Treatment Of Unruptured Cerebral Aneurysms Research Articles

Alopecia due to an allergic reaction to metal head-pins used in a neurosurgical operation.

Background:Allergic reactions to the metal head-pins of a head fixation holder are rare.Case Description:A 45-year-old woman was referred to our hospital for the treatment of unruptured cerebral aneurysms. She underwent successful surgical treatment using four head-pins of the Sugita frame. At her first outpatient visit 3 weeks after discharge, redness, sores, and focal hair loss were noted at all four areas where the pinning had been performed. The pin fixation was considered to be responsible for the alopecia because the condition of the scalp lesions was even in all four parts. Six months later, the scalp regained hair. The head-pins were made of stainless steel, containing iron, nickel, chromium, and other components. A previous history of contact dermatitis to metal jewellery was later proven.Conclusion:The history of metal allergy should have been carefully elicited because head fixation with head-pins is essential for neurosurgical procedures.

Influence of Diabetes Mellitus and Cigarette Smoking on Variability of the Clopidogrel-Induced Antiplatelet Effect and Efficacy of Active Management of the Target P2Y12 Reaction Unit Range in Patients Undergoing Neurointerventional Procedures

Optimal antiplatelet inhibition is essential in patients undergoing neurointerventional procedures; however, variability in response to clopidogrel can contribute to thromboembolic and hemorrhagic complications. The present study evaluated the influence of diabetes mellitus and cigarette smoking on clopidogrel reactivity. Between 2011 and 2013, 71 consecutive patients underwent aneurysmal coil embolization (CE) or carotid artery stenting (CAS) and received clopidogrel (75 mg daily) and aspirin (100 mg daily) before the treatment. The patients were divided into 2 groups: CE (n = 31) and CAS (n = 40). The patients underwent prospective assessment of preoperative platelet function using VerifyNow assay and received adjunctive cilostazol (200 mg daily, triple antiplatelet therapy) in case of clopidogrel hyporesponse. Patients with clopidogrel hyper-response underwent clopidogrel dose reduction (clopidogrel, 12.5-50 mg daily). Clopidogrel resistance was noted in 15 patients (37.5%) in the CAS group and in 4 patients (12.9%) in the CE group (P = .031). Clopidogrel hyper-response was noted in 2 patients (5%) in the CAS group and in 11 patients (54.8%) in the CE group (P < .001). There was a significant difference in the baseline clinical characteristics between the 2 groups. In the multivariate logistic regression analysis, diabetes and age were independent predictors of clopidogrel hyporesponse, whereas current smoker was an independent predictor of clopidogrel hyper-response. Significant differences in baseline clinical characteristics were present when comparing patients undergoing endovascular treatment of unruptured cerebral aneurysms and carotid artery stenosis. Diabetes mellitus and current smoker status were independent factors related to reactivity to clopidogrel.

Elective endovascular treatment of unruptured intracranial aneurysms: a management case series of patient outcomes after institutional change to admit patients principally to postanesthesia care unit rather than to intensive care.

Our intention in this case series was to review the postoperative care and neurologic outcomes of patients who had undergone elective endovascular treatment of unruptured intracranial aneurysms. The case series is unique managerially in that a progressively increasing percentage of patients were admitted to the postanesthesia care unit (PACU; 1:2 nurse-to-patient ratio) and subsequently to the neurosurgical ward (1:3 nurse-to-patient ratio) instead of directly to the intensive care unit (ICU; 1:1 nurse-to-patient ratio). A retrospective review was performed of 170 consecutive elective endovascular procedures to treat unruptured intracranial aneurysms between July 2009 and September 2012. Data included patient, aneurysm, procedural characteristics, and adverse events within 96 hours after the procedure. Rates of ICU admission and perioperative neurologic adverse events were compared over time. Although direct ICU admission rates decreased over time (P < 0.0001) from 100% to 15%, perioperative neurologic event rates did not change (P = 0.79). Sixteen of 170 patients experienced perioperative neurologic events. The percentages of patients with neurologic events who died or had deficits that did not resolve before discharge were 38% (3 of 8) among patients directly admitted to the ICU versus 38% (3 of 8) among those first admitted to the PACU. Although the duration of anesthesia was greater among patients admitted to the ICU, duration was not useful in predicting decisions on the day of surgery for individual patients. The duration of anesthesia also was not meaningfully associated with information available preoperatively (i.e., for use when scheduling the case). In centers in which PACU and ward care are comparable to those in this case series, in the absence of intraoperative events with the potential for ongoing cerebral ischemia, most patients undergoing elective endovascular treatment of unruptured cerebral aneurysms can be managed without direct ICU admission. Scheduling all these procedures by using the mean historical anesthesia duration is reasonable.

Microembolism after Endovascular Treatment of Unruptured Cerebral Aneurysms: Reduction of its Incidence by Microcatheter Lumen Aspiration.

PurposeDiffusion-weighted MR images (DWI) obtained after endovascular treatment of cerebral aneurysms frequently show multiple high-signal intensity (HSI) dots. The purpose of this study was to see whether we could reduce their incidence after embolization of unruptured cerebral aneurysms by modification of our coiling technique, which involves the deliberate aspiration of the microcatheter lumen right after delivery of each detachable coil into the aneurysm sac.Materials and MethodsFrom January 2011 to June 2011, all 71 patients with unruptured cerebral aneurysms were treated using various endovascular methods. During the earlier period, 37 patients were treated using our conventional embolization technique (conventional period). Then 34 patients were treated with a modified coiling technique (modified period). DWI was obtained on the following day. We compared the occurrence of any DWI HSI lesions and the presence of the symptomatic lesions during the two time periods.ResultsThe incidence of the DWI HSI lesions differed significantly at 89.2% (33/37) during the conventional period and 26.5% (9/34) during the modified period (p < 0.0001). The incidence of symptomatic lesions differed between the two periods (29.7% during the conventional period vs. 2.9% during the modified period, p < 0.003).ConclusionAspiration of the inner content of the microcatheter right after detachable coil delivery was helpful for the reduction of the incidence of microembolisms after endovascular coil embolization for the treatment of unruptured cerebral aneurysms.

P-006 Initial Response to Aspirin Therapy Measured with the PFA-100 Assay in Patients Undergoing Endovascular Treatment of Unruptured Cerebral Aneurysms

Background and purposeRecent studies have examined the variability in response to clopidogrel therapy in patients undergoing endovascular treatment of unruptured cerebral aneurysms; however, no study has systematically assessed patient response...

Aneurysmal wall enhancement and perianeurysmal edema after endovascular treatment of unruptured cerebral aneurysms

Perianeurysmal edema and aneurysm wall enhancement are previously described phenomenon after coil embolization attributed to inflammatory reaction. We aimed to demonstrate the prevalence and natural course of these phenomena in unruptured aneurysms after endovascular treatment and to identify factors that contributed to their development. We performed a retrospective analysis of consecutively treated unruptured aneurysms between January 2000 and December 2011. The presence and evolution of wall enhancement and perianeurysmal edema on MRI after endovascular treatment were analyzed. Variable factors were compared among aneurysms with and without edema. One hundred thirty-two unruptured aneurysms in 124 patients underwent endovascular treatment. Eighty-five (64.4 %) aneurysms had wall enhancement, and 9 (6.8 %) aneurysms had perianeurysmal brain edema. Wall enhancement tends to persist for years with two patterns identified. Larger aneurysms and brain-embedded aneurysms were significantly associated with wall enhancement. In all edema cases, the aneurysms were embedded within the brain and had wall enhancement. Progressive thickening of wall enhancement was significantly associated with edema. Edema can be symptomatic when in eloquent brain and stabilizes or resolves over the years. Our study demonstrates the prevalence and some appreciation of the natural history of aneurysmal wall enhancement and perianeurysmal brain edema following endovascular treatment of unruptured aneurysms. Aneurysmal wall enhancement is a common phenomenon while perianeurysmal edema is rare. These phenomena are likely related to the presence of inflammatory reaction near the aneurysmal wall. Both phenomena are usually asymptomatic and self-limited, and prophylactic treatment is not recommended.

Variability in initial response to standard clopidogrel therapy, delayed conversion to clopidogrel hyper-response, and associated thromboembolic and hemorrhagic complications in patients undergoing endovascular treatment of unruptured cerebral aneurysms

Background and purposeVariability in response to clopidogrel therapy is increasingly being recognized as an important factor in thromboembolic and hemorrhagic complications encountered after neurointerventional procedures. This study aims to determine...

Regional and socioeconomic disparities in the treatment of unruptured cerebral aneurysms in the USA: 2000–2010

BackgroundThe Institute of Medicine called attention to the pervasive differences in treatments and outcomes between ethnic groups. We sought to highlight the geographic and racial disparities in access to treatment...

The role of anatomical anomalies in anterior communicating artery aneurysm rupture

Abstract Background and purpose:limited data exist to guide proper patient selection for preventive treatment of unruptured cerebral aneurysms. Cerebral aneurysms have been associated with anomalies of arterial segments that are forming the brain arterial circle of Willis but whether this association is also related to aneurysm rupture is not known. The occurrence of cerebral aneurysm rupture when a circle of Willis anomaly was present or absent was compared. Material and methods: we have performed this study on a number of 312 cases, of which 87 were dissections, 22 dissection followed by plastic injection, 135 magnetic resonance angiography (MRA), 75 computer tomography angiography (CTA), 40 digital subtraction angiographies (DSA), 30 in vivo (intraoperatory) observation. Brain vascular imaging was reviewed for aneurysm size, morphology and presence of anterior cerebral artery anomalies. Results: we divided the study group in 2 cohorts, one control group of 272 cases, in which we have study the anatomical variants occurrence and aneurysm occurrence in general population and another included 45 patients admitted thru emergency room for subarachnoid hemorrhage, of those 38 were ruptured aneurysm of anterior communicating artery (ACoA). Mean aneurysm size was 8.9 mm. An anterior cerebral artery anomaly was identified in 31 cases (81.5%). Multivariate analysis revealed a higher risk of aneurysm rupture when an anterior cerebral artery was present. Conclusions: this study shows that anterior cerebral artery anomalies are more commonly found in ruptured as opposed to unruptured ACoA aneurysms. The presence of an ACA anomaly may be an important characteristic for selecting patients for preventive aneurysm treatment.

O-018 Variability in Response to a 75mg Daily Clopidogrel Dose in a Cohort of 90 Patients Undergoing Endovascular Treatment of Unruptured Cerebral Aneurysms

Background and PurposeRecent studies have suggested that variability in response to clopidogrel therapy may explain some of the thromboembolic and hemorrhagic complications encountered after endovascular treatment of cerebral aneurysms with...

Comparative Effectiveness of Unruptured Cerebral Aneurysm Therapies

Endovascular therapy has increasingly become the most common treatment for unruptured cerebral aneurysms in the United States. We evaluated a national, multi-hospital database to examine recent utilization trends and compare periprocedural outcomes between clipping and coiling treatments of unruptured aneurysms. The Premier Perspective database was used to identify patients hospitalized between 2006 to 2011 for unruptured cerebral aneurysm who underwent clipping or coiling therapy. A logistic propensity score was generated for each patient using relevant patient, procedure, and hospital variables, representing the probability of receiving clipping. Covariate balance was assessed using conditional logistic regression. Following propensity score adjustment using 1:1 matching methods, the risk of in-hospital mortality and morbidity was compared between clipping and coiling cohorts. A total of 4899 unruptured aneurysm patients (1388 clipping, 3551 coiling) treated at 120 hospitals were identified. Following propensity score adjustment, clipping patients had a similar likelihood of in-hospital mortality (odds ratio [OR], 1.43; 95% confidence interval [CI], 0.49-4.44; P=0.47) but a significantly higher likelihood of unfavorable outcomes, including discharge to long-term care (OR, 4.78; 95% CI, 3.51-6.58; P<0.0001), ischemic complications (OR, 3.42; 95% CI, 2.39-4.99; P<0.0001), hemorrhagic complications (OR, 2.16; 95% CI, 1.33-3.57; P<0.0001), postoperative neurological complications (OR, 3.39; 95% CI, 2.25-5.22; P<0.0001), and ventriculostomy (OR, 2.10; 95% CI, 1.01-4.61; P=0.0320) compared with coiling patients. Among patients treated for unruptured intracranial aneurysms in a large sample of hospitals in the United States, clipping was associated with similar mortality risk but significantly higher periprocedural morbidity risk compared with coiling.

Abstract TP80: Incidence And Risk Factors For The Growth And Rupture Of Unruptured Cerebral Aneurysms. Results Of Annual Radiologic Follow Up Study.

Background: The recent trend of the treatment of unruptured cerebral aneurysms(UIAs) is going to be conservative. Their natural history of rupture and growth is still unkown. We present the results of annual radiological follow-up study in UIAs. Method: In recent 12 years, we have found 121patients with 148 unruptured cerebral aneurysms were followed annually using 3D-CTA or MRA. Mean follow-up period was 5.5 year. Several factors influencing rupture or growth were statistically examined. Results: Among 121 patients, 9 ruptured and 11 showed growth of UIAs. Annual rupture rate was 1.3% per year and annual growth rate was 1.6% per year. Aneurysm size was the sole factor influencing rupture(P&lt;0.001), whereas female sex and multiplicity were major factors influencing aneurysm growth(P&lt;0.05). Under size 3mm, annual growth rate was 3.0% whereas annual rupture rate was 0.7%. In 4-6mm, growth rate was 1.6% and rupture rate was 1.6%. In 7-9mm, growth rate was 0 and rupture rate was 5.8%. In over 10mm, growth rate was 2.9% and rupture rate was 11.6%. Within 1 year, rupture occurred in 4 cases, and growth was found in 1 case. Conclusions: By annual radiological examination, growth of UIAs was noted more frequently than aneurysm rupture. Especially UIAs under 3mm, growth was 4 times higher than rupture, radiological follow up is effective for aneurysm rupture. Within 1 year, initially found UIAs should be carefully followed in a short interval.

脳外科医療の質 : 「未破裂脳動脈瘤」の臨床プロセス設計

脳外科医療の質 : 「未破裂脳動脈瘤」の臨床プロセス設計

In-hospital outcomes associated with stent-assisted endovascular treatment of unruptured cerebral aneurysms in the USA

BackgroundAdjunctive stenting has increasingly become an acceptable option for the endovascular treatment of unruptured aneurysms. The Nationwide Inpatient Sample (NIS) was used to compare US in-hospital outcomes related to coiling...

患者満足度の観点からみた未破裂脳動脈瘤治療適応の個別的決定に関する因子の検討

Decision making on the prophylactic treatment of unruptured cerebral aneurysms (UCA) is a complicated process. Not only the medical condition but also the patient’s psychological factors can influence the patient’s decision as to whether to accept possibly invasive procedures or choose conservative management that may include an insidious risk of UCA rupture. Questionnaires were mailed to patients diagnosed with UCA’s between January 2002 and December 2012 in three affiliated institutions. The contents were factors affecting individual choices of prophylactic treatment or conservative treatment. At the same time, we examined patients’ Quality of Life (QOL) scoring according to Medical Outcome Study Short Form 36 Version2 (SF-36) when the questionnaires were mailed. Of the 114 patients who completed the questionnaires, 55 opted for prophylactic treatment for UCA and 59 chose conservative management for UCA. The prophylactic treatment group was strongly influenced by four factors: annual rupture rate, age, effect of SAH on family members, and personal trust in the doctor (p<0.05). This retrospective study on QOL of the patient after diagnosis showed the reliability of the health professionals and the psychological relationship between doctor and patient are crucial factors in making appropriate decisions in the prophylactic treatment of UCA.

Hospitalization Costs for Endovascular and Surgical Treatment of Unruptured Cerebral Aneurysms in the United States Are Substantially Higher Than Medicare Payments

Both endovascular and surgical options are available for treatment of unruptured cerebral aneurysms. We conducted a study to determine the costs versus Medicare reimbursement for hospitalization of these patients, which is important information for understanding the economic impact of these patients on hospitals. Using the NIS, we identified hospitalizations for clipping and coiling of unruptured cerebral aneurysms from 2001 to 2008 by cross-matching ICD-9 codes for diagnosis of unruptured aneurysm with procedure codes for clipping or coiling of cerebral aneurysms and excluding all patients with subarachnoid hemorrhage and intracerebral hemorrhage. Hospital costs for 2008 were correlated with age, sex, and discharge status and compared with Medicare payments. Costs of both clipping and coiling have increased from 2001 to 2008. The median 2008 hospital costs were $23,574 (IQR, $18,233-$29,941) for clipping and $25,734 (IQR, $17,436-$35,846) for coiling without complications, which were higher than the average Medicare payment of $12,599. The median hospital costs were $36,188 (IQR, $21,831-$55,308) for clipping and $40,502 (IQR, $24,289-$50,108) for coiling treatments complicated by major morbidity and $68,165 (IQR, $32,972-$100,211) for clipping and $56,020 for coiling treatments complicated by mortality, which were higher than the average Medicare payment for patients with major complications and comorbidities of $22,946. In multivariate analysis, female sex was associated with higher costs for coiling (P = .02), and poor discharge status was associated with higher costs for both clipping (P < .001) and coiling (P < .001). Hospitalization costs for patients undergoing clipping and coiling of unruptured cerebral aneurysms are substantially higher than Medicare payments.

O-021 Hospitalization costs for endovascular and surgical treatment of unruptured cerebral aneurysms in the USA are substantially higher than medicare payments

Background and PurposeEndovascular and surgical options are both available for the treatment of unruptured cerebral aneurysms. Knowledge of the costs for hospitalization of these patients is important to understanding economic...

The Treatment of Unruptured Cerebral Aneurysms: Cause for Concern?

In this issue of the American Journal of Neuroradiology are 2 articles examining the risks associated with the treatment of unruptured intracranial aneurysms (UIAs).[1][1],[2][2] These articles used the National Inpatient Sample (NIS) data base. This samples one-third of all nonfederal hospital

Effect of Age on Outcomes of Treatment of Unruptured Cerebral Aneurysms

Age might differentially affect outcomes in patients treated for unruptured cerebral aneurysms with surgical clipping versus endovascular coil therapy. We evaluated a large administrative database to determine the effect of age on outcomes in patients treated for unruptured cerebral aneurysm. Using the National Inpatient Sample, we evaluated morbidity (discharge to long-term facility) and mortality of patients undergoing clipping or coiling of unruptured cerebral aneurysms in the United States between 2001 and 2008. Outcomes were evaluated in relation to four age strata: younger than 50 years; 50 to 64 years; 65 to 79 years; and patients 80 years or older. Patients younger than 50 years old undergoing coiling had significantly lower morbidity rates when compared to patients who underwent clipping (3.5% versus 8.1%; P<0.0001), but no difference in mortality (0.6% versus 0.6%; P=0.72). Patients between 50 and 64 years old undergoing coiling had significantly decreased morbidity (4.0% versus 13.7%; P<0.0001) and mortality (0.5% versus 1.1%; P<0.0001) when compared to patients who underwent clipping. Coiled patients 65 to 79 years old had lower morbidity (6.9% versus 26.8%; P<0.0001) and mortality (0.8% versus 2.0%; P<0.0001) compared to patients who underwent clipping. Patients aged 80 years or older undergoing coiling also had lower morbidity (9.8% versus 33.5%; P<0.0001) and mortality (2.4% versus 21.4%; P<0.0001) when compared to patients who have undergone clipping. Patients treated with endovascular coiling have significantly less morbidity and mortality than those treated with surgical clipping, and these differences become more pronounced with age.

The role of circle of Willis anomalies in cerebral aneurysm rupture

Background and purposeLimited data exist to guide patient selection for preventive treatment of unruptured cerebral aneurysms. Cerebral aneurysms have been associated with circle of Willis anomalies but whether this association...