GUIDELINES FOR THE SURGICAL TREATMENT OF UNRUPTURED INTRACRANIAL ANEURYSMS

Neurosurgery ◽  
2008 ◽  
Vol 62 (1) ◽  
pp. 183-194 ◽  
Author(s):  
Ricardo J. Komotar ◽  
J Mocco ◽  
Robert A. Solomon
Keyword(s):  
Medical Center ◽  
Adult Population ◽  
Cerebral Aneurysms ◽  
The Elderly ◽  
Low Risk ◽  
Endovascular Coiling ◽  
Case Volume ◽  
Unruptured Aneurysms ◽  
Unruptured Intracranial Aneurysms ◽  
Incidental Aneurysms

Abstract THE MANAGEMENT OF unruptured cerebral aneurysms remains one of the most controversial topics in neurosurgery. To this end, we discuss the diagnosis and estimated prevalence of these lesions as well as review the literature regarding the rate of rupture for cerebral aneurysms and risks of operative intervention. Our interpretation of the literature concludes that aneurysms are present in approximately 1% of the adult population, varying between less than 1% in young adults to 4% in the elderly. The yearly risk of subarachnoid hemorrhage for an unruptured intracranial aneurysm is approximately 1% for lesions 7 to 10 mm in diameter. Based on these assumptions, we recommend that 1) with rare exceptions, all symptomatic unruptured aneurysms should be treated; 2) small, incidental aneurysms less than 5 mm in diameter should be managed conservatively in virtually all cases; 3) aneurysms larger than 5 mm in patients younger than 60 years of age should be seriously considered for treatment; 4) large, incidental aneurysms larger than 10 mm should be treated in nearly all patients younger than 70 years of age; and 5) microsurgical clipping rather than endovascular coiling should be the first treatment choice in low-risk cases. Critical to our guidelines is collaboration by a highly experienced cerebrovascular team of microneurosurgeons and endovascular neurosurgeons working at a tertiary medical center with a high case volume and using a decision-making paradigm designed to offer only low-risk treatments. In certain patients for whom both treatment and natural history carry high risks, such as those with giant aneurysms, nonoperative management is typically elected.

scholarly journals Endovascular management of intracranial aneurysms during pregnancy in three cases and review of the literature

2015 ◽  
Vol 21 (6) ◽  
pp. 654-658 ◽  
Author(s):  
Peng Liu ◽  
Xianli Lv ◽  
Youxiang Li ◽  
Ming Lv
Keyword(s):  
Cesarean Section ◽  
Cerebral Aneurysms ◽  
Endovascular Coiling ◽  
Review Of The Literature ◽  
Endovascular Techniques ◽  
Healthy Baby ◽  
Unruptured Aneurysms ◽  
Gestational Week ◽  
Basilar Tip Aneurysm ◽  
Case Basis

We present three cases of cerebral aneurysms (1 unruptured; 2 ruptured) treated with endovascular techniques in pregnancies. The first ruptured case is a 28-year-old female on 20th gestational week. After the endovascular coiling, the patient suffered persistent hemiparesis and delivered a healthy baby by cesarean section. The second ruptured case is a 25-year-old female on 36th week of pregnancy. She died of aneurysm re-rupture after delivery of a healthy baby by cesarean section. The third unruptured case is a 31-year-old woman on the 26th gestational week of pregnancy who died of a giant basilar tip aneurysm after stent-assisted coiling. Ruptured aneurysm obliteration should be prioritized followed by vaginal delivery or cesarean section. The decision regarding the treatment of unruptured aneurysms should be carefully considered on a case-by-case basis. Stent-assisted coiling may be applicable to aneurysm during pregnancy.

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.

Prevalence of asymptomatic incidental aneurysms: review of 4568 arteriograms

2002 ◽  
Vol 96 (1) ◽  
pp. 43-49 ◽  
Author(s):  
H. Richard Winn ◽  
John A. Jane ◽  
James Taylor ◽  
Donald Kaiser ◽  
Gavin W. Britz
Keyword(s):  
Prevalence Rate ◽  
Cerebral Aneurysms ◽  
Anterior Circulation ◽  
Content Type ◽  
Unruptured Aneurysms ◽  
Incidental Aneurysms ◽  
Unruptured Cerebral Aneurysms ◽  
The University ◽  
Yearly Rate ◽  
Fine Print

Object. The prevalence of unruptured cerebral aneurysms is unknown, but is estimated to be as high as 5%. The goal of this study was to determine the prevalence of asymptomatic incidental aneurysms. Methods. The authors studied all cerebral arteriography reports produced at a single institution, the University of Virginia, between April 1969 and January 1980. A review of 3684 arteriograms demonstrated 24 cases of asymptomatic aneurysms, yielding a prevalence rate of 0.65%. The majority (67%) of the 24 patients harboring unruptured aneurysms were women. More than 90% of the unruptured aneurysms were located in the anterior circulation and in locations similar to those found in patients with ruptured aneurysms. Nearly 80% of the aneurysms were smaller than 1 cm in their greatest diameter. The frequency of asymmetrical unruptured aneurysms (0.6–1.5%) was constant throughout all relevant age ranges (35–84 years). Conclusions. While keeping in mind appropriate caveats in extrapolating from these data, the prevalence rate of asymptomatic unruptured aneurysms found in the present study allows an estimation of the yearly rate of rupture of these lesions. The authors suggest that this yearly rate of rupture falls within the range of 1 to 2%.

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 Microembolism after endovascular coiling of unruptured cerebral aneurysms: incidence and risk factors

2016 ◽  
Vol 124 (3) ◽  
pp. 777-783 ◽  
Author(s):  
Jung Cheol Park ◽  
Deok Hee Lee ◽  
Jae Kyun Kim ◽  
Jae Sung Ahn ◽  
Byung Duk Kwun ◽  
...  
Keyword(s):  
Risk Factors ◽  
Multivariate Analysis ◽  
Previous History ◽  
Cerebral Aneurysms ◽  
Endovascular Coiling ◽  
High Signal ◽  
Unruptured Intracranial Aneurysms ◽  
Apparent Diffusion ◽  
Apparent Diffusion Coefficient Maps ◽  
Unruptured Cerebral Aneurysms

OBJECT The incidence and risk factors of microembolic lesions on MR diffusion-weighted imaging (DWI) were analyzed after the endovascular coiling of unruptured intracranial aneurysms (UIAs). METHODS Data obtained from 271 consecutive patients (70 men and 201 women; median age 57 years; range 23–79 years) who presented with UIA for coil embolization between July 2011 and June 2013 were analyzed. Two independent reviewers examined the DWI and apparent diffusion coefficient maps obtained the following day for the presence of restrictive diffusion spots and counted the number of spots. Multivariate analysis was then performed to identify independent risk factors for developing microembolism following the coiling of an aneurysm. RESULTS Microembolic lesions were noted in 101 of 271 patients (37.3%). The results of the multivariate analysis showed that the following factors significantly influenced the risk for microembolism: age, diabetes, previous history of ischemic stroke, high-signal FLAIR lesions in the white matter, multiple aneurysms, and the insertion of an Enterprise stent (all ORs > 1.0 and all p values < 0.05). Previously known risk factors such as prolonged procedure duration, aneurysm size, and decreased antiplatelet function did not show any significant influence. CONCLUSIONS The incidence of microembolism after endovascular coiling of UIA was not low. Lesions occurred more frequently in patients with vascular status associated with old age, diabetes, and previous stroke. Aneurysm multiplicity and the type of stent used for treatment also influenced lesion occurrence.

Endovascular Treatment of Incidental Cerebral Aneurysms

1999 ◽  
Vol 5 (1_suppl) ◽  
pp. 79-81 ◽  
Author(s):  
Y. Murayama ◽  
F. Viñuela ◽  
G.R. Duckwiler ◽  
Y.P. Gobin ◽  
G. Guglielmi
Keyword(s):  
Average Length ◽  
Medical Center ◽  
Clinical Status ◽  
Cerebral Aneurysms ◽  
Clinical Complications ◽  
Incidental Aneurysms ◽  
Procedural Complications ◽  
Aneurysm Occlusion ◽  
Incomplete Occlusion ◽  
Neurologically Intact

One hundred and fifteen patients with 120 intracranial incidental aneurysms were embodied using the GDC endovascular technique at UCLA Medical Center. Angiographic results showed complete or near complete aneurysm occlusion in 109 aneurysms (91%) and an incomplete occlusion in five aneurysms (4%). An unsuccessful GDC embolization was attempted in six aneurysms (5%). One hundred and nine patients (94.8%) remained neurologically intact or unchanged from initial clinical status. Five patients (43%) deteriorated due to immediate procedural complications. All these complications occurred in the first 50 patients. No clinical complications were observed in the last 65 patients. In Groups 1 and 3, the average length of hospitalization was 3.3 days. The technical evolution of the GDC technology has proved to be safe for the treatment of incidental aneurysms (0% morbidity in the last 65 patients). The topography of the aneurysm/s and the clinical condition of the patient did not influence final anatomical or clinical outcomes. GDC technology also brings a positive economical impact by decreasing hospitalization time and eliminating postembolization ICU care.

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.

scholarly journals Association between Size and Location with Cerebral Aneurysms Rupture

1969 ◽  
Vol 30 (3) ◽  
pp. 190-196
Author(s):  
Dan Zimelewicz Oberman
Keyword(s):  
Cerebral Aneurysms ◽  
Preventive Treatment ◽  
Cross Sectional Study ◽  
Aneurysm Rupture ◽  
High Morbidity ◽  
Anterior Circulation ◽  
Cross Sectional ◽  
Unruptured Aneurysms ◽  
Unruptured Intracranial Aneurysms ◽  
Significant Difference

Introduction: Aneurysm rupture is the most dangerous complication with high morbidity and mortality rate, greater than 40%. Identifying risk factors for aneurysm rupture is extremely important for selecting patients who may truly benefit from preventive treatment. Objective: The aim of this study was to review our patients with ruptured and unruptured intracranial aneurysms and determine if there was an association between the size and location of aneurysms and their rupture. Methods: A cross-sectional study was performed in adult patients with cerebral aneurysm diagnosed from March 2015 to February 2017. Patients were divided into two groups, one with ruptured aneurysms and the other with unruptured aneurysms. Location according to anterior and posterior circulation was recorded. Size was stratified in three categories: (1) less than 7 mm; (2) between 7-12 mm; and (3) bigger than 13 mm in diameters. Results: During this period 80 patients were diagnosed with cerebral aneurysms. A total of 106 aneurysms were identified, 33 aneurysms were ruptured and 73 were unruptured. The mean sizes were 7.88 ± 6.23 mm and 5.35 ± 3.24 mm, respectively. There was statistically significant differences in aneurysm size (p<0.03) between the ruptured and unruptured group. Logistic regression revealed a higher association of rupture of anterior circulation aneurysm when size was ≥ 4mm (p<0.02). Conclusions: There was a significant difference between the size of ruptured and unruptured aneurysm groups. Anterior circulation aneurysms≥4mm revealed a higher association with rupture. This suggest this location should be evaluated more carefully for preventive treatment.

Treatment of ruptured and unruptured cerebral aneurysms in the USA: a paradigm shift

2018 ◽  
Vol 10 (Suppl 1) ◽  
pp. i69-i76 ◽  
Author(s):  
Ning Lin ◽  
Kevin S Cahill ◽  
Kai U Frerichs ◽  
Robert M Friedlander ◽  
Elizabeth B Claus
Keyword(s):  
Hospital Mortality ◽  
Cerebral Aneurysms ◽  
Unruptured Aneurysm ◽  
Ruptured Aneurysm ◽  
Teaching Hospitals ◽  
Endovascular Coiling ◽  
Surgical Clipping ◽  
Unruptured Aneurysms ◽  
The Usa ◽  
Over Time

BackgroundIntegration of data from clinical trials and advancements in technology predict a change in selection for treatment of patients with cerebral aneurysm.ObjectiveTo describe patterns of use and in-hospital mortality associated with surgical and endovascular treatments of cerebral aneurysms over the past decade.Materials and methodsThe data are 34 899 hospital discharges with a diagnosis of ruptured or unruptured cerebral aneurysm from 1998 to 2007 identified from the Nationwide Inpatient Sample (NIS). The rates of endovascular coiling and surgical clipping and in-hospital mortality among patients with an aneurysm are examined over a decade by hospital and patient demographic characteristics.ResultsFrom 1998 to 2007, 20 134 discharges with a ruptured aneurysm and 14 765 discharges with an unruptured aneurysm were identified. Over this decade, the number of patients discharged with a ruptured aneurysm was stable while the number discharged with an unruptured aneurysm increased significantly. The use of endovascular coiling increased at least twofold for both groups of patient (p<0.001) with the majority of unruptured aneurysms treated with coiling by 2007. Although whites were more likely than non-whites to undergo coiling versus clipping for a ruptured aneurysm (OR=1.30; 95% CI 1.13 to 1.48) and men with unruptured aneurysms were more likely than women to undergo coiling (OR=1.26; 95% CI 1.13 to 1.40), by 2007 differences in treatment selection by gender and racial subgroups were decreased or statistically non-significant. Over time the use of coiling spread from primarily large, teaching hospitals to smaller, non-teaching hospitals.ConclusionsThe majority of unruptured aneurysms in the USA are now treated with endovascular coiling. Although surgical clipping is used for treatment of most ruptured aneurysms, its use is decreasing over time. Dissemination of endovascular procedures appears widespread across patient and hospital subgroups.

scholarly journals Contemporary management of incidental intracranial aneurysms

2005 ◽  
Vol 18 (1) ◽  
pp. 1-7 ◽  
Author(s):  
Ramachandra P. Tummala ◽  
Mustafa K. Bas ¸Kaya ◽  
Roberto C. Heros
Keyword(s):  
Natural History ◽  
Intracranial Aneurysms ◽  
Noninvasive Imaging ◽  
Attractive Alternative ◽  
Unruptured Aneurysms ◽  
Diagnosis And Management ◽  
Unruptured Intracranial Aneurysms ◽  
Incidental Aneurysms ◽  
History Of ◽  
Contemporary Management

The management of unruptured intracranial aneurysms has changed significantly in recent years and continues to evolve. The three main factors that have affected the management of unruptured intracranial aneurysms are as follows: 1) increased availability of noninvasive imaging technology, resulting in increased detection of incidental aneurysms; 2) improved understanding of the natural history of unruptured aneurysms; and 3) the advent of neuroendovascular therapy. In this report, the authors discuss the implications of these factors in the diagnosis and management of truly incidental, asymptomatic aneurysms and review the current practice patterns at their institution. Historical and current articles regarding noninvasive neuroimaging, aneurysm screening, endovascular and surgical therapy, and the natural history of unruptured aneurysms were reviewed. Current practices used for diagnosis and management of incidental aneurysms at the authors' institution were also reviewed. The management of incidental intracranial aneurysms has become an increasingly controversial subject in recent years. Improvements in noninvasive imaging resulting in detection of an increasing number of incidental aneurysms, the establishment of endovascular therapy as an attractive alternative to surgery, and studies indicating a more benign natural history for unruptured aneurysms than previously thought have led to significant changes in neurosurgical practice. Safety and long-term efficacy are the goals of treatment for unruptured aneurysms. Until conclusive studies are completed, the experience of the neurovascular team at each institution and the art of patient selection for treatment will continue to play a fundamental role in the management of these lesions.

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