Frequency and risk factors for postoperative aneurysm residual after microsurgical clipping

Abstract Objective Aneurysm residuals after clipping are a well-known problem, but the course of aneurysm remnants in follow-up is not well studied. No standards or follow-up guidelines exist for treatment of aneurysm remnants. The aim of this study was to evaluate the risk factors for postoperative aneurysm remnants and their changes during follow-up. Methods We performed a retrospective analysis of 666 aneurysms treated via clipping in our hospital from 2006 to 2016. Postoperative and follow-up angiographic data were analyzed for aneurysm remnants and regrowth. Clinical parameters and aneurysm-specific characteristics were correlated with radiological results. Results The frequency of aneurysm residuals was 12% (78/666). Aneurysms located in the middle cerebral artery (p = 0.02) showed a significantly lower risk for incomplete aneurysm occlusion. Larger aneurysms with a diameter of 11–25 mm (p = 0.005) showed a significantly higher risk for incomplete aneurysm occlusion. Five patients underwent re-clipping during the same hospital stay. Remnants were stratified based on morphological characteristics into “dog ears” (n = 60) and “broad based” (n = 13). The majority of the “dog ears” stayed stable, decreased in size, or vanished during follow-up. Broad-based remnants showed a higher risk of regrowth. Conclusions A middle cerebral artery location seems to lower the risk for the incomplete clip occlusion of an aneurysm. Greater aneurysm size (11–25 mm) is associated with a postoperative aneurysm remnant. The majority of “dog-ear” remnants appear to remain stable during follow-up. In these cases, unnecessarily frequent angiographic checks could be avoided. By contrast, broad-based residuals show a higher risk of regrowth that requires close imaging controls if retreatment cannot be performed immediately.

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Pipeline-assisted coil embolization of a large middle cerebral artery pseudoaneurysm in a 9-month-old infant: experience from the youngest flow diversion case

Journal of Neurosurgery Pediatrics ◽

10.3171/2018.6.peds18165 ◽

2018 ◽

Vol 22 (5) ◽

pp. 532-540 ◽

Cited By ~ 5

Author(s):

Geoffrey P. Colby ◽

Bowen Jiang ◽

Matthew T. Bender ◽

Narlin B. Beaty ◽

Erick M. Westbroek ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Coil Embolization ◽

Pediatric Population ◽

Flow Diversion ◽

Left Middle Cerebral Artery ◽

Artery Pseudoaneurysm ◽

First Case ◽

Aneurysm Occlusion

Intracranial aneurysms in the pediatric population are rare entities. The authors recently treated a 9-month-old infant with a 19-mm recurrent, previously ruptured, and coil-embolized left middle cerebral artery (MCA) pseudoaneurysm, which was treated definitively with single-stage Pipeline-assisted coil embolization. The patient was 5 months old when she underwent resection of a left temporal Grade 1 desmoplastic infantile ganglioglioma at an outside institution, which was complicated by left MCA injury with a resultant 9-mm left M1 pseudoaneurysm. Within a month, the patient had two aneurysmal rupture events and underwent emergency craniectomy for decompression and evacuation of subdural hematoma. The pseudoaneurysm initially underwent coil embolization; however, follow-up MR angiography (MRA) revealed aneurysm recanalization with saccular enlargement to 19 mm. The patient underwent successful flow diversion–assisted coil embolization at 9 months of age. At 7 months after the procedure, follow-up MRA showed complete aneurysm occlusion without evidence of in-stent thrombosis or stenosis. Experience with flow diverters in the pediatric population is still in its early phases, with the youngest reported patient being 22 months old. In this paper the authors report the first case of such a technique in an infant, whom they believe to be the youngest patient to undergo cerebral flow diversion treatment.

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Long-term results of middle cerebral artery aneurysm clipping in the Barrow Ruptured Aneurysm Trial

Journal of Neurosurgery ◽

10.3171/2017.10.jns172183 ◽

2019 ◽

Vol 130 (3) ◽

pp. 895-901 ◽

Cited By ~ 4

Author(s):

Michael A. Mooney ◽

Elias D. Simon ◽

Scott Brigeman ◽

Peter Nakaji ◽

Joseph M. Zabramski ◽

...

Keyword(s):

Endovascular Treatment ◽

Middle Cerebral Artery ◽

Clinical Outcomes ◽

Cerebral Artery ◽

Long Term Results ◽

Ruptured Aneurysm ◽

Microsurgical Clipping ◽

Mca Aneurysm

OBJECTIVEA direct comparison of endovascular versus microsurgical treatment of ruptured middle cerebral artery (MCA) aneurysms in randomized trials is lacking. As endovascular treatment strategies continue to evolve, the number of reports of endovascular treatment of these lesions is increasing. Herein, the authors report a detailed post hoc analysis of ruptured MCA aneurysms treated by microsurgical clipping from the Barrow Ruptured Aneurysm Trial (BRAT).METHODSThe cases of patients enrolled in the BRAT who underwent microsurgical clipping for a ruptured MCA aneurysm were reviewed. Characteristics of patients and their clinical outcomes and long-term angiographic results were analyzed.RESULTSFifty patients underwent microsurgical clipping of a ruptured MCA aneurysm in the BRAT, including 21 who crossed over from the endovascular treatment arm. Four patients with nonsaccular (e.g., dissecting, fusiform, or blister) aneurysms were excluded, leaving 46 patients for analysis. Most (n = 32; 70%) patients presented with a Hunt and Hess grade II or III subarachnoid hemorrhage, with a high prevalence of intraparenchymal blood (n = 23; 50%), intraventricular blood (n = 21; 46%), or both. At the last follow-up (up to 6 years after treatment), clinical outcomes were good (modified Rankin Scale score 0–2) in 70% (n = 19) of 27 Hunt and Hess grades I–III patients and in 36% (n = 4) of 11 Hunt and Hess grade IV or V patients. There were no instances of rebleeding after the surgical clipping of aneurysms in this series at the time of last clinical follow-up.CONCLUSIONSMicrosurgical clipping of ruptured MCA aneurysms has several advantages over endovascular treatment, including durability over time. The authors report detailed outcome data of patients with ruptured MCA aneurysms who underwent microsurgical clipping as part of a prospective, randomized trial. These results should be used for comparison with future endovascular and surgical series to ensure that the best results are being achieved for patients with ruptured MCA aneurysms.

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Microsurgical treatment of unruptured middle cerebral artery aneurysms: a large, contemporary experience

Journal of Neurosurgery ◽

10.3171/2018.1.jns172466 ◽

2019 ◽

Vol 130 (5) ◽

pp. 1498-1504 ◽

Cited By ~ 6

Author(s):

Eric S. Nussbaum ◽

Michael T. Madison ◽

James K. Goddard ◽

Jeffrey P. Lassig ◽

Kevin M. Kallmes ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Morbidity Rate ◽

Parent Artery ◽

Complication Rates ◽

Surgical Morbidity ◽

Indocyanine Green Videoangiography ◽

Parent Artery Occlusion ◽

Aneurysm Occlusion

OBJECTIVEAdvances in endovascular therapy for the treatment of middle cerebral artery (MCA) aneurysms have led to scrutiny of its benefits compared with microsurgical repair. To provide information regarding complication rates and outcomes, the authors reviewed the results of a large series of unruptured MCA aneurysms treated with open microsurgery.METHODSThe authors included all patients who underwent surgical repair of an unruptured MCA aneurysm between 1997 and 2015. All surgical procedures, including clipping, wrapping, bypass, and parent artery occlusion, were performed by a single neurosurgeon. Aneurysm occlusion was assessed using intraoperative digital subtraction angiography (DSA) or DSA and indocyanine green videoangiography in all cases. Postoperatively, all patients were monitored in a neurointensive care unit overnight. Clinical follow-up was scheduled for 2–4 weeks after surgery, and angiographic follow-up was performed in those patients with subtotally occluded aneurysms at 1, 2, and 5 years postoperation.RESULTSThe authors treated 750 unruptured MCA aneurysms in 716 patients: 649 (86.5%) aneurysms were small, 75 (10.0%) were large, and 26 (3.5%) were giant. Most aneurysms (n = 677, 90%) were treated by primary clip reconstruction. The surgical morbidity rate was 2.8%, and the mortality rate was 0%. Complete angiographic aneurysm occlusion was achieved in 92.0% of aneurysms. At final follow-up, 713 patients had a modified Rankin Scale (mRS) score of 0, 2 patients had an mRS score of 2 or 3, and 1 had an mRS score of 4.CONCLUSIONSIn high-volume centers, microsurgical management of MCA aneurysms can be performed with very low morbidity rates. Currently, microsurgical repair appears to be a highly effective method of treating MCA aneurysms.

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Early experience treating intracranial aneurysms using Accero: a novel, fully visible, low profile braided stent with platinum–nitinol composite wire technology

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-015918 ◽

2020 ◽

Vol 13 (1) ◽

pp. 49-53

Author(s):

Alberto Nania ◽

Nicholas Dobbs ◽

Johannes DuPlessis ◽

Peter Keston ◽

Jonathan Downer

Keyword(s):

Cerebral Artery ◽

Anterior Communicating Artery ◽

Clinical Consequence ◽

Composite Wire ◽

Postoperative Hematoma ◽

Low Profile ◽

Angiographic Data ◽

Aneurysm Occlusion ◽

Braided Stent

BackgroundAccero is an innovative, fully visible, self-expanding braided stent with platinum–nitinol composite wire technology, produced by Acandis.ObjectiveTo assess the technical success and safety of this new stent by evaluating the intraprocedural behavior and complication rate, and the short-term follow-up results.MethodsForty-one consecutive patients suitable for stent-assisted coiling were selected for the use of Accero in an 11-month period. Clinical, procedural, and angiographic data, as well as 30-day morbidity, were recorded. The angiographic results, clinical follow-up at 30 days, and early imaging follow-up at 3 or 6 months were analyzed, when available.ResultsForty-one aneurysms were treated with stent-assisted coiling. All cases were elective, of which 19 were previously untreated aneurysms and 22 were recurrent aneurysms. Aneurysm location was anterior communicating artery complex (16), basilar (12 cases), middle cerebral artery bifurcation (9 cases), and internal cerebral artery (4 cases). The stent was successfully deployed and aneurysm occlusion with coils achieved in 100% of our patients. One case of on table in-stent thrombosis occurred, which resolved after administration of glycoprotein IIB/IIIA inhibitor, with no clinical consequence, and one case of postoperative hematoma at the arteriotomy site, which was managed conservatively. On early follow-up, available for 37 patients, the complete occlusion rate was 76%, with only two recurrences needing further treatment. Satisfactory aneurysm occlusion was therefore achieved in 95% of cases.ConclusionStent-assisted coiling with the Accero braided stent proved safe and effective.

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Microsurgical Clipping of Unruptured Middle Cerebral Artery Bifurcation Aneurysms: Incidence of and Risk Factors for Procedure-Related Complications

World Neurosurgery ◽

10.1016/j.wneu.2015.01.023 ◽

2015 ◽

Vol 83 (5) ◽

pp. 666-672 ◽

Cited By ~ 16

Author(s):

Joonho Chung ◽

Chang-Ki Hong ◽

Yu Shik Shim ◽

Jin-Yang Joo ◽

Yong Cheol Lim ◽

...

Keyword(s):

Risk Factors ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Microsurgical Clipping

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Endovascular Treatment of Ruptured Middle Cerebral Artery Aneurysms With a Low-Profile Visualized Intraluminal Support Device

Frontiers in Neurology ◽

10.3389/fneur.2020.631745 ◽

2021 ◽

Vol 11 ◽

Author(s):

Gaici Xue ◽

Yu Zhou ◽

Peng Liu ◽

Qiao Zuo ◽

Pengfei Yang ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Multicenter Studies ◽

Neurologic Outcomes ◽

Low Profile ◽

Angiographic Data ◽

Perioperative Complication ◽

Middle Cerebral Artery Aneurysms

Objective: Stenting in ruptured middle cerebral artery (MCA) aneurysms was reported with a high perioperative complication rate. However, the treatment devices and physician's experience have continued to evolve. We performed this retrospective study to evaluate the safety and efficacy of LVIS stent-assisted coiling for ruptured MCA aneurysms.Methods: Patients with acutely ruptured MCA aneurysms treated between November 2014 and October 2019 were retrospectively reviewed. Clinical and angiographic data of those treated with LVIS stents were collected from a prospectively maintained database.Results: A total of 40 patients with 40 ruptured MCA aneurysms were enrolled, which comprised 26.3% (40/152) of all the ruptured MCA aneurysms at the same time. All stents were successfully deployed except for one (2.5%), which had a poor stent opening. Ischemic procedure-related complications were encountered in three patients (7.5%). One patient died of complications related to high-grade SAH on admission. Follow-up (mean 15.9 months) angiography was performed for 36 patients, which showed 33 (91.7%) aneurysms were completely occluded, 1 (2.8%) was improved, 1 (2.8%) was stable, and 1 (2.8%) was recanalized. Clinical follow-up (mean 29.6 months) was available for all survived patients, which showed 38 (95.0%) patients had favorable neurologic outcomes (mRS score 0–2), and 2 (5.0%) patients had poor neurologic outcomes.Conclusion: The use of LVIS stents is feasible, safe, and effective with glycoprotein IIb/IIIa inhibitor for the treatment of ruptured MCA aneurysms in the acute setting. Prospective, multicenter studies with larger sample sizes are still required to further evaluate the safety and long-term efficacy.

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Pipeline embolization of proximal middle cerebral artery aneurysms: A multicenter cohort study

Interventional Neuroradiology ◽

10.1177/15910199211015578 ◽

2021 ◽

pp. 159101992110155

Author(s):

David C Lauzier ◽

Brandon K Root ◽

Yasha Kayan ◽

Josser E Delgado Almandoz ◽

Joshua W Osbun ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Cerebral Aneurysms ◽

Volume Reduction ◽

Multicenter Cohort Study ◽

Angiographic Data ◽

Aneurysm Volume ◽

Proximal Middle Cerebral Artery ◽

Aneurysm Occlusion ◽

Middle Cerebral Artery Aneurysms

Background and purpose Flow diversion of aneurysms located in the M1 segment and middle cerebral artery bifurcation with Pipeline embolization device is sometimes performed, but further study is needed to support its regular use in aneurysm treatment. Here, we report measures of safety and efficacy for Pipeline embolization in the proximal middle cerebral artery in a multi-center cohort. Materials and methods Clinical and angiographic data of eligible patients were retrospectively obtained from participating centers and assessed for key clinical and angiographic outcomes. Additional details were extracted for patients with complications. Results In our multi-center cohort, complete aneurysm occlusion was achieved in 71% (17/24) of treated aneurysms. There were no deaths or disabling strokes, but non-disabling ischemic strokes occurred in 8% (2/24) of patients. For aneurysms in the M1 segment, complete aneurysm occlusion was observed in 75% (12/16) of aneurysms, aneurysm volume reduction was observed in 100% (16/16) of aneurysms, and non-disabling ischemic strokes occurred in 13% (2/16) of patients. For aneurysms at the middle cerebral artery bifurcation, complete aneurysm occlusion was observed in 63% (5/8) of aneurysms, aneurysm volume reduction occurred in 88% (7/8) of aneurysms, and ischemic or hemorrhagic complications occurred in 0% (0/8) of patients. Conclusion Pipeline embolization of cerebral aneurysms in the M1 segment and middle cerebral artery bifurcation demonstrated a 71% rate of complete aneurysm occlusion. There were no deaths or disabling strokes, but there was an 8% rate of non-disabling ischemic strokes.

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Microsurgical clipping of middle cerebral artery aneurysms: complications and risk factors for complications

10.21203/rs.3.rs-1048020/v1 ◽

2021 ◽

Author(s):

Thomas METAYER ◽

Arthur Leclerc ◽

Alin Borha ◽

Stephane Derrey ◽

Olivier Langlois ◽

...

Keyword(s):

Risk Factors ◽

Cerebral Ischemia ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Ruptured Aneurysm ◽

Safe Procedure ◽

Neck Size ◽

Microsurgical Treatment ◽

Microsurgical Clipping ◽

Middle Cerebral Artery Aneurysms

Abstract Objective Middle cerebral artery aneurysms (MCAas) with rupture and unruptured IAs are considered good candidates for microsurgery. The objective of the present study was to evaluate the risk of complications and the risk factors for microsurgical treatment of MCAas to better define the indications for microsurgery. Methods We conducted a retrospective cohort study based on data provided from three French tertiary neurosurgical units from January 1, 2013 to May 31, 2020. We first collected data on all the patients who required microsurgical treatment for MCAas. We evaluated the frequency of complications and finally searched for the risk factors for complications after microsurgery. Complications were defined as a composite criterion with the presence of one of the following: procedural-related death, symptomatic cerebral ischemia, impossible exclusion, incomplete exclusion, or (re)bleeding of the treated aneurysm and symptomatic surgical site hematoma. We then compared patients with and without complications using univariate and multivariate analyses. Results Between January 2013 and May 2020, 292 MCAas in 284 patients were treated. A total of 29 (9.9%) MCAas had a complication. The complications were as follows: symptomatic cerebral ischemia: 4.8%, aneurysm rebleeding: 0.3%, surgical site hematoma: 1.0%, impossible exclusion: 0.3%, and incomplete exclusion: 4.1%. However, severe complications, defined as death or a modified Rankin score (mRs) score ≥4 at 3 months, were infrequent and occurred in 7/292 patients (2.4%). In the multivariate analysis, independent risk factors for complications were the following: a ruptured aneurysm, a larger maximum IA size, a larger neck size, and arterial branches passing less than <1 mm from the IA neck or dome. Conclusions MCAa surgery is a safe procedure with a low rate of serious procedure-related complications and an excellent rate of occlusion. The risk factors for complications are a ruptured aneurysm, a larger IA, a larger neck size, and the presence of an “en passage” arterial branch less than 1 mm from the IA. In these cases, at least for factors that do not present a significant difficulty for EVT, such as the presence of an “en passage” artery or ruptured IA, EVT has to be more thoroughly discussed.

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Vascular Morphology has No Direct Relationship with Atherosclerotic Plaque Burden in Patients with Symptomatic Middle Cerebral Artery Stenosis

Current Neurovascular Research ◽

10.2174/1567202616666190618122746 ◽

2019 ◽

Vol 16 (3) ◽

pp. 224-231

Author(s):

Lu Liu ◽

Chengju Huo ◽

Hao Sun ◽

Hua Yang ◽

Rui Zhang ◽

...

Keyword(s):

Risk Factors ◽

Middle Cerebral Artery ◽

Clinical Outcomes ◽

Cerebral Artery ◽

Atherosclerotic Plaque ◽

Direct Relationship ◽

Plaque Burden ◽

Vascular Morphology ◽

Common Risk Factors

Background: The vascular morphology and the characteristics of atherosclerotic plaques in the middle cerebral artery (MCA) have not been fully studied with high-resolution magnetic resonance imaging (HR-MRI). Objectives: HR-MRI was applied to investigate vascular morphology and atherosclerotic plaque in patients with symptomatic MCA stenosis. Materials and Methods: A total of 343 patients with symptomatic MCA stenosis were enrolled in this study. All the patients were examined by HR-MRI to analyze the morphology of MCA and the M1 segment (MCA-M1), the characteristics and the location of the plaques. Results: The proportion of L-shaped MCA-M1 decreased, while the proportion of S-shaped MCAM1 increased with age. The anterior plaques were the most common in all the patients. The superior plaques were relatively common in patients with L-shaped and U-shaped MCA-M1, while the inferior plaques were relatively common in patients with inverted U-shaped and S-shaped MCAM1. Among all the plaques, the majority were isointense or heterogeneous. The MCA-M1 morphology had no direct relationship with the common risk factors of atherosclerosis and the clinical outcomes of the patients after 12 months of follow up. Conclusion: The morphology of MCA-M1 is not directly related to the plaque burden or the degree of stenosis in patients with symptomatic MCA stenosis. The morphology of MCA-M1 is not associated with the risk factors of atherosclerosis, or the clinical outcomes of the patients.

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Aneurysm remnant after clipping: the risks and consequences

Journal of Neurosurgery ◽

10.3171/2015.10.jns151536 ◽

2016 ◽

Vol 125 (5) ◽

pp. 1249-1255 ◽

Cited By ~ 29

Author(s):

Ramazan Jabbarli ◽

Daniela Pierscianek ◽

Karsten Wrede ◽

Philipp Dammann ◽

Marc Schlamann ◽

...

Keyword(s):

Risk Factors ◽

Cerebral Artery ◽

University Hospital ◽

Vascular Control ◽

Clinical Trial Registration ◽

Younger Age ◽

Aneurysm Occlusion ◽

Aneurysmal Bleeding

OBJECTIVE The complete clipping of a cerebral aneurysm usually warrants its sustained occlusion, while clip remnants may have far-reaching consequences. The aim of this study is to identify the risk factors for clip remnants requiring retreatment and/or exhibiting growth. METHODS All consecutive patients with primary aneurysm clipping performed at University Hospital of Essen between January 1, 2003, and December 31, 2013, were eligible for this study. Aneurysm occlusion was judged on obligatory postoperative digital subtraction angiography and the need for repeated vascular control. The identified clip remnants were correlated with various demographic and clinical characteristics of the patients, aneurysm features, and surgery-related aspects. RESULTS Of 616 primarily clipped aneurysms, postoperative angiography revealed 112 aneurysms (18%) with clip remnants requiring further control (n = 91) or direct retreatment (n = 21). Seven remnants exhibited growth during follow-up, whereas 2 cases were associated with aneurysmal bleeding. Therefore, a total of 28 aneurysms (4.5%) were retreated as clip remnants (range 1 day to 67 months after clipping). In the multivariate analysis, the need for retreatment of clip remnant was correlated with the aneurysm's initial size (> 12 mm; OR 3.22; p = 0.035) and location (anterior cerebral artery > internal carotid artery > posterior circulation > middle cerebral artery; OR 1.85; p = 0.003). Younger age with a cutoff at 45 years (OR 33.31; p = 0.004) was the only independent predictor for remnant growth. CONCLUSIONS The size and location of the aneurysm are the main risk factors for clip remnants requiring retreatment. Because of the risk for growth, younger individuals (< 45 years old) with clip remnants require a long-term (> 5 years) vascular follow-up. Clinical trial registration no: DRKS00008749 (Deutsches Register Klinischer Studien)

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