Microsurgical Clipping Techniques and Outcomes for Paraclinoid Internal Carotid Artery Aneurysms

2019 ◽  
Author(s):  
Tomoya Kamide ◽  
Jan-Karl Burkhardt ◽  
Halima Tabani ◽  
Michael Safaee ◽  
Michael T Lawton
Keyword(s):  
Clinical Outcomes ◽  
Cerebrovascular Disorders ◽  
Complication Rates ◽  
Surgical Clipping ◽  
Visual Deficits ◽  
Microsurgical Clipping ◽  
Paraclinoid Aneurysms ◽  
Complete Obliteration ◽  
Clipping Technique ◽  
Carotid Aneurysms

Abstract BACKGROUND Microsurgical clipping of paraclinoid aneurysms presents unique technical challenges because of the anatomical complexity of the paraclinoid region. OBJECTIVE To analyze microsurgical clipping techniques, complications, and outcomes associated with paraclinoid aneurysms, with a focus on clip selection and clipping technique according to aneurysm location. METHODS From 1997 to 2016, 231 unruptured paraclinoid aneurysms from 216 patients were treated using microsurgical clipping. We retrospectively reviewed patient records to analyze clinical outcomes. RESULTS A total of 80 aneurysms (34.6%) were treated with simple clipping. Among them, fenestrated clips were used with superior hypophyseal artery (SHA) aneurysms, but curved clips were used with most other aneurysms. A total of 151 aneurysms (65.6%) were treated using multiple clips, including tandem clipping for ophthalmic artery (OphA) aneurysms, tandem angled-fenestrated clipping for SHA and ventral carotid aneurysms, stacked clipping for dorsal carotid aneurysms, and various techniques for clinoidal segment/carotid cave aneurysms. Postoperative angiography was performed in 214 aneurysms (92.6%), and complete obliteration was confirmed in 195 aneurysms (91.1%). Using the modified Rankin Scale (mRS), overall functional outcome was good (mRS 0-2) in 99.6% of patients, although 30 cases (13.0%) showed new postoperative visual deficits. CONCLUSION Surgical clipping of paraclinoid aneurysms is an excellent treatment modality with good clinical outcomes and acceptable complication rates, particularly in centers with large experience in the microsurgical management of cerebrovascular disorders. Appropriate clip selection and clipping techniques are required to perform complete and safe clipping.

scholarly journals Microsurgical clipping of ophthalmic artery aneurysms: surgical results and visual outcomes with 208 aneurysms

2018 ◽  
Vol 129 (6) ◽  
pp. 1511-1521 ◽  
Author(s):  
Tomoya Kamide ◽  
Halima Tabani ◽  
Michael M. Safaee ◽  
Jan-Karl Burkhardt ◽  
Michael T. Lawton
Keyword(s):  
Endovascular Therapy ◽  
Ophthalmic Artery ◽  
Visual Field Defects ◽  
Unruptured Aneurysms ◽  
Visual Outcomes ◽  
Visual Deficits ◽  
Microsurgical Clipping ◽  
Paraclinoid Aneurysms ◽  
Aneurysm Occlusion ◽  
Flow Diverters

OBJECTIVEWhile most paraclinoid aneurysms can be clipped with excellent results, new postoperative visual deficits are a concern. New technology, including flow diverters, has increased the popularity of endovascular therapy. However, endovascular treatment of paraclinoid aneurysms is not without procedural risks, is associated with higher rates of incomplete aneurysm occlusion and recurrence, and may not address optic nerve compression symptoms that surgical debulking can. The increasing endovascular management of paraclinoid aneurysms should be justified by comparisons to surgical benchmarks. The authors, therefore, undertook this study to define patient, visual, and aneurysm outcomes in the most common type of paraclinoid aneurysm: ophthalmic artery (OphA) aneurysms.METHODSResults from microsurgical clipping of 208 OphA aneurysms in 198 patients were retrospectively reviewed. Patient demographics, aneurysm morphology (size, calcification, etc.), clinical characteristics, and patient outcomes were recorded and analyzed.RESULTSDespite 20% of these aneurysms being large or giant in size, complete aneurysm occlusion was accomplished in 91% of 208 cases, with OphA patency preserved in 99.5%. The aneurysm recurrence rate was 3.1% and the retreatment rate was 0%. Good outcomes (modified Rankin Scale score 0–2) were observed in 96.2% of patients overall and in all 156 patients with unruptured aneurysms. New visual field defects (hemianopsia or quadrantanopsia) were observed in 8 patients (3.8%), decreased visual acuity in 5 (2.4%), and monocular blindness in 9 (4.3%). Vision improved in 9 (52.9%) of the 17 patients with preoperative visual deficits.CONCLUSIONSThe most important risk associated with clipping OphA aneurysms is a new visual deficit. Meticulous microsurgical technique is necessary during anterior clinoidectomy, aneurysm dissection, and clip application to optimize visual outcomes, and aggressive medical management postoperatively might potentially decrease the incidence of delayed visual deficits. As the results of endovascular therapy and specifically flow diverters become known, they warrant comparison with these surgical benchmarks to determine best practices.

Predictor of Visual Impairment Following Paraclinoid Aneurysm Surgery: Special Consideration of Surgical Microanatomy Related to Paraclinoid Structures

2020 ◽  
Vol 20 (1) ◽  
pp. 45-54
Author(s):  
Nakao Ota ◽  
Ioannis Petrakakis ◽  
Kosumo Noda ◽  
Takanori Miyazaki ◽  
Tomomasa Kondo ◽  
...  
Keyword(s):  
Visual Acuity ◽  
Visual Field ◽  
Visual Impairment ◽  
Multivariate Logistic Regression Analysis ◽  
Visual Deficits ◽  
Microsurgical Clipping ◽  
Paraclinoid Aneurysm ◽  
Paraclinoid Aneurysms ◽  
Visual Field Deficits

Abstract BACKGROUND Microsurgical clipping with extradural anterior clinoidectomy (EDAC) for paraclinoid aneurysm is an established technique with good angiographic outcomes, although postoperative worsening of visual acuity remains a concern. Multiple reports show visual acuity deteriorating after clipping, yet the cause remains unclear. OBJECTIVE To analyze results of asymptomatic paraclinoid aneurysm surgeries treated with EDACs, specifically focusing on the microanatomy of paraclinoid structure dissection. This determined the causes of delayed visual impairment and microsurgical indications. METHODS Results of the treatment with EDAC of 94 patients with cerebral aneurysm and normal preoperative visual acuity but also full visual fields were retrospectively analyzed. RESULTS The mean aneurysm size was 6.2 (±3.3) mm. Clipping was performed in 87 cases and trapping in 7 cases. Complete angiographic occlusion was observed in 91 patients. In 26 cases, a postoperative visual deficit occurred. A total of 20 cases exhibited partial visual field deficits, including 5 who were asymptomatic. Visual deficits were only detectable by postoperative ophthalmologic testing. Six showed light perception impairment or blinding. Of the 15 patients with symptomatic partial visual field deficits, 5 showed improvement at follow-up. Visual deficits persisted in 22 patients at the last follow-up. Multivariate logistic regression analysis revealed that medial projecting aneurysm (adjusted odds ratio [OR]: 10.43) and the opening of the carotidoculomotor membrane (adjusted OR: 5.19) were significantly related to visual impairment. CONCLUSION Excess dissection of carotidoculomotor membranes causes postoperative delayed visual worsening. For treating small, asymptomatic paraclinoid aneurysms, carotidoculomotor membranes should not be opened, and microsurgical clipping should not be performed for preoperative asymptomatic medial projecting aneurysms.

scholarly journals Surgical Outcomes of Patients After Treatment of Ruptured Anterior Communicating Artery Aneurysms: “Real-World” Evidence From Southern Thailand

2021 ◽  
Author(s):  
Kanisorn Sungkaro ◽  
Thara Tunthanathip ◽  
Chin Taweesomboonyat ◽  
Anukoon Kaewborisutsakul
Keyword(s):  
Clinical Outcomes ◽  
Brain Infarction ◽  
Neurological Status ◽  
Aneurysm Rupture ◽  
Anterior Communicating Artery ◽  
Surgical Clipping ◽  
Microsurgical Clipping ◽  
Real World Evidence ◽  
Southern Thailand ◽  
Poor Outcomes

Abstract Background Anterior communicating artery (AComA) aneurysm rupture are the most common cause of subarachnoid hemorrhage worldwide. We aim to evaluate the clinical outcomes of patients with ruptured AComA aneurysms who underwent microsurgical clipping and factors related to poor outcomes at our institute. Methods We retrospectively review 150 consecutive patients with ruptured AComA aneurysm who underwent surgical clipping in eleven-year period. Their clinical and radiologic features, as well as, clinical outcomes, were reviewed. In addition, logistic regression analysis was performed to identify independent factor for unfavorable clinical outcomes (modified Rankin scale 3–6). Results Enrolled patients included 83 male 67 females with mean age of 51.3 ± 11.5 years. Admission neurological status with a Hunt and Hess grade of 1 or 2 (97 patients; 64.7%) and a WFNS grade of 1 or 2 (109 patients; 72.6%). Unfavorable outcomes at 6 months was observed in 23 (22.0%) patients and mortality rate was 8.0%. The multivariate analysis showed that preoperative intraventricular hemorrhage (IVH) (P < 0.001; OR, 19.66; 95% CI, 5.10–75.80), A1 hypoplasia (P < 0.001; OR, 8.90; 95% CI, 2.82–28.04), and postoperative cerebral infarction (P = 0.025; OR, 3.21; 95% CI, 1.16–8.88) were strongly independent risk factor for unfavorable outcomes in this group. Conclusions Among the ruptured AComA aneurysm patients who underwent surgical clipping; proper management of preoperative IVH, A1 hypoplasia and intensive care for postoperative brain infarction are warrant for improved the surgical outcome.

scholarly journals Uncemented versus cemented arthroplasty after metal-on-metal total hip replacement in patients with femoral neck fractures: a retrospective study

2021 ◽  
Vol 49 (5) ◽  
pp. 030006052110122
Author(s):  
Wenlu Liu ◽  
Huanyi Lin ◽  
Xianshang Zeng ◽  
Meiji Chen ◽  
Weiwei Tang ◽  
...  
Keyword(s):  
Femoral Neck ◽  
Clinical Outcomes ◽  
Total Hip Replacement ◽  
Hip Replacement ◽  
Femoral Neck Fractures ◽  
Harris Hip Score ◽  
Complication Rates ◽  
Total Hip ◽  
Metal On Metal

Objective To compare the clinical outcomes of primary metal-on-metal total hip replacement (MoM-TR) converted to uncemented total hip replacement (UTR) or cemented total hip replacement (CTR) in patients with femoral neck fractures (AO/OTA: 31B/C). Methods Patient data of 234 UTR or CTR revisions after primary MoM-TR failure from March 2007 to January 2018 were retrospectively identified. Clinical outcomes, including the Harris hip score (HHS) and key orthopaedic complications, were collected at 3, 6, and 12 months following conversion and every 12 months thereafter. Results The mean follow-up was 84.12 (67–100) months for UTR and 84.23 (66–101) months for CTR. At the last follow-up, the HHS was better in the CTR- than UTR-treated patients. Noteworthy dissimilarities were correspondingly detected in the key orthopaedic complication rates (16.1% for CTR vs. 47.4% for UTR). Statistically significant differences in specific orthopaedic complications were also detected in the re-revision rate (10.3% for UTR vs. 2.5% for CTR), prosthesis loosening rate (16.3% for UTR vs. 5.9% for CTR), and periprosthetic fracture rate (12.0% for UTR vs. 4.2% for CTR). Conclusion In the setting of revision of failed primary MoM-TR, CTR may demonstrate advantages over UTR in improving functional outcomes and reducing key orthopaedic complications.

scholarly journals Overview of Robotic Technology in Spine Surgery

2021 ◽  
pp. 155633162110266
Author(s):  
Ram K. Alluri ◽  
Fedan Avrumova ◽  
Ahilan Sivaganesan ◽  
Avani S. Vaishnav ◽  
Darren R. Lebl ◽  
...  
Keyword(s):  
Economic Impact ◽  
Pedicle Screw ◽  
Clinical Outcomes ◽  
Spine Surgery ◽  
Screw Placement ◽  
Complication Rates ◽  
Robotic Technology ◽  
Pedicle Screw Placement ◽  
The Past ◽  
Compare And Contrast

As robotics in spine surgery has progressed over the past 2 decades, studies have shown mixed results on its clinical outcomes and economic impact. In this review, we highlight the evolution of robotic technology over the past 30 years, discussing early limitations and failures. We provide an overview of the history and evolution of currently available spinal robotic platforms and compare and contrast the available features of each. We conclude by summarizing the literature on robotic instrumentation accuracy in pedicle screw placement and clinical outcomes such as complication rates and briefly discuss the future of robotic spine surgery.

scholarly journals Sequential transarterial chemoembolization and early radiofrequency ablation improves clinical outcomes for early-intermediate hepatocellular carcinoma in a 10-year single-center comparative study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Liangliang Yan ◽  
Yanqiao Ren ◽  
Kun Qian ◽  
Xuefeng Kan ◽  
Hongsen Zhang ◽  
...  
Keyword(s):  
Hepatocellular Carcinoma ◽  
Radiofrequency Ablation ◽  
Combination Therapy ◽  
Clinical Outcomes ◽  
Transarterial Chemoembolization ◽  
Response Rate ◽  
Multivariable Analysis ◽  
Complication Rates ◽  
Tace Treatment

Abstract Background Transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) are effective treatment methods for unresectable hepatocellular carcinoma (HCC). However, there is still a lack of clinical research on whether early sequential RFA, compared with late combination therapy, can improve the long-term efficacy of initial TACE treatment. Methods This retrospective study investigated a cohort of patients who underwent combination therapy using TACE and RFA (TACE followed by RFA) from January 2010 to January 2020 at our medical centre. A total of 96 patients underwent TACE combined with early RFA (usually during the first hospitalization), which was called TACE + eRFA. Thirty-four patients received 1–2 palliative TACE treatments first and then underwent TACE treatment combined with late RFA (TACE + lRFA). All patients continued to receive palliative TACE treatments after intrahepatic lesion progression until reaching intolerance. The overall survival (OS) rate, time to tumour progression (TTP), tumour response rate and major complication rates were compared between the two groups. Results There were significant differences in the median OS (46 months vs 33 months; P = 0.013), median TTP (28 months vs 14 months; P < 0.00), objective response rate (ORR) (89.6% vs 61.8%, P = 0.000) and disease control rate (DCR) (94.8% vs 73.5% P = 0.002) between the two groups. Multivariable analysis revealed that the Barcelona Clinic Liver Cancer stage was an independent risk factor for OS. Meanwhile, multivariable analysis revealed that TACE + eRFA was associated with an enhanced TTP. Conclusion Early sequential RFA treatment in patients with early-intermediate HCC can improve local tumour control and clinical outcomes while reducing the frequency of TACE treatment. In clinical practice, in HCC patients initially treated with TACE, it is recommended to combine RFA as soon as possible to obtain long-term survival.

Retrograde Suction Decompression for Clipping of a Giant Ophthalmic Internal Carotid Artery Aneurysm: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Visish M Srinivasan ◽  
Michael Zhang ◽  
Lea Scherschinski ◽  
Alexander C Whiting ◽  
Mohamed A Labib ◽  
...  
Keyword(s):  
Visual Acuity ◽  
Carotid Artery ◽  
Internal Carotid ◽  
Artery Aneurysm ◽  
Carotid Bifurcation ◽  
Aneurysm Neck ◽  
Microsurgical Clipping ◽  
Complex Anatomy ◽  
Internal Carotid Artery Aneurysm ◽  
Paraclinoid Aneurysms

Abstract Microsurgical clipping of large paraclinoid aneurysms is challenging because of the complex anatomy of the dural rings, lack of easy proximal control, and wide aneurysm necks. Proximal retrograde suction decompression, or the Dallas technique, can reduce aneurysm turgor and, with aspiration of the trapped cervical and supraclinoid internal carotid arteries (ICAs), can collapse the aneurysm to aid microsurgical clipping.1-5  A woman in her late 30s presented with decreased right-eye visual acuity. Informed written consent was obtained for microsurgical management and publication. Upon cervical exposure of the carotid bifurcation, we performed a standard pterional craniotomy, trans-sylvian exposure, and intradural anterior clinoidectomy. After burst suppression and cross-clamping of the carotid, we inserted an angiocatheter at the common carotid artery (CCA). Distal temporary clips were placed on the posterior communicating artery and C7 ICA. With the cervical ICA unclamped, retrograde suction was continuously applied to deflate the aneurysm. We applied 2 pairs of fenestrated-booster clips to the aneurysm dome and a fifth clip to the aneurysm neck. After restoration of flow, indocyanine green angiography and Doppler assessments were performed. The proximal clip was converted into a curved clip to optimize ICA flow.  Postoperative angiography confirmed complete occlusion of the aneurysm. The patient was discharged on postoperative day 3, with stable visual acuity.6 This video demonstrates that retrograde suction decompression via the cervical CCA can be safely performed to facilitate clipping of complex paraclinoid ICA aneurysms. Comprehensive planning of temporary aneurysm trapping for suction decompression and permanent clip construct for aneurysm occlusion are needed for effective aneurysm repair.

Abstract 126: Comparison of Flow Diversion and Coiling in Large Unruptured Intracranial Saccular Aneurysms

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Nohra Chalouhi ◽  
Stavropoula Tjoumakaris ◽  
Robert M Starke ◽  
L Fernando Gonzalez ◽  
Ciro Randazzo ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Multivariable Analysis ◽  
Flow Diversion ◽  
Similar Proportion ◽  
Anterior Communicating Artery ◽  
Patient Age ◽  
Aneurysm Size ◽  
Patient Âgé ◽  
Complete Obliteration ◽  
Saccular Aneurysms

Background and purpose: Flow diversion has emerged as an important tool for management of intracranial aneurysms. The purpose of this study was to compare flow diversion and traditional embolization strategies in terms of safety, efficacy, and clinical outcomes in patients with unruptured, large saccular aneurysms (≥ 10 mm). Methods: Forty patients treated with the Pipeline Embolization Device (PED) were matched in a 1:3 fashion with 120 patients treated with coiling based on patient age and aneurysm size. Fusiform and anterior communicating artery aneurysms were eliminated from the analysis. Procedural complications, angiographic results, and clinical outcomes were analyzed and compared. Results: There were no differences between the 2 groups in terms of patient age, gender, aneurysm size, and aneurysm location. The rate of procedure-related complications did not differ between the PED (7.5%) and the coil group (7.5% p=1). At the latest follow-up, a significantly higher proportion of aneurysms treated with PED (86%) achieved complete obliteration compared to coiled aneurysms (41%, p<0.001). In multivariable analysis, coiling was an independent predictor of nonocclusion. Retreatment was necessary in fewer patients in the PED group (2.8%) than the coil group (37%, p<0.001). A similar proportion of patients attained a favorable outcome (mRS 0-2) in the PED group (92%) and the coil group (94%, p=0.8). Conclusion: The PED provides higher aneurysm occlusion rates than coiling, with no additional morbidity and similar clinical outcomes. These findings suggest that the PED is a preferred treatment option for large unruptured saccular aneurysms.

scholarly journals Is Allograft Reconstruction of the Medial Ulnar Collateral Ligament of the Elbow a Viable Option for Nonelite Athletes? Outcomes at a Mean of 8 Years

2020 ◽  
Vol 8 (10) ◽  
pp. 232596712095914
Author(s):  
Justin C. Kennon ◽  
Erick M. Marigi ◽  
Chad E. Songy ◽  
Chris Bernard ◽  
Shawn W. O’Driscoll ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Case Series ◽  
Ulnar Collateral Ligament ◽  
Ulnar Neuropathy ◽  
Complication Rates ◽  
Collateral Ligament ◽  
Level Of Evidence ◽  
Functional Scores ◽  
The Mean

Background: The rate of elbow medial ulnar collateral ligament (MUCL) injury and surgery continues to rise steadily. While authors have failed to reach a consensus on the optimal graft or anchor configuration for MUCL reconstruction, the vast majority of the literature is focused on the young, elite athlete population utilizing autograft. These studies may not be as applicable for the “weekend warrior” type of patient or for young kids playing on high school leagues or recreationally without the intent or aspiration to participate at an elite level. Purpose: To investigate the clinical outcomes and complication rates of MUCL reconstruction utilizing only allograft sources in nonelite athletes. Study Design: Case series; Level of evidence, 4. Methods: Patient records were retrospectively analyzed for individuals who underwent allograft MUCL reconstruction at a single institution between 2000 and 2016. A total of 25 patients met inclusion criteria as laborers or nonelite (not collegiate or professional) athletes with a minimum of 2 years of postoperative follow-up. A review of the medical records for the included patients was performed to determine survivorship free of reoperation, complications, and clinical outcomes with use of the Summary Outcome Determination (SOD) and Timmerman-Andrews scores. Statistical analysis included a Wilcoxon rank-sum test to compare continuous variables between groups with an alpha level set at .05 for significance. Subgroup analysis included comparing outcome scores based on the allograft type used. Results: Twenty-five patients met all inclusion and exclusion criteria. The mean time to follow-up was 91 months (range, 25-195 months), and the mean age at the time of surgery was 25 years (range, 12-65 years). There were no revision operations for recurrent instability. The mean SOD score was 9 (range, 5-10) at the most recent follow-up, and the Timmerman-Andrews scores averaged 97 (range, 80-100). Three patients underwent subsequent surgical procedures for ulnar neuropathy (n = 2) and contracture (n = 1), and 1 patient underwent surgical intervention for combined ulnar neuropathy and contracture. Conclusion: Allograft MUCL reconstruction in nonelite athletes demonstrates comparable functional scores with many previously reported autograft outcomes in elite athletes. These results may be informative for elbow surgeons who wish to avoid autograft morbidity in common laborers and nonelite athletes with MUCL incompetency.

scholarly journals The effects of surgical treatment and sclerotherapy for intramuscular venous malformations: a comparative clinical study

2021 ◽  
Vol 48 (6) ◽  
pp. 622-629
Author(s):  
Yun Hyun Kim ◽  
Jeong Yeop Ryu ◽  
Joon Seok Lee ◽  
Seok Jong Lee ◽  
Jong Min Lee ◽  
...  
Keyword(s):  
Surgical Treatment ◽  
Treatment Group ◽  
Clinical Outcomes ◽  
Vascular Malformations ◽  
Medical Center ◽  
Surgical Excision ◽  
Complication Rates ◽  
Venous Malformations ◽  
Treatment Groups ◽  
Comparative Clinical Study

Background Venous malformations (VMs) are the most common type of vascular malformations. Intramuscular venous malformations (IMVMs) are lesions involving the muscles, excluding intramuscular hemangiomas. The purpose of this study was to compare clinical outcomes between patients with IMVMs who were treated with sclerotherapy and those who were treated with surgical excision.Methods Of 492 patients with VMs treated between July 2011 and August 2020 at a single medical center for vascular anomalies, 63 patients diagnosed with IMVM were retrospectively reviewed. Pain, movement limitations, swelling, and quality of life (QOL) were evaluated subjectively, while radiological outcomes were assessed by qualified radiologists at the center. Complication rates were also evaluated, and radiological and clinical examinations were used to determine which treatment group (sclerotherapy or surgical excision) exhibited greater improvement.Results Although there were no significant differences in pain (P=0.471), swelling (P=0.322), or the occurrence of complications (P=0.206) between the two treatment groups, the surgical treatment group exhibited significantly better outcomes with regard to movement limitations (P=0.010), QOL (P=0.013), and radiological outcomes (P=0.017). Moreover, both duplex ultrasonography and magnetic resonance imaging showed greater improvements in clinical outcomes in the surgical excision group than in the sclerotherapy group.Conclusions Although several studies have examined IMVM treatment methods, no clear guidelines for treatment selection have been developed. Based on the results of this study, surgical excision is strongly encouraged for the treatment of IMVMs.

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