scholarly journals Microsurgical Treatment of Pediatric Intracranial Aneurysms

Neurosurgery ◽  
2010 ◽  
Vol 67 (2) ◽  
pp. 237-250 ◽  
Author(s):  
Udaya K. Kakarla ◽  
Elisa J. Beres ◽  
Francisco A. Ponce ◽  
Steven W. Chang ◽  
Vivek R. Deshmukh ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Intracranial Aneurysms ◽  
De Novo ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Circulatory Arrest ◽  
Morbidity Rate ◽  
Parent Vessel ◽  
Vessel Occlusion

Abstract BACKGROUND Pediatric aneurysms are rare and complex to treat. Long-term angiographic and clinical data after microsurgical or endovascular therapies are lacking. OBJECTIVE To study the clinical and radiographic outcomes in aneurysms in pediatric patients treated with microsurgery. METHODS Between 1989 and 2005, 48 patients ≤ 18 years of age (28 boys, 20 girls; mean age, 12.3 years) were treated for intracranial aneurysms. Patient charts were reviewed retrospectively for age, presentation, type and location of aneurysm(s), surgical approach, complications, and clinical and angiographic outcomes. Rates of aneurysm recurrence and de novo formation were calculated. RESULTS Seventy-two aneurysms were treated. Presentations included incidental aneurysm (35%), aneurysmal subarachnoid hemorrhage (17%), stroke (13%), and traumatic subarachnoid hemorrhage (10%). Location was anterior circulation in 76% and posterior circulation in 24%. Twenty-eight (39%) were fusiform/dissecting, and 16 (23%) were giant. Most aneurysms were clipped directly. A vascular bypass with parent-vessel occlusion was used to treat 13 aneurysms (18%). Hypothermic circulatory arrest was used to treat 10 aneurysms (14%), all involving the basilar artery. The perioperative morbidity rate was 25%. There were no deaths. The long-term morbidity rate was 14%, and the mortality rate was 3%. Clinical outcome was favorable in 92% and 94% at discharge and follow-up, respectively (mean, 59 months; median, 32 months). At angiographic follow-up (mean, 53 months; median, 32 months), the annual recurrence rate was 2.6%, and the annual rate of de novo formation or growth was 7.8%. CONCLUSION Pediatric aneurysms require complex microsurgical techniques to achieve favorable outcomes. They leave higher rates of recurrence and de novo formation or growth than their adult counterparts, which mandates lifelong follow-up.

scholarly journals Sole Stenting with Large Cell Stents for Very Small Ruptured Intracranial Aneurysms

2014 ◽  
Vol 20 (1) ◽  
pp. 45-53 ◽  
Author(s):  
Young-Joon Kim ◽  
Jung HO Ko
Keyword(s):  
Intracranial Aneurysms ◽  
Large Cell ◽  
Bleeding Complications ◽  
Parent Vessel ◽  
Vessel Occlusion ◽  
Ruptured Intracranial Aneurysms ◽  
Small Aneurysms ◽  
Flow Diverting Stent

A flow-diverting stent such as the Pipeline embolization device (PED, ev3 Endovascular, Plymouth, MN, USA) and Silk flow-diverting stent (Balt Extrusion, Montmorency, France) offers an acceptable alternative for the treatment of difficult aneurysms according to their morphologies, including giant, wide-necked, fusiform, and blister types. However, complications arising from the use of these stents have frequently been reported including several cases of branch artery occlusion and delayed occlusion of the stented parent vessel shortly after antiplatelet medications were discontinued, highlighting the potential need for long-term antiplatelet therapy, and disastrous bleeding complications in unruptured aneurysm. In addition, these microcell stents are difficult to use in distal aneurysms located over the ICA bifurcation and basilar tip because of the stiffness of the device, and perforating vessel occlusion is more likely to occur due to the characteristics of the stent. Before the era of flow-diverting microcell stents, large cell intracranial stents like the Neuroform stent (Boston Scientific/Target Therapeutic, Fremont, CA, USA) and Enterprise stent (Cordis Neurovascular, Miami, FL, USA) without coiling were used to provide flow-diverting effects for complex intracranial aneurysms. Sole stenting has been used even in cases of ruptured aneurysm, with patients on different antiplatelet medications. However, no single endovascular institute has embraced sole stenting using large cell intracranial stents as a systemized treatment for ruptured intracranial aneurysms. Here we designed this study to evaluate the possibility of safely treating very small aneurysms using one or two stents without coiling during the period of subarachnoid hemorrhage (SAH). This retrospective study was conducted with eight patients who had rupture of very small intracranial aneurysms (less than 3 mm in size). All were treated using the Neuroform and the Enterprise stents; there was single stenting in five, in-stent telescopic stenting in two, and Y-configured stenting in one. The angiographic results with clinical outcomes were collected and analyzed. Complete aneurysm obliteration was observed in three cases, and size reduction or stable angiographic findings was found in five cases on the last follow-up angiography. No growing aneurysm or rebleeding was found on any follow-up angiography. Thromboembolic complications were found in one patient. It is difficult to make conclusions on the long-term efficacy of this technique with such a small number of cases, however sole stenting with a large cell intracranial stent for the treatment of very small aneurysms may be used safely as an alternative treatment even during an episode of SAH.

THE STOCKHOLM 20-YEAR FOLLOW-UP OF ANEURYSMAL SUBARACHNOID HEMORRHAGE OUTCOME

Neurosurgery ◽  
2007 ◽  
Vol 60 (6) ◽  
pp. 1017-1024 ◽  
Author(s):  
Göran Edner ◽  
Håkan Almqvist
Keyword(s):  
Subarachnoid Hemorrhage ◽  
De Novo ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Hospital Records ◽  
Long Term Outcome ◽  
Aneurysm Formation ◽  
Long Term Follow Up ◽  
De Novo Aneurysm

Abstract OBJECTIVE To assess the clinical and radiological long-term outcome after aneurysmal subarachnoid hemorrhage (SAH) in a defined referral area regarding recurrent SAH and de novo aneurysm formation. METHODS One hundred and two 1-year survivors after aneurysmal SAH, who were treated at the Neurosurgical Clinic, South Hospital, Stockholm, Sweden, between 1983 and 1985, were followed for 20 years. Forty-nine surviving patients were reevaluated. Hospital records and death certificates were scrutinized for all 53 nonsurviving patients. Clinical history penetration, Mini Mental Status, Rankin Disability Score, and Barthel Index were used to evaluate the outcome. Computed tomographic angiography was used to investigate the cerebral arteries. RESULTS One hundred and two patients were traced. Fifty-three patients were deceased. One patient had a hospital record of sustaining an aneurysmal SAH from a known but not clipped aneurysm. Three patients had nonaneurysmal intracerebral hemorrhage and two sustained traumatic SAH. There were 49 surviving patients. Six refused follow-up. None of these patients had hospital records of intracranial disease. Three of the 43 remaining patients could not be tested. None of the survivors had experienced a new SAH. Aneurysm base remnants were observed in 1% (eight patients, 790 person-years of follow-up) and de novo aneurysms were observed in 0.9% (seven patients, 790 person-years of follow-up). CONCLUSION From this epidemiological survey of patients with aneurysmal SAH, it was found that none of the patients experienced a recurrent subarachnoid bleed from the treated aneurysm during a 20-year follow-up period. Thus, a routine extreme long-term follow-up period is not necessary. De novo aneurysm formation and possible enlargements of aneurysm base remnants were observed in almost 2% of patients per person year and should, therefore, be subject of a routine, long-term follow-up.

scholarly journals Lack of impact of polycystic kidney disease on the outcome of aneurysmal subarachnoid hemorrhage: a matched case-control study

2020 ◽  
pp. 1-8
Author(s):  
Heidi J. Nurmonen ◽  
Terhi Huttunen ◽  
Jukka Huttunen ◽  
Arttu Kurtelius ◽  
Satu Kotikoski ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Kidney Disease ◽  
Polycystic Kidney Disease ◽  
De Novo ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Polycystic Kidney ◽  
Significant Difference ◽  
De Novo Aneurysm

OBJECTIVEThe authors set out to study whether autosomal dominant polycystic kidney disease (ADPKD), an established risk factor for intracranial aneurysms (IAs), affects the acute course and long-term outcome of aneurysmal subarachnoid hemorrhage (aSAH).METHODSThe outcomes of 32 ADPKD patients with aSAH between 1980 and 2015 (median age 43 years; 50% women) were compared with 160 matched (age, sex, and year of aSAH) non-ADPKD aSAH patients in the prospectively collected Kuopio Intracranial Aneurysm Patient and Family Database.RESULTSAt 12 months, 75% of the aSAH patients with ADPKD versus 71% of the matched-control aSAH patients without ADPKD had good outcomes (Glasgow Outcome Scale score 4 or 5). There was no significant difference in condition at admission. Hypertension had been diagnosed before aSAH in 69% of the ADPKD patients versus 27% of controls (p < 0.001). Multiple IAs were present in 44% of patients in the ADPKD group versus 25% in the control group (p = 0.03). The most common sites of ruptured IAs were the anterior communicating artery (47% vs 29%, p = 0.05) and the middle cerebral artery bifurcation (28% vs 31%), and the median size was 6.0 mm versus 8.0 mm (p = 0.02). During the median follow-up of 11 years, a second aSAH occurred in 3 of 29 (10%) ADPKD patients and in 4 of 131 (3%) controls (p = 0.11). A fatal second aSAH due to a confirmed de novo aneurysm occurred in 2 (6%) of the ADPKD patients but in none of the controls (p = 0.027).CONCLUSIONSThe outcomes of ADPKD patients with aSAH did not differ significantly from those of matched non-ADPKD aSAH patients. ADPKD patients had an increased risk of second aSAH from a de novo aneurysm, warranting long-term angiographic follow-up.

Revascularization and Aneurysm Surgery: Current Status

Neurosurgery ◽  
1985 ◽  
Vol 16 (1) ◽  
pp. 111-116 ◽  
Author(s):  
Robert F. Spetzler ◽  
Philip L. Carter
Keyword(s):  
Intracranial Aneurysms ◽  
Current Status ◽  
Aneurysm Surgery ◽  
Parent Vessel ◽  
Vessel Occlusion ◽  
Flow Measurements ◽  
Stump Pressure ◽  
Blood Flow Measurements ◽  
Vessel Ligation

Abstract Unclippable intracranial aneurysms are most effectively treated by hunterian ligation; however, the attendant risk of cerebral ischemia is significant. Many techniques have been used in an attempt to predict the safety of proximal vessel occlusion. Unfortunately, there is none that is risk-free and highly successful. A combination of stump pressure and cerebral blood flow measurements has been shown to be the most accurate in the acute assessment. In addition, recent studies have demonstrated that the long term risk of carotid ligation is significant. Extracranial-intracranial bypass grafting (EC-IC) has been shown to improve the safety of parent vessel ligation and is a low risk procedure. Whenever hunterian ligation is planned for the treatment of an intracranial aneurysm, EC-IC should be strongly considered. (Neurosurgery 16:111–116, 1985)

Clinical complications and outcomes of angiographically negative subarachnoid hemorrhage

Neurology ◽  
2019 ◽  
Vol 92 (20) ◽  
pp. e2385-e2394 ◽  
Author(s):  
Cody L. Nesvick ◽  
Soliman Oushy ◽  
Lorenzo Rinaldo ◽  
Eelco F. Wijdicks ◽  
Giuseppe Lanzino ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Confidence Interval ◽  
Ventriculoperitoneal Shunt ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Delayed Cerebral Ischemia ◽  
Tertiary Referral Center ◽  
Short And Long Term ◽  
Csf Diversion

ObjectiveTo define the in-hospital course, complications, short- and long-term functional outcomes of patients with angiographically negative subarachnoid hemorrhage (anSAH), particularly those with aneurysmal-pattern anSAH (aanSAH).MethodsRetrospective cohort study of patients with aneurysmal subarachnoid hemorrhage (aSAH), aanSAH, and perimesencephalic-pattern anSAH (panSAH) treated at a single tertiary referral center between January 2006 and April 2018. Ninety-nine patients with anSAH (33 aanSAH and 66 panSAH) and 464 patients with aSAH were included in this study. Outcomes included symptomatic hydrocephalus requiring CSF drainage, need for ventriculoperitoneal shunt, radiographic vasospasm, delayed cerebral ischemia (DCI), radiographic infarction, disability level within 1 year of ictus, and at last clinical follow-up as defined by the modified Rankin Scale.ResultsPatients with aanSAH and panSAH had similar rates of DCI and radiologic infarction, and patients with aanSAH had significantly lower rates compared to aSAH (p ≤ 0.018). Patients with aanSAH were more likely than those with panSAH to require temporary CSF diversion and ventriculoperitoneal shunt (p ≤ 0.03), with similar rates to those seen in aSAH. Only one patient with anSAH died in the hospital. Compared to those with aSAH, patients with aanSAH were significantly less likely to have a poor functional outcome within 1 year of ictus (odds ratio 0.26, 95% confidence interval 0.090–0.75) and at last follow-up (hazard ratio 0.30, 95% confidence interval 0.19–0.49, p = 0.002).ConclusionsDCI is very uncommon in anSAH, but patients with aanSAH have a similar need for short- and long-term CSF diversion to patients with aSAH. Nevertheless, patients with aanSAH have significantly better short- and long-term outcomes.

scholarly journals Endovascular Treatment of Small Ruptured Intracranial Aneurysms (<5 mm)

2019 ◽  
Vol 30 (4) ◽  
pp. 817-826
Author(s):  
Fei Peng ◽  
Xin Feng ◽  
Xin Tong ◽  
Baorui Zhang ◽  
Luyao Wang ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Intracranial Aneurysms ◽  
Cox Proportional Hazards ◽  
Parent Artery ◽  
Parent Vessel ◽  
Fisher Grade ◽  
Wide Neck ◽  
Ruptured Intracranial Aneurysms

Abstract Purpose To investigate the long-term clinical and angiographic outcomes and their related predictors in endovascular treatment (EVT) of small (<5 mm) ruptured intracranial aneurysms (SRA). Methods The study retrospectively reviewed patients with SRAs who underwent EVT between September 2011 and December 2016 in two Chinese stroke centers. Medical charts and telephone call follow-up were used to identify the overall unfavorable clinical outcomes (OUCO, modified Rankin score ≤2) and any recanalization or retreatment. The independent predictors of OUCO and recanalization were studied using univariate and multivariate analyses. Multivariate Cox proportional hazards models were used to identify the predictors of retreatment. Results In this study 272 SRAs were included with a median follow-up period of 5.0 years (interquartile range 3.5–6.5 years) and 231 patients with over 1171 aneurysm-years were contacted. Among these, OUCO, recanalization, and retreatment occurred in 20 (7.4%), 24 (12.8%), and 11 (7.1%) patients, respectively. Aneurysms accompanied by parent vessel stenosis (AAPVS), high Hunt-Hess grade, high Fisher grade, and intraoperative thrombogenesis in the parent artery (ITPA) were the independent predictors of OUCO. A wide neck was found to be a predictor of recanalization. The 11 retreatments included 1 case of surgical clipping, 6 cases of coiling, and 4 cases of stent-assisted coiling. A wide neck and AAPVS were the related predictors. Conclusion The present study demonstrated relatively favorable clinical and angiographic outcomes in EVT of SRAs in long-term follow-up of up to 5 years. THE AAPVS, as a morphological indicator of the parent artery for both OUCO and retreatment, needs further validation.

scholarly journals Endovascular Treatment of Intracranial Aneurysms in the Flow Diverter Era: Frequency of Use and Results in a Consecutive Series of 550 Treatments in a Single Centre

2014 ◽  
Vol 20 (4) ◽  
pp. 428-435 ◽  
Author(s):  
Willem Jan van Rooij ◽  
Ratna S Bechan ◽  
Jo P. Peluso ◽  
Menno Sluzewski
Keyword(s):  
Intracranial Aneurysms ◽  
Flow Diverter ◽  
Flow Diversion ◽  
Consecutive Series ◽  
Complication Rates ◽  
Parent Vessel ◽  
Vessel Occlusion ◽  
Permanent Neurological Deficit ◽  
Flow Diverters

Flow diverter devices became available in our department in 2009. We considered treatment with flow diverters only in patients with aneurysms not suitable for surgery or conventional endovascular techniques. This paper presents our preliminary experience with flow diverters in a consecutive series of 550 endovascular aneurysm treatments. Between January 2009 and July 2013, 550 endovascular treatments for intracranial aneurysms were performed. Of these, 490 were first-time aneurysm treatments in 464 patients and 61 were additional treatments of previously coiled aneurysms in 51 patients. Endovascular treatments consisted of selective coiling in 445 (80.8%), stent-assisted coiling in 68 (12.4%), balloon-assisted coiling in 13 (2.4%), parent vessel occlusion in 12 (2.2%) and flow diverter treatment in 12 (2.2%). Eleven patients with 12 aneurysms were treated with flow diverters. Two patients had ruptured dissecting aneurysms. One patient with a basilar trunk aneurysm died of acute in stent thrombosis and another patient died of brain stem ischaemia at 32 months follow-up. One patient had ischaemia with permanent neurological deficit. Two aneurysms are still open at up to 30 months follow-up. Flow diversion was used in 2% of all endovascular treatments. Both our own poor results and the high complication rates reported in the literature have converted our initial enthusiasm to apprehension and hesitancy. The safety and efficacy profile of flow diversion should discourage the use of these devices in aneurysms that can be treated with other techniques.

scholarly journals Endovascular Management for P2 Aneurysms of the Posterior Cerebral Artery

2009 ◽  
Vol 15 (3) ◽  
pp. 341-348 ◽  
Author(s):  
X. Lv ◽  
Y. Li ◽  
C. Jiang ◽  
Z. Wu
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Effective Treatment ◽  
Posterior Cerebral Artery ◽  
Parent Artery ◽  
Endovascular Management ◽  
Parent Vessel ◽  
Vessel Occlusion ◽  
Presenting Symptoms ◽  
Parent Vessel Occlusion

This study evaluated the outcomes of endovascular management for P2-segment aneurysms. From 2003 to 2008, 14 consecutive patients with P2 aneurysms were treated endovascularly by proximal P2 segment occlusion at our institution. The aneurysms included 12 P2a and two P2p aneurysms. Presenting symptoms were caused by subarachnoid hemorrhage (SAH) in six patients, stroke in five, and isolated headaches in three. Mean follow-up was 14 months. Twelve aneurysms were treated with proximal P2 segment occlusion without parent artery revascularization. Twelve aneurysms were at the P2a and two aneurysms at the P2p. Two patients developed hemianopsia after the procedure and one recovered completely within six months follow-up with one still persistent at 22-month follow-up. Proximal parent vessel occlusion was a relatively safe, effective treatment for P2 aneurysms that posed low risk for early or delayed ischemia or infarction.

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