Treatment and diagnosis of cerebral aneurysms in the post-International Subarachnoid Aneurysm Trial (ISAT) era: trends and outcomes

2020 ◽  
Vol 12 (7) ◽  
pp. 682-687 ◽  
Author(s):  
Evan Luther ◽  
David J McCarthy ◽  
Marie-Christine Brunet ◽  
Samir Sur ◽  
Stephanie H Chen ◽  
...  
Keyword(s):  
Treatment Modality ◽  
Cerebral Aneurysms ◽  
Mortality Rates ◽  
Endovascular Embolization ◽  
Primary Therapy ◽  
Surgical Clipping ◽  
Unruptured Aneurysms ◽  
Unruptured Intracranial Aneurysms ◽  
International Subarachnoid Aneurysm Trial ◽  
Treatment Changes

BackgroundFollowing publication of the International Subarachnoid Aneurysm Trial (ISAT), treatment paradigms for cerebral aneurysms (CAs) shifted from open surgical clipping to endovascular embolization as primary therapy in a majority of cases. However, comprehensive analyses evaluating more recent CA diagnosis patterns, patient populations and outcomes as a function of treatment modality remain rare.MethodsThe National Inpatient Sample from 2004 to 2014 was reviewed. Aneurysmal subarachnoid hemorrhages (aSAHs) and unruptured intracranial aneurysms (UIAs) with a treatment of surgical clipping or endovascular therapy (EVT) were identified. Time trend series plots were created. Linear and logistic regressions were utilized to quantify treatment changes.Results114 137 aSAHs and 122 916 UIAs were reviewed. aSAH (+732/year, p=0.014) and UIA (+2550/year, p<0.0001) discharges increased annually. The annual caseload of surgical clippings for aSAH decreased (−264/year, p=0.0002) while EVT increased (+366/year, p=0.0003). For UIAs, the annual caseload for surgical clipping remained stable but increased for EVT (+615/year, p<0.0001). The rate of incidentally diagnosed UIAs increased annually (+1987/year; p<0.0001). Inpatient mortality decreased for clipping (p<0.0001) and EVT in aSAH (p<0.0001) (2004 vs 2014—clipping 13% vs 11.7%, EVT 15.8% vs 12.7%). Mortality rates for clipped UIAs decreased over time (p<0.0001) and remained stable for EVT (2004 vs 2014—clipping 1.57% vs 0.40%, EVT 0.59% vs 0.52%).ConclusionRuptured and unruptured CAs are increasingly being treated with EVT over clipping. Incidental unruptured aneurysm diagnoses are increasing dramatically. Mortality rates of ruptured aneurysms are improving regardless of treatment modality, whereas mortality in unruptured aneurysms is only improving for surgical clipping.

scholarly journals Peri-Procedural Morbidity and Mortality Associated with Stent-Assisted Coiling for Intracranial Aneurysms

2013 ◽  
Vol 19 (1) ◽  
pp. 43-48 ◽  
Author(s):  
K. Wang ◽  
Y. Sun ◽  
A-M. Li
Keyword(s):  
Intracranial Aneurysms ◽  
Cerebral Aneurysms ◽  
Mortality Rates ◽  
Stent Migration ◽  
Aneurysm Rupture ◽  
Morbidity And Mortality ◽  
Unruptured Aneurysms ◽  
Ruptured Aneurysms ◽  
Attractive Option ◽  
Technological Improvements

Despite experience and technological improvements, stent-assisted coiling for intracranial aneurysms still has inherent risks. We evaluated peri-procedural morbidity and mortality associated with stent-assisted coiling for intracranial aneurysms. Patients with cerebral aneurysms that were broad-based (>4 mm) or had unfavorable dome/neck ratios (<1.5) were enrolled in this study between February and November 2011 at our center. Aneurysms were treated with the self-expanding neurovascular stents with adjunctive coil embolization. Seventy-two consecutive patients (27 men and 45 women; 22–78 years of age; mean age, 52.8 years) underwent 13 procedures for 13 ruptured aneurysms and 64 procedures for 73 unruptured aneurysms. Nine [11.7%, 95% CI(4.5%–18.9%)] procedure-related complications occurred: one and eight with initial embolization of ruptured and unruptured aneurysms, respectively. Complications included six acute in-stent thromboses, one spontaneous stent migration, one post-procedural aneurysm rupture, and one perforator occlusion. Three complications had no neurologic consequences. Two caused transient neurologic morbidity, two persistent neurologic morbidity, and two death. Procedure-related neurologic morbidity and mortality rates, respectively, were as follows: overall, 5.2% (95%CI, 0.2%–10.2%) and 2.6% (95%CI, 0%–6.2%); ruptured aneurysms, 7.7% (95%CI, 0%–36%) and 0% (95%CI, 0%–25%); unruptured aneurysms, 4.7% (95%CI, 0%–9.9%) and 3.1% (95%CI, 0%–7.3%). Combined procedure-related morbidity and mortality rates for ruptured and unruptured aneurysms were 7.7% (95%CI, 1.7%–13.7%) and 7.8% (95%CI, 1.8%–13.8%), respectively. Stent-assisted coiling is an attractive option for intracranial aneurysms. However, stent-assisted coiling for unruptured aneurysms is controversial for its comparable risk to natural history.

Intraoperative motor and somatosensory evoked potential monitoring during surgical clipping of ruptured and unruptured intracranial aneurysms: a comparative study

2021 ◽  
pp. 1-8
Author(s):  
Hao You ◽  
Xing Fan ◽  
Jiajia Liu ◽  
Dongze Guo ◽  
Zhibao Li ◽  
...  
Keyword(s):  
Evoked Potential ◽  
Motor Evoked Potential ◽  
Critical Values ◽  
Somatosensory Evoked Potential ◽  
Short Term ◽  
Surgical Clipping ◽  
Unruptured Aneurysms ◽  
Ruptured Aneurysms ◽  
Unruptured Intracranial Aneurysms

OBJECTIVE The current study investigated the correlation between intraoperative motor evoked potential (MEP) and somatosensory evoked potential (SSEP) monitoring and both short-term and long-term motor outcomes in aneurysm patients treated with surgical clipping. Moreover, the authors provide a relatively optimal neurophysiological predictor of postoperative motor deficits (PMDs) in patients with ruptured and unruptured aneurysms. METHODS A total of 1017 patients (216 with ruptured aneurysms and 801 with unruptured aneurysms) were included. Patient demographic characteristics, clinical features, intraoperative monitoring data, and follow-up data were retrospectively reviewed. The efficacy of using changes in MEP/SSEP to predict PMDs was assessed using binary logistic regression analysis. Subsequently, receiver operating characteristic curve analysis was performed to determine the optimal critical value for duration of MEP/SSEP deterioration. RESULTS Both intraoperative MEP and SSEP monitoring were significantly effective for predicting short-term (p < 0.001 for both) and long-term (p < 0.001 for both) PMDs in aneurysm patients. The critical values for predicting short-term PMDs were amplitude decrease rates of 57.30% for MEP (p < 0.001 and area under the curve [AUC] 0.732) and 64.10% for SSEP (p < 0.001 and AUC 0.653). In patients with an unruptured aneurysm, the optimal critical values for predicting short-term PMDs were durations of deterioration of 17 minutes for MEP (p < 0.001 and AUC 0.768) and 21 minutes for SSEP (p < 0.001 and AUC 0.843). In patients with a ruptured aneurysm, the optimal critical values for predicting short-term PMDs were durations of deterioration of 12.5 minutes for MEP (p = 0.028 and AUC 0.706) and 11 minutes for SSEP (p = 0.043 and AUC 0.813). CONCLUSIONS The authors found that both intraoperative MEP and SSEP monitoring are useful for predicting short-term and long-term PMDs in patients with unruptured and ruptured aneurysms. The optimal intraoperative neuromonitoring method for predicting PMDs varies depending on whether the aneurysm has ruptured or not.

Abstract 1122‐000145: Impact of Age on Outcomes Following Endovascular vs Clipping of Ruptured and Unruptured Cerebral Aneurysms

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Hamidreza Saber ◽  
Naoki Kaneko ◽  
David Kimball ◽  
Jose Morales ◽  
Satoshi Tateshima ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Endovascular Therapy ◽  
Age Groups ◽  
Cerebral Aneurysms ◽  
Unruptured Aneurysm ◽  
Favorable Outcome ◽  
Hospital Length Of Stay ◽  
Surgical Clipping ◽  
Unruptured Aneurysms ◽  
Unruptured Cerebral Aneurysms

Introduction : Age is an important determinant of outcome in patients with unruptured or ruptured cerebral aneurysms. Advancements in endovascular therapies have significantly impacted patient selection and treatment of patients with cerebral aneurysm. Recent release of the National claims data for 2017–2018 provides the opportunity to explore novel population‐level outcomes following clipping vs endovascular treatment of ruptured and unruptured cerebral aneurysms in different age groups. Methods : Analysis of US National Inpatient Sample of hospitalizations with aneurysmal subarachnoid hemorrhage (aSAH) or unruptured aneurysms treated with clipping or endovascular therapy from January 1, 2017 to December 31, 2018. Pre‐defined age strata included: younger than 50 years; 50–64 years; 65–79 years; and 80 years or older. Primary outcomes included in‐hospital mortality and favorable outcome defined as discharge to home. Results : Overall, 34,955 hospitalizations with unruptured aneurysm treatment, (26,695 endovascular and 8,260 surgical clipping), and 17,525 hospitalizations with aSAH were identified in the study period. In unruptured aneurysm group, endovascular therapy was associated with significantly higher favorable outcome across all age groups, and lower mortality in those 65 years or older (all P<0.001) when compared to clipping. Median hospital length‐of‐stay was 1 day (IQR 1–4) in endovascular vs 4 days (IQR 3–8) in clipping group (P<0.001). In aSAH group, endovascular therapy was associated with higher favorable outcome in 50–80 years age groups when compared to clipping, with no significant differences for in‐hospital mortality outcome (Table). Significantly more favorable outcomes were achieved with coiling vs clipping in those aged 65 or above with unruptured aneurysms. Conclusions : In 2017–2018 in US, unruptured aneurysm patients treated with endovascular therapy had significantly lower morbidity and mortality compared to those treated with surgical clipping, and differences were more pronounced with age. Similar but less strong association was observed in patients with aSAH.

scholarly journals 3D rotational DSA: Diagnostic and therapeutic approach to cerebral aneurysms

2019 ◽  
Vol 1 (2) ◽  
pp. 3-7
Author(s):  
Karuna Tamrakar Karki ◽  
Duan Chuan Zhi ◽  
Li Tie Lin
Keyword(s):  
Digital Subtraction Angiography ◽  
Selection Criterion ◽  
Cerebral Aneurysms ◽  
Endovascular Embolization ◽  
Age Difference ◽  
Digital Subtraction ◽  
Parent Vessel ◽  
Treatment Protocols ◽  
Unruptured Aneurysms ◽  
Cranial Nerve Dysfunction

Background and purpose: Digital subtraction angiography (DSA), a minimally invasive procedure for an exceptional visualization of cerebrovascular angioarchitecture, has become an important imaging technique for inclusive evaluation and therapeutic embolization. Our purpose is to share the importance of DSA for evaluation of cerebral aneurysms. Material and method: A total of 148 patients with suspected intracranial aneurysm underwent digital subtraction angiography during January 2005 to December 2009. Preliminarily aortogram was considered in old age group (>50yrs) before supra-aortic angiography. Patient’s selection criterion included both ruptured and unruptured aneurysms. 3D rotational effect was applied for all complex cerebral aneurysms with unfavorable dome neck ratio. DSA was accomplished into 2- 6 standard projections for every vascular territory for optimal visualization and accurate evaluation of cerebral aneurysms. Result: 21 were males and 48 were females. Age difference was ranged between 26-78 years with an average of 51.5years. Among 288 patients, total detected aneurysms were 480. 32 presented with SAH, 21 presented with headache and 14 patients came with cranial nerve dysfunction during admission. 3 had negative angiography irrespective to spontaneous subarachnoid hemorrhage. Delineation of aneurysmal neck improved with rotation effect of 3D DSA in 80% of patients. Parent vessel and its relationship to adjacent vessels was better demonstrated with rotational angiography in >50% of cases. Endovascular embolization was done in 80 patients in same setting. Conclusion: DSA with 3D rotational technique is an essential radio-imaging tool for accurate characterization of cerebrovascular diseases and subsequently beneficial to elaborate on their potential treatment protocols.

Treatment of Cerebral Aneurysms: Surgical, Endovascular or Combined Intervention

1998 ◽  
Vol 4 (1_suppl) ◽  
pp. 153-158 ◽  
Author(s):  
H. Sano ◽  
Y. Kato ◽  
F.B. Singh ◽  
N. Kanaoka ◽  
K. Shankar ◽  
...  
Keyword(s):  
Retrospective Study ◽  
Treatment Group ◽  
Intervention Group ◽  
Cerebral Aneurysms ◽  
Endovascular Embolization ◽  
Good Recovery ◽  
Surgical Clipping ◽  
Ruptured Aneurysms ◽  
Incidental Aneurysms ◽  
Combined Intervention

A retrospective study of 437 cases of cerebral aneurysms over a 4 year period is reported. Surgical clipping was performed in 322 cases (254 ruptured and 68 incidental aneurysms) and endovascular embolization was done in 50 cases (26 ruptured and 24 incidental aneurysms). No intervention (either surgical or endovascular) was performed in 65 patients. In the direct surgical treatment group, mortality was 1.5% in incidental and 9.8% in ruptured aneurysms and good recovery was seen in 98.5% and 74.8% cases respectively. In the endovascular intervention group, results were poor due to the severity of their neurological grading and older age. Mortality was 42.3% in ruptured and 4.2% in incidental aneurysms. Six out of 26 ruptured and 11 out 24 incidental aneurysm patients had complications in the endovascular treatment group. We have discussed the results and indications for both modes of treatment in our study.

Surgical management of unruptured intracranial aneurysms

1994 ◽  
Vol 80 (3) ◽  
pp. 440-446 ◽  
Author(s):  
Robert A. Solomon ◽  
Matthew E. Fink ◽  
John Pile-Spellman
Keyword(s):  
Surgical Management ◽  
Intracranial Aneurysms ◽  
Clinical Decision Making ◽  
Mass Effect ◽  
Endovascular Embolization ◽  
Surgical Morbidity ◽  
Content Type ◽  
Unruptured Aneurysms ◽  
Unruptured Intracranial Aneurysms ◽  
Fine Print

✓ The surgical management of patients with unruptured intracranial aneurysms continues to be controversial. The criteria for withholding treatment or choosing between endovascular embolization and conventional microsurgery are not well delineated. The present study analyzes the morbidity and mortality that can be expected with modern surgical management of unruptured aneurysms, and therefore serves as a point of reference for clinical decision-making in this group of patients. A total of 202 consecutive operations for attempted clipping of unruptured intracranial aneurysms are reported. Subarachnoid hemorrhage from another aneurysm was the most common presentation (55 cases). Thirty-seven patients presented with headache, 36 with mass effect from the aneurysm, and 19 with embolic events; 11 aneurysms were associated with an arteriovenous malformation, 10 caused seizures, and 34 were incidental findings. Excellent or good outcome was achieved in 100% of patients with aneurysms less than 10 mm in diameter, 95% with aneurysms 11 to 25 mm, and 79% with aneurysms greater than 25 mm. Except for giant basilar aneurysms, size (and not location) of the aneurysm was the key predictor of risk for surgical morbidity. These data may be useful when discussing with patients the risk:benefit ratio of choosing between conservative management, endovascular embolization, and microsurgical clipping.

The incidence and treatment of asymptomatic, unruptured cerebral aneurysms

1994 ◽  
Vol 80 (2) ◽  
pp. 217-223 ◽  
Author(s):  
Toshio Nakagawa ◽  
Kazuo Hashi
Keyword(s):  
Early Detection ◽  
Internal Carotid ◽  
Cerebral Aneurysms ◽  
Maximum Diameter ◽  
Anterior Communicating Artery ◽  
Content Type ◽  
Unruptured Aneurysms ◽  
Unruptured Intracranial Aneurysms ◽  
History Of ◽  
Unruptured Cerebral Aneurysms

✓ The importance of early detection by various radiological techniques of asymptomatic, unruptured aneurysms as a means of preventing subarachnoid hemorrhage (SAH) is discussed in this report. Four hundred volunteers underwent clinical and radiological evaluations between March, 1988, and September, 1992. Studies included a neurological examination as well as digital subtraction cerebral angiography via a femoral arterial catheter, computerized tomography, T1- and T2-weighted magnetic resonance (MR) imaging of the whole brain, and MR angiography. The evaluation revealed 27 asymptomatic, unruptured intracranial aneurysms in 26 volunteers, for an incidence of 6.5%. The subjects ranged in age from 39 to 71 years, with an average of 55 years. The aneurysms were located on the internal carotid artery in 13 cases (48%), the anterior communicating artery in six (22%), the middle cerebral artery in six (22%), and the basilar artery in two (7%). Aneurysms ranged in size from 5 mm or less in 16 cases, 6 to 10 mm in nine, and 11 to 15 mm in one; one aneurysm was more than 15 mm, with a maximum diameter of 2 cm. Volunteers with a family history of SAH within the second degree of consanguinity showed a higher incidence of aneurysms (17.9%). Aneurysm clipping was performed on 20 of the 26 cases with no significant morbidity or mortality. These findings support the contention that aggressive early detection of unruptured aneurysms may improve the outcome in patients harboring cerebral aneurysms by preventing the devastating effects of SAH.

scholarly journals Both Surgical Clipping and Endovascular Embolization of Unruptured Intracranial Aneurysms Are Associated With Long-term Improvement in Self-Reported Quantitative Headache Scores

Neurosurgery ◽  
2011 ◽  
Vol 69 (1) ◽  
pp. 128-134 ◽  
Author(s):  
Ankeet A Choxi ◽  
Alia K Durrani ◽  
Robert A Mericle
Keyword(s):  
Endovascular Treatment ◽  
Intracranial Aneurysms ◽  
Pain Scale ◽  
Endovascular Embolization ◽  
Senior Author ◽  
Dramatic Improvement ◽  
Surgical Clipping ◽  
Unruptured Intracranial Aneurysms ◽  
Before And After

Abstract BACKGROUND: The most common presenting symptom for unruptured intracranial aneurysms (UIAs) is headache (HA). However, most experts believe that UIAs associated with HAs are unrelated and incidental. OBJECTIVE: To analyze the incidence and characterization of HAs in patients with UIAs before and after treatment with either surgical clipping or endovascular embolization. METHOD: We prospectively determined the presence, sidedness, and severity of HAs preoperatively in patients who presented to the senior author with a UIA. A validated, quantitative 11-point HA pain scale was used in all patients. The same HA assessments were performed again on these patients an average of 32.4 months postoperatively. RESULTS: In this study, 92.45% (n = 53) of patents for whom we were able to obtain both a preoperative and postoperative pain score had an improvement in their HAs. The average quantitative HA score was 5.87 preoperatively vs 1.39 postoperatively (P &lt; .001). There was no relationship found between the following: (1) HA severity vs aneurysm size, (2) sidedness of aneurysm vs sidedness of HA, and (3) HA improvement after surgical vs endovascular treatment. CONCLUSION: This study suggests that surgical and endovascular treatment of a UIA is associated with dramatic improvement in self-reported HA score an average of 32.4 months postoperatively.

Natural history and general management of unruptured intracranial aneurysms

2004 ◽  
Vol 17 (5) ◽  
pp. 1-6 ◽  
Author(s):  
Peng Roc Chen ◽  
Kai Frerichs ◽  
Robert Spetzler
Keyword(s):  
Natural History ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Cerebral Aneurysms ◽  
Population Based ◽  
Unruptured Aneurysms ◽  
Unruptured Intracranial Aneurysms ◽  
Risk Of Rupture ◽  
History Of ◽  
Unruptured Cerebral Aneurysms ◽  
Noninvasive Neuroimaging

After an aneurysmal subarachnoid hemorrhage, nearly half of the patients die and the half who survive suffer from irreversible cerebral damage. With increasing use of noninvasive neuroimaging techniques (for example, magnetic resonance and computerized tomography angiography), more unruptured cerebral aneurysms are found. To understand the prevalence of unruptured aneurysms in the general population, along with the risks of aneurysm formation, data on growth and rupture rates are crucial. The risk of rupture in aneurysms smaller than 10 mm is still not quite clear without a population-based prospective study. Nevertheless, a 0.5 to 2% annual risk may be a reasonable estimate. Growing aneurysms and those larger than 10 mm carry a higher rate of rupture. The management of an unruptured intracranial aneurysm should be based on a thorough understanding of the natural history of these lesions and careful evaluation of the morbidity and mortality levels associated with each treatment option.

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