms (8 patients had 12 aneurysms except MCA and 2 patients had 2 MCA aneurysms at one side). In one patient, a combination of «mirror» aneurysms of MCA and internal carotid artery was found. The group included 8 (40 %) men and 12 (60 %) women. The average age of the patients was (47.11 ± 11.73) years; range 23‒64 years. 8 (40 %) patients had subarachnoid hemorrhage due to MCA aneurysm rupture, in another 3 (15 %) patients another aneurysm was the cause of rupture, and 9 (45 %) of patients underwent surgery for unruptured aneurysms. The choice of treatment strategy and its staging, peri-procedural (bleeding, migration of coils, thrombus formation) and postoperative complications and the result of the treatment at the time of discharge and 3–6 months after the final treatment were analyzed. Qualitative assessment of aneurysm occlusion was performed intraoperatively and during follow-up angiographic examinations according to the modified Raymond‒Roy scale.Results. Of all 54 aneurysms in 20 patients, 49 aneurysms (40 MCA aneurysms and 9 aneurysms in other localization) were excluded endovascularly, 1 MCA aneurysm was clipped, and 4 aneurysms due to their small size were left for observation with regular follow-up examinations due to the low risk of rupture. Bilateral one-session endovascular occlusion of the «mirror» MCA aneurysms was performed in 11 patients, and staged procedure was performed in 9. Among 40 surgically treated «mirror» MCA aneurysms, 24 (60 %) were excluded with only coiling, 7 (17.5 %) with stent assistance coiling, 7 (17.5 %) with balloon assistance coiling, 1 aneurysm (2.5 %) was treated with parent artery occlusion, and 1 aneurysm (2.5 %) was clipped. Intraoperative complications occurred in 2 patients. One patient had an intraoperative rupture of an ICA aneurysm combined with «mirror» MCA aneurysms, which could not be stopped and ICA sacrifice was performed. In another, the coils migrated into the artery. In the first patient, the course of the disease was complicated with brain infarction in the left ICA region. Another patient was prescribed antiplatelet therapy in postoperative period, which was uneventful. Follow-up angiography studies were available in 16 patients. At the follow-up examination, significant recanalization of one of the MCA aneurysm was detected in two patients, who were successfully occluded during the second procedure without negative clinical outcome. In 15 patients at the control examination, the evaluation of the result according to the mRS was 1 – 2 points, and in 1 patient ‒ 3 points.Conclusions. Our series demonstrates that the outcomes of endovascular treatment of the «mirror» MCA aneurysms have comparable risks of periprocedural and post-procedural complications, with the general population of patients with both ruptured and unruptured MCA aneurysms. Best treatment strategy must be individualized with careful planning, considering which aneurysm should be excluded first, the possible sequence of treatment, depending on the clinical presentation, type of intervention, age, patient preference and available options. It is also necessary to assess the traumatic nature of treatment methods. In our opinion, endovascular interventions have obvious advantages over bilateral craniotomies or extended combined unilateral approaches, which in turn has the potential to improve the results of treatment, both in the short and long term, and to reduce its duration and cost.

Race as a factor in adverse outcomes following unruptured aneurysm surgery

IntroductionStrong evidence demonstrates that race is associated with health outcomes. Previous neurosurgical research has focused predominantly on subjective data, such as patient satisfaction. Our objective was to assess whether racial disparities are present in primary objective outcomes for treatment of intracranial, unruptured aneurysms in the United States. MethodsData from the 2012–2015 National Inpatient Sample (NIS) database was analyzed. Patients who underwent either open or endovascular treatment of unruptured intracranial aneurysms were included (n = 11663). Patients were stratified by race, and those of unknown race or whose race sample size was too underpowered for analysis were excluded (n = 1202), along with those who experienced head trauma (n = 110) or concurrent AVM (n = 71). Poor outcome was defined as in-hospital mortality, discharge to a nursing facility or hospice, placement of a tracheostomy tube, or placement of a gastrostomy tube. The associations between race and adverse outcomes were determined through multivariate logistic regression, corrected for potentially confounding variables such as age, sex, procedural type, elective procedure, obesity, diabetes, tobacco, severity of illness, and hospital type. Results7478 White, 1460 Black, 1086 Hispanic, and 279 Asian patients were included in the final analysis. Complication rates were not significantly different between races, however Black patients experienced the highest proportion of complications (24 %). After adjusting for confounders, the odds of poor outcomes were significantly higher for Black patients (OR = 1.32 95 % CI: 1.07–1.62; p = 0.008) when compared to White patients. Black and Hispanic patients demonstrated a longer length of stay (Black, B: 0.04; 95 % CI: 0.03, 0.06; p < 0.001; Hispanic, B: 0.04; 95 % CI: 0.02, 0.05; p < 0.001) when compared to White patients. ConclusionOur nationwide analysis using the NIS suggests that Black patients treated for unruptured intracranial aneurysms experience worse outcomes and longer lengths of stay when compared to White patients. Recognizing the differences in objective outcomes and the presence of neurosurgical healthcare disparities is an important first step in providing equitable care to all patients. Future studies that carefully follow the social determinants of health and consider more confounding factors in the association between outcomes and determinants are needed.

Evolution of open surgery for unruptured intracranial aneurysms over a fifteen year period–increased difficulty and morbidity

ObjectiveThe approach to intervention for unruptured intracranial aneurysms (UIAs) remains controversial. Utilization of endovascular techniques for aneurysm repair increased dramatically during the last decade. We sought to analyze recent national trends for electively treated (open and endovascular) UIAs focusing on pre-existing patient disease burden and intervention modality selection. MethodsThe Nationwide Inpatient Sample (NIS) national database was used to identify patients with primary diagnosis codes of unruptured intracranial aneurysm between 1999 and 2014. Patients were dichotomized by intervention into endovascular or open surgical treatment. Analysis of pre-existing disease severity were calculated using the Elixhauser comorbidity index. Complications of combined peri-procedural stroke or death during admission and hospital length of stay were used as primary endpoints for comparison. ResultsThe percent of total UIAs treated electively with open approach decreased from more than 95 % of cases in 1999 to less than 25 % in 2014. Patients undergoing clipping were 3 years younger than those in the endovascular group (p < 0.001). The rate of primary endpoint complications (stroke and death) and length of stay for open cases saw a decrease throughout the study but remained statistically higher when compared to the endovascular group over the study period (p < 0.001). Additionally, non-neurologic complications increased over the time period for open cases. The average preoperative co-morbid disease severity for all groups treated increased over this interval. Conversely, the relative volume of endovascular cases increased but the rate of complications and average group disease remained statistically lower than the surgical clipping group (p < 0.05). ConclusionThe percent of UIAs treated electively with open approach has decreased since 1999 with a concomitant increase in complication rate in particular compared to endovascular cases. However, the health characteristics of patients treated with surgical clipping show an increase in severity of pre-existing co-morbidities. Further research into factors contributing to this finding, including potential socioeconomic differences and changes in surgeon experience are needed.

The 5-Factor Modified Frailty Index as a More Useful Associated Factor Than Chronological Age After Unruptured Cerebral Aneurysm Surgery: A Nationwide Registry Study.

Although chronological age is associated with mortality and morbidity after surgery for unruptured cerebral aneurysms (UCAs), there is little evidence regarding an association between the simplified 5-factor modified frailty index (mFI-5) and postoperative outcomes based on age group. To investigate the association of the mFI-5 score with worse outcomes, mortality, and complications in patients after surgery for UCA by chronological age groups using a Japanese national database. This study included 32 902 patients with UCAs enrolled in a Japanese national database between 2011 and 2015. Age group (younger than 65 years, 65-74 years, and 75 years or older), sex, UCA location, treatment, medications, Barthel Index (BI), medical history, mFI-5 score, and in-hospital mortality and complications were evaluated. We identified risk factors for worsening BI score, in-hospital mortality, and overall postoperative complications in each age group. In total, 14 465 patients were enrolled in this study. Multivariable analysis showed that elderly groups and patients with an mFI-5 score ≥2 items were associated with worsening BI scores (odds ratio 1.95; 95% CI 1.52-2.51) and in-hospital complications (odds ratio 1.79; CI 1.49-2.15), despite having no association with in-hospital mortality. Multivariable analysis by age groups showed that the mFI-5 score ≥2 items was associated with in-hospital complications in all age groups, unlike chronological age in patients younger than 74 years. The mFI-5 score was a more useful associated factor of in-hospital complications than chronological age in patients younger than 74 years undergoing surgery for UCA.

Temporary arterial occlusion (TAO) as independent prognostic factor in unruptured aneurysm surgery: A cohort study

BackgroundTemporary arterial occlusion (TAO) is a technique widely used in cerebrovascular surgery. However, few studies have evaluated the independent long-term effects of TAO or given detailed information about the complications during in-hospital stay. ObjectiveThis study aims to investigate the independent impact of TAO during unruptured intracranial aneurysm surgery on short and long-term outcomes. MethodsThe study included surgical elective patients diagnosed with unruptured aneurysm and indication of microsurgical treatment. Outcome assessment included occurrence of intra-operative (IOC) and post-operative (POC) complications, as well as Glasgow Outcome Scale (GOS) score 6 months after discharge. Results114 patients were included and 36 were followed. TAO was associated with POC (OR = 2.08; CI 95% 1.12–3.96; p = 0.01). The group with TAO and intraoperative rupture (IOR) did not differ from the group with TAO without IOR in terms of POC (p = 0.65) and IOC (p = 0.78). IOR (p = 0.16) and number of occlusions (p = 0.23) did not change GOS, but the total time of occlusion was associated with neurologic worsening (p = 0.034) during follow-up. The TAO group had larger aneurysm size and higher frequency of irregular lesions, when compared to the entire study group. Aneurysm location was not associated with POC (p = 0.25), IOC (0.17) or GOS (p = 0.75). ConclusionThe location of temporary clip placement and the number of clips did not influence the short- and long-term outcomes of patients with unruptured intracranial aneurysms. However, presence of temporary clips was associated with POC regardless of IOR occurrence and increased total time of occlusion was associated with poor outcomes after 6 months.

Race as a Factor in Adverse Outcomes Following Unruptured Aneurysm Surgery

Race as a Factor in Adverse Outcomes Following Unruptured Aneurysm Surgery

Risk factors and outcome analysis of patients with intraoperative rupture (IOR) of ruptured cerebral aneurysm during microsurgical clipping

Purpose To analyse baseline characteristics of patients with intraoperative rupture (IOR) or non-IOR who underwent microsurgical clipping for ruptured intracranial aneurysms. Additionally, to asses functional outcome in terms of Glasgow Outcome Scale (GOS) at 6 and 12 months. Methods A retrospective analysis of 471 patients who underwent microsurgical clipping for ruptured intracranial aneurysms from 2007 to 2018 in Nepal Mediciti Hospital, Nepal. Patients who underwent surgery for unruptured aneurysm were excluded from the study. The association of the base line characteristic in IOR and non-IOR were analysed. Variables analysed were the Hunt and Hess Scale (HHS) dichotomized as (1–3) and (4–5), Modified Fisher Scale dichotomized as (0–2) and (3–4), type of rupture, use of brain retractor, timing of IOR during surgery, aneurysmal factors (size of the neck, location, lobulation) and time of surgery. Outcome, GOS dichotomized into favourable (4–5) and unfavourable (1–3), assessed at 6 months and 12 months. Results Out of 471 patients treated for ruptured intracranial aneurysm, IOR occurred in 57 (12.10%) with mean age 49.47 (SD ±12.9), occurred more in smoker than non-smoker (45.6% vs. 18.6%; p=.000) and regular alcohol consumers (36.8% vs. 17.9%; p=.004). Favourable outcome with GOS (4–5) at 6 months was observed among patients with lower HHS (1–3), p=.025 and lower MFS (0–2), p=.04. However, outcome at 12 months was better associated with MFS (p=.013) and aneurysm size (p=.038), with more favourable outcome associated with aneurysm less than 10 mm. Conclusions Alcohol consumption and smoking are associated risk factors that may contribute to IOR. HHS and MFS are strong predictors of outcome for IOR patients at 6 months. However, at 12 months, MFS is more predictive of outcome. Aneurysms greater than 10 mm had a strong association with outcome at 12 months than 6 months.

Correlation of Inflow Velocity Ratio Detected by Phase Contrast Magnetic Resonance Angiography with the Bleb Color of Unruptured Intracranial Aneurysms

BackgroundIntraoperative rupture is the most fatal and catastrophic complication of surgery for unruptured intracranial aneurysms (UIAs); thus, it is extremely useful to predict reddish and thin-walled regions of the UIA before surgery. Although several studies have reported a relationship between the hemodynamic characteristics and intracranial aneurysm wall thickness, a consistent opinion is lacking. We aimed to investigate the relationship between objectively and quantitatively evaluated bleb wall color and hemodynamic characteristics using phase-contrast magnetic resonance angiography (PC-MRA).MethodsTen patients diagnosed with UIA who underwent surgical clipping and preoperative magnetic resonance imaging along with PC-MRA were included in this study. Bleb wall color was evaluated from an intraoperative video. Based on the Red (R), Green, and Blue values, bleb wall redness (modified R value; mR) was calculated and compared with the hemodynamic characteristics obtained from PC-MRA.ResultsThe wall redness distribution of 18 blebs in 11 UIAs in 10 patients was analyzed. Bleb/neck inflow velocity ratio (Vb/Va: r = 0.66, P = 0.003) strongly correlated with mR, whereas bleb/neck inflow rate ratio (r = 0.58, P = 0.012) correlated moderately. Multivariate regression analysis revealed that only Vb/Va (P = 0.017) significantly correlated with mR. There was no correlation between wall shear stress and mR.ConclusionsThe bleb redness of UIAs and Vb/Va, calculated using PC-MRA, showed a significantly greater correlation. Thus, it is possible to predict bleb thickness noninvasively before surgery. This will facilitate more detailed pre- and intraoperative strategies for clipping and coiling for safe surgery.

An Evaluation of the Safety and Feasibility of Adenosine-assisted Clipping Surgery for Unruptured Cerebral Aneurysms: Study Protocol.

The effectiveness of adenosine-induced flow arrest in surgical clipping for the cerebral aneurysms with difficulties in temporary clip placement to the proximal main trunk has been reported. This is the first clinical trial to evaluate the safety and feasibility of adenosine-assisted clipping surgery for unruptured cerebral aneurysms (UCAs) in Japan. The inclusion criteria are as follows: patients over 20 years old, patients who agree to be enrolled in this study after providing informed consent, patients who undergo clipping surgery for UCA in our institute, and patients in whom the surgeons (T.H. or I.D.) judge that decompression of the aneurysm is effective. The primary endpoint is a modified Rankin Scale (mRS) score 30 days after surgery. We plan to enroll 10 patients in this study. The original protocol of adenosine administration was established in this trial. Herein, we present the study protocol.

Verbalna memorija u bolesnika nakon operacije rupturirane i nerupturirane cerebralne aneurizme

A cerebral aneurysm is a bulge in the wall of a brain blood vessel with a risk to rupture. It occurs in about 2% of the population, somewhat more often in women. Most aneurysms are located in the anterior circulation area. Aneurysm rupture is relatively rare and accounts for 5% of all cerebrovascular brain incidents. Ruptured and asymptomatic/unruptured aneurysms are often treated surgically at the Department of Neurosurgery, Medical School University of Zagreb. The study included 134 patients after cerebral aneurysm surgery during the last 10 years, and neuropsychological testing was performed on average 77 days after surgery. The average age was 52 years and they completed an average of 12 years of education. In the group of patients included in this study, 40.3% of them were operated after ruptured, and 59.7% for unruptured cerebral aneurysm. Most aneurysms were located in the middle cerebral and anterior communicating arteries. With regard to lateralization, there was an equal number of aneurysms located in the right and left hemisphere and bilaterally (on the anterior communicating artery). As part of regular neuropsychological assessment, tests of verbal learning and memory (numerical, logical and mechanical memory) were applied. The aims of the study were to find out whether patients operated for ruptured cerebral aneurysms show greater verbal memory impairments than patients operated for unruptured cerebral aneurysms and whether there was the significant effect of lateralization of aneurysm (to check the interaction effect of both rupture and lateralization on those functions). The results obtained show that, even though there are no statistically significant differences between groups of patients that underwent surgery for ruptured and unruptured brain aneurysm, patients show a trend of somewhat better results on most of the verbal memory functions after surgery for unruptured brain aneurysm. The results show statistically significant difference between groups of patients that underwent surgery for ACoA aneurysm and those with right lateralized cerebral aneurysms on most of the trails on AVLT test. Also, patients with operated ACoA aneurysm have significantly worse scores in learning process (AVLT 3 and AVLT 4) and especially on short-term and long-term verbal memory than the patients who were operated for left or right lateralized aneurysm.

Readmission following extracranial-intracranial bypass surgery in the United States: nationwide rates, causes, risk factors, and volume-driven outcomes.

Extracranial-intracranial (EC-IC) bypass surgery remains an important treatment option for patients with moyamoya disease (MMD), intracranial arteriosclerotic disease (ICAD) with symptomatic stenosis despite the best medical management, and complex aneurysms. The therapeutic benefit of cerebral bypass surgery depends on optimal patient selection and the minimization of periprocedural complications. The nationwide burden of readmissions and associated complications following EC-IC bypass surgery has not been previously described. Therefore, the authors sought to analyze a nationwide database to describe the national rates, causes, risk factors, complications, and morbidity associated with readmission following EC-IC bypass surgery for MMD, ICAD, and aneurysms. The Nationwide Readmissions Database (NRD) was queried for the years 2010-2014 to identify patients who had undergone EC-IC bypass for MMD, medically failed symptomatic ICAD, or unruptured aneurysms. Predictor variables included demographics, preexisting comorbidities, indication for surgery, and hospital bypass case volume. A high-volume center (HVC) was defined as one that performed 10 or more cases/year. Outcome variables included perioperative stroke, discharge disposition, length of stay, total hospital costs, and readmission (30 days, 90 days). Multivariable analysis was used to identify predictors of readmission and to study the effect of treatment at HVCs on quality outcomes. In total, 2500 patients with a mean age of 41 years were treated with EC-IC bypass surgery for MMD (63.1%), ICAD (24.5%), or unruptured aneurysms (12.4%). The 30- and 90-day readmission rates were 7.5% and 14.0%, respectively. Causes of readmission included new stroke (2.5%), wound complications (2.5%), graft failure (1.5%), and other infection (1.3%). In the multivariable analysis, risk factors for readmission included Medicaid/self-pay (OR 1.6, 95% CI 1.1-2.4, vs private insurance), comorbidity score (OR 1.2, 95% CI 1.1-1.4, per additional comorbidity), and treatment at a non-HVC (OR 1.9, 95% CI 1.1-3.0). Treatment at an HVC (17% of patients) was associated with significantly lower rates of nonroutine discharge dispositions (13.4% vs 26.7%, p = 0.004), ischemic stroke within 90 days (0.8% vs 2.9%, p = 0.03), 30-day readmission (3.9% vs 8.2%, p = 0.03), and 90-day readmission (8.6% vs 15.2%, p = 0.01). These findings were confirmed in a multivariable analysis. The authors estimate that centralization to HVCs may result in 333 fewer nonroutine discharges (50% reduction), 12,000 fewer hospital days (44% reduction), 165 fewer readmissions (43%), and a cost savings of $15.3 million (11% reduction). Readmission rates for patients after EC-IC bypass are comparable with those after other common cranial procedures and are primarily driven by preexisting comorbidities, socioeconomic status, and treatment at low-volume centers. Periprocedural complications, including stroke, graft failure, and wound complications, occurred at the expected rates, consistent with those in prior clinical series. The centralization of care may significantly reduce perioperative complications, readmissions, and hospital resource utilization.