Treatment outcomes of 1-stage clipping of multiple unruptured intracranial aneurysms via keyhole approaches

OBJECTIVE Complete exclusion of multiple unruptured intracranial aneurysms (UIAs) in one session of intervention may be ideal. However, such situations are not always feasible in terms of treatment modalities and outcomes. The authors aimed to analyze their experience with 1-stage clipping of multiple UIAs. METHODS Medical records between March 2013 and December 2018 were retrospectively reviewed, and 111 1-stage keyhole approaches in 110 patients with 261 multiple UIAs were ultimately included in this study. Clinical and radiological outcomes were analyzed, as well as postoperative complications up to 1 month after the surgery and their risk factors. RESULTS Keyhole approaches included unilateral supraorbital in 87 operations (78.4%), bilateral supraorbital in 12 (10.8%), and others in 12. The mean operative duration was 169.6 minutes (range 80–490 minutes). The highest numbers of aneurysms clipped at once were 2 (73.9%) and 3 (18.9%). Complete exclusion and residual neck of the clipped aneurysms were achieved in 89.3% and 7.3%, respectively. There was no significant difference between pre- and postoperative 1-month neurological states (p = 0.14). The permanent morbidity rate was 1.8% (n = 2), and there were no deaths. Postoperative transient neurological deterioration (TND) with no radiological and electrophysiological abnormalities occurred in 8 operations (7.2%). Hypertension was the only significant risk factor for postoperative TND (adjusted odds ratio 17.03, 95% confidence interval 1.99–2232.24, p = 0.01). CONCLUSIONS One-stage clipping of multiple UIAs via keyhole approaches showed satisfactory treatment outcomes with a low permanent morbidity. Patients with chronic hypertension had a high risk of postoperative TND.

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Antiplatelet Premedication for Stent-Assisted Coil Embolization of Intracranial Aneurysms: Low-Dose Prasugrel vs Clopidogrel

Neurosurgery ◽

10.1093/neuros/nyx591 ◽

2017 ◽

Vol 83 (5) ◽

pp. 981-988 ◽

Cited By ~ 21

Author(s):

Hyun Ho Choi ◽

Jung Jun Lee ◽

Young Dae Cho ◽

Moon Hee Han ◽

Won-Sang Cho ◽

...

Keyword(s):

Coil Embolization ◽

Intracranial Aneurysms ◽

Low Dose ◽

Significant Risk ◽

Cerebral Aneurysms ◽

Significant Risk Factor ◽

Thromboembolic Events ◽

Antiplatelet Medication ◽

Unruptured Intracranial Aneurysms ◽

Significant Difference

Abstract BACKGROUND The use of antiplatelet medications to prevent thrombosis in the treatment of cerebral aneurysms with stents has become widely emphasized. OBJECTIVE To compare low-dose prasugrel with clopidogrel in stent-assisted coil embolization of intracranial aneurysms. METHODS This is a retrospective review of 311 aneurysms from 297 patients who underwent stent-assisted endovascular coil embolization of unruptured intracranial aneurysm between November 2014 and March 2017. Thromboembolic and hemorrhagic adverse events were compared between 207 patients who received low-dose prasugrel (PSG group) and 90 patients who received clopidogrel (CPG group). RESULTS P2Y12 reaction unit (PRU) values were significantly lower in the PSG group (PSG group vs CPG group, 132.3 ± 76.9 vs 238.1 ± 69.1; P < .001); the percentage of inhibition was also statistically higher in the PSG group (54.0 ± 26.0% vs 20.8 ± 18.6%; P < .001). Thromboembolic events occurred less frequently in the PSG group than in the CPG group (0.9% vs 6.4%; P = .01), whereas there was no significant difference in the percentage of hemorrhagic complications (0.5% vs 2.2%; P = .22). In the multivariate analysis, clopidogrel as the antiplatelet medication was the sole significant risk factor for thromboembolism in this series of patients undergoing stent-assisted coil embolization. CONCLUSION Use of low-dose PSG as an antiplatelet premedication is quick, effective, and safe for stent-assisted coil embolization of unruptured intracranial aneurysms. Prasugrel premedication significantly lowered the frequency of thromboembolic events without increasing the risk of hemorrhage.

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Surgical Clipping of Very Small Unruptured Intracranial Aneurysms

Neurosurgery ◽

10.1227/neu.0000000000000991 ◽

2015 ◽

Vol 78 (1) ◽

pp. 47-52 ◽

Cited By ~ 19

Author(s):

Michaël Bruneau ◽

Sepideh Amin-Hanjani ◽

Päivi Koroknay-Pal ◽

Philippe Bijlenga ◽

Behnam Rezai Jahromi ◽

...

Keyword(s):

Neurological Deficit ◽

Intracranial Aneurysms ◽

Significant Risk ◽

Perioperative Period ◽

Significant Risk Factor ◽

Posterior Circulation ◽

Morbidity Rate ◽

Surgical Clipping ◽

Anterior Circulation ◽

Unruptured Intracranial Aneurysms

Abstract BACKGROUND: Treatment of very small unruptured intracranial aneurysms (VSUIAs, defined as ⩽3 mm) can be indicated in selected circumstances. The feasibility and outcomes of endovascular therapy for VSUIAs have been recently published; however, the efficacy and complication rate of surgical clipping has not been reported in any large series to date. OBJECTIVE: We conducted a multicenter study to examine surgical outcomes for VSUIAs. METHODS: All consecutive patients undergoing surgery for a VSUIA in 4 neurosurgical centers between October 2001 and December 2012 were retrospectively analyzed. RESULTS: In the study, 183 patients (128 women, mean age 51.3 years) were treated with 190 procedures for a total of 228 aneurysms. Most were anterior circulation aneurysms (n = 215). The majority were directly clipped (n = 222, 97.4%), with coagulation or wrapping in the remainder. After 1 reoperation for incomplete clipping, postoperative imaging of 225 aneurysms confirmed complete occlusion in 221 (98.2%), 1 neck remnant (0.44%), and 3 partial occlusions (1.3%). Mortality was 0%. Early postoperative neurological deficit developed in 12 patients (6.6%); posterior circulation location was a significant risk factor for early neurological deficit (P < .001). Middle cerebral artery aneurysms had the lowest rate of postoperative deficits at 1.5% (P = .023). After the initial 30-day perioperative period, all deficits related to treatment of posterior circulation aneurysms recovered; overall neurological morbidity decreased to 2.7% with no mortality. CONCLUSION: VSUIA clipping is highly effective and is associated with a low morbidity rate. For VSUIAs selected for treatment, our data support surgical clipping as the modality of choice.

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Increased rupture risk in small intracranial aneurysms associated with methamphetamine use

Interventional Neuroradiology ◽

10.1177/1591019920959534 ◽

2020 ◽

pp. 159101992095953

Author(s):

Dylan Noblett ◽

Lotfi Hacein-Bey ◽

Ben Waldau ◽

Jordan Ziegler ◽

Brian Dahlin ◽

...

Keyword(s):

Intracranial Aneurysms ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Significant Risk ◽

Retrospective Chart Review ◽

Anterior Circulation ◽

Unruptured Aneurysms ◽

Methamphetamine Use ◽

Aneurysm Size ◽

Unruptured Intracranial Aneurysms ◽

History Of

Background Aneurysmal subarachnoid hemorrhage (SAH) is the most common cause of nontraumatic SAH. Current guidelines generally recommend observation for unruptured intracranial aneurysms smaller than 7 mm, for those are considered at low risk for spontaneous rupture according to available scoring systems. Objective We observed a tendency for SAH in small intracranial aneurysms in patients who are methamphetamine users. A retrospective, single center study to characterize the size and location of ruptured and unruptured intracranial aneurysms in methamphetamine users was performed. Materials and methods Clinical characteristics and patient data were collected via retrospective chart review of patients with intracranial aneurysms and a history of methamphetamine use with a specific focus on aneurysm size and location. Results A total of 62 patients were identified with at least one intracranial aneurysm and a history of methamphetamine use, yielding 73 intracranial aneurysms (n = 73). The mean largest diameter of unruptured aneurysms (n = 44) was 5.1 mm (median 4.5, SD 2.5 mm), smaller than for ruptured aneurysms (n = 29) with a mean diameter of 6.3 mm (median 5.5, SD 2.5 mm). Aneurysms measuring less than 7 mm presented with SAH in 36.5%. With regard to location, 28% (n = 42) of anterior circulation aneurysms less than 7 mm presented with rupture, in contrast to 70% (n = 10) of posterior circulation aneurysms which were found to be ruptured. Conclusions Methamphetamine use may be considered a significant risk factor for aneurysmal SAH at a smaller aneurysm size than for other patients. These patients may benefit from a lower threshold for intervention and/or aggressive imaging and clinical follow-up.

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Natural history of unruptured intracranial aneurysms: probability of and risk factors for aneurysm rupture

Journal of Neurosurgery ◽

10.3171/jns/2008/108/5/1052 ◽

2008 ◽

Vol 108 (5) ◽

pp. 1052-1060 ◽

Cited By ~ 105

Author(s):

Seppo Juvela ◽

Matti Porras ◽

Kristiina Poussa

Keyword(s):

Risk Factors ◽

Intracranial Aneurysms ◽

Smoking Status ◽

Significant Risk ◽

Significant Risk Factor ◽

Aneurysm Rupture ◽

Unruptured Aneurysms ◽

Unruptured Intracranial Aneurysms ◽

History Of

Object The authors conducted a study to investigate the long-term natural history of unruptured intracranial aneurysms and the predictive risk factors determining subsequent rupture in a patient population in which surgical selection of cases was not performed. Methods One hundred forty-two patients with 181 unruptured aneurysms were followed from the 1950s until death or the occurrence of subarachnoid hemorrhage or until the years 1997 to 1998. The annual and cumulative incidence of aneurysm rupture as well as several potential risk factors predictive of rupture were studied using life-table analyses and Cox's proportional hazards regression models including time-dependent covariates. The median follow-up time was 19.7 years (range 0.8–38.9 years). During 2575 person-years of follow up, there were 33 first-time episodes of hemorrhage from previously unruptured aneurysms, for an average annual incidence of 1.3%. In 17 patients, hemorrhage led to death. The cumulative rate of bleeding was 10.5% at 10 years, 23% at 20 years, and 30.3% at 30 years after diagnosis. The diameter of the unruptured aneurysm (relative risk [RR] 1.11 per mm in diameter, 95% confidence interval [CI] 1–1.23, p = 0.05) and patient age at diagnosis inversely (RR 0.97 per year, 95% CI 0.93–1, p = 0.05) were significant independent predictors for a subsequent aneurysm rupture after adjustment for sex, hypertension, and aneurysm group. Active smoking status at the time of diagnosis was a significant risk factor for aneurysm rupture (RR 1.46, 95% CI 1.04–2.06, p = 0.033) after adjustment for size of the aneurysm, patient age, sex, presence of hypertension, and aneurysm group. Active smoking status as a time-dependent covariate was an even more significant risk factor for aneurysm rupture (adjusted RR 3.04, 95% CI 1.21–7.66, p = 0.02). Conclusions Cigarette smoking, size of the unruptured intracranial aneurysm, and age, inversely, are important factors determining risk for subsequent aneurysm rupture. The authors conclude that such unruptured aneurysms should be surgically treated regardless of their size and of a patient's smoking status, especially in young and middle-aged adults, if this is technically possible and if the patient's concurrent diseases are not contraindications. Cessation of smoking may also be a good alternative to surgery in older patients with small-sized aneurysms.

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Cognitive Outcome and Clinically Silent Thromboembolic Events After Coiling of Asymptomatic Unruptured Intracranial Aneurysms

Neurosurgery ◽

10.1227/neu.0b013e3182846f74 ◽

2012 ◽

Vol 72 (4) ◽

pp. 638-645 ◽

Cited By ~ 16

Author(s):

Dong-Hun Kang ◽

Yang-Ha Hwang ◽

Yong-Sun Kim ◽

Geum Ye Bae ◽

Seung Jae Lee

Keyword(s):

Cognitive Deficits ◽

Coil Embolization ◽

Intracranial Aneurysms ◽

Cognitive Outcome ◽

Cognitively Impaired ◽

Thromboembolic Events ◽

Cognitive Changes ◽

Focal Neurological Deficit ◽

Unruptured Intracranial Aneurysms ◽

Significant Difference

Abstract BACKGROUND: Thromboembolic events are the most common complication after coiling of unruptured intracranial aneurysms (UIAs). However, it remains unclear whether these clinically silent ischemic lesions (CSILs) have any clinical significance. OBJECTIVE: To evaluate cognitive outcome after coil embolization of asymptomatic UIAs and its relationship with CSILs after the procedure. METHODS: We prospectively enrolled 40 UIA patients who showed no new focal neurological deficit after coil embolization. CSILs were assessed with diffusion-weighted imaging (DWI) within 1 day after the procedure. A battery of neuropsychological tests was performed 3 times: preoperatively and postoperatively at 1 and 4 weeks after coil embolization. RESULTS: The incidence of cognitive impairment after coiling in patients with UIAs was 44% (17 of 39) at 1 week and 19% (7 of 37) at 4 weeks after coil embolization. DWI within 1 day after coil embolization revealed that 60% of patients (24 of 40) showed CSILs. However, no significant difference was found in any mean cognitive scores or in the number of cognitively impaired variables between patients with and without CSILs at weeks 1 and 4. Additional correlation analysis revealed no correlations between the number of CSILs on DWI and the cognitive sum z score at both 1 and 4 weeks. CONCLUSION: Exhaustive neuropsychological evaluation of UIA patients who underwent coil embolization demonstrated recovery or improvements from baseline cognitive function after 4 weeks, although some patients still showed cognitive deficits at 4 weeks after the procedure. However, we found no statistically significant relationship between the presence and number of CSILs on DWI and cognitive changes after the procedure.

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Short- and Long-Term Safety and Efficacy of Self-Expandable Leo Stents Used Alone or with Coiling for Ruptured and Unruptured Intracranial Aneurysms: A Retrospective Observational Study

Journal of Clinical Medicine ◽

10.3390/jcm10194541 ◽

2021 ◽

Vol 10 (19) ◽

pp. 4541

Author(s):

François Lebeaupin ◽

Pierre-Olivier Comby ◽

Marc Lenfant ◽

Pierre Thouant ◽

Brivaël Lemogne ◽

...

Keyword(s):

Risk Factor ◽

Success Rate ◽

Intracranial Aneurysms ◽

Univariate Analysis ◽

Significant Risk ◽

Significant Risk Factor ◽

Unruptured Intracranial Aneurysms ◽

Intracranial Complications ◽

Procedural Success

To assess the efficacy and safety of the Leo stent used alone or with coiling to treat complex intracranial aneurysms (IAs) not eligible for simple or balloon-assisted coiling, this single-center retrospective study included consecutive adults with ruptured or unruptured IAs treated in 2011–2018 by stenting with or without coiling. The indication for stenting was IA complexity precluding simple or balloon-assisted coiling. Extensive data on the patients, IAs, antiplatelet treatments, procedures, and outcomes over the first 36 months were collected. Risk factors for early complications (univariate analysis) and delayed ischemia (multivariate analysis) were sought. We include 64 patients with 66 IAs. The procedural success rate was 65/66 (98.5%). Obliteration was Raymond Roy class I or II for 85% of IAs. Six patients died including four of the 12 patients presenting with subarachnoid hemorrhage, which was the only significant risk factor for early major complications. At 1 month, 45/64 (69%) had no disabilities. No rebleeding was reported. Ischemia was detected by routine MRI in 20 (35%) of the 57 patients with long-term data and was asymptomatic in 14. The stent-within-a-stent configuration was the only independent risk factor for ischemia. The Leo stent used alone or with coils to manage challenging IAs was associated with a high procedural success rate and complete or nearly complete IA obliteration of 85% of IAs. The high frequency of ischemia is ascribable to our use of routine serial MRI. In patients with bleeding, the Leo stent was associated with an excess risk of early, major, intracranial complications, as compared to patients without bleeding. Long-term follow-up was marked by the occurrence of ischemic events in the vascular territory of the stent, mostly silent.

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Clinical characteristics associated with sentinel headache in patients with unruptured intracranial aneurysms

Interventional Neuroradiology ◽

10.1177/1591019920971977 ◽

2020 ◽

pp. 159101992097197

Author(s):

Zheng Wan ◽

Hao Meng ◽

Ning Xu ◽

Tianyi Liu ◽

Zhongping Chen ◽

...

Keyword(s):

Intracranial Aneurysms ◽

Clinical Characteristics ◽

Therapeutic Strategy ◽

Multivariable Analysis ◽

Clinical History ◽

Aneurysm Rupture ◽

Clinical Feature ◽

Unruptured Intracranial Aneurysms ◽

Significant Difference ◽

Sh Group

Objective Sentinel headache (SH) is considered as a signal of the impending rupture of an aneurysm. However, it is difficult to diagnose whether the headaches of patients are associated with unstable aneurysms. Therefore, there is some doubt about the importance of headaches in patients with unruptured intracranial aneurysms (UIAs). This study was performed to explore the existence and clinical characteristics of SH associated with aneurysms. Methods Thirty-six patients with a single UIA were collected in this study. Patients were symptomatically categorized into two groups: SH and non-SH. The PHASES scores and patient and aneurysm characteristics were analyzed. Two independent MRI experts who were blinded to the patients’ clinical history conducted the analysis of the SWI results. Results There were 15 patients with sentinel headache. No significant difference was found in patient’s basic information and history. The SH group had a higher PHASES score than the non-SH group (P < 0.05). In univariable analysis, abnormal SWI signals were significantly more frequent in the SH group (P < 0.01) and the inflow angle was significantly lower in the non-SH group (P < 0.05). In multivariable analysis, abnormal signals in SWI were an independent factor associated with SH (P < 0.01). Conclusions SH exists in patients with UIAs and may indicate a high risk of aneurysm rupture. Abnormal signals on SWI may serve as a clinical feature to identify aneurysm-related SH and be helpful for the formulation of therapeutic strategy. Aneurysm geometry may also be related to SH but need further studies in the future.

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Surgical and Endovascular Comprehensive Treatment Outcomes of Unruptured Intracranial Aneurysms: Reduction of Treatment Bias

World Neurosurgery ◽

10.1016/j.wneu.2019.03.005 ◽

2019 ◽

Vol 126 ◽

pp. e878-e887 ◽

Cited By ~ 3

Author(s):

Christopher S. Ogilvy ◽

Noah J. Jordan ◽

Luis C. Ascanio ◽

Alejandro A. Enriquez-Marulanda ◽

Mohamed M. Salem ◽

...

Keyword(s):

Treatment Outcomes ◽

Intracranial Aneurysms ◽

Comprehensive Treatment ◽

Unruptured Intracranial Aneurysms ◽

Treatment Bias

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Safety and effectiveness of the Low Profile Visualized Intraluminal Support (LVIS and LVIS Jr) devices in the endovascular treatment of intracranial aneurysms: results of the TRAIL multicenter observational study

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2017-013375 ◽

2017 ◽

Vol 10 (7) ◽

pp. 675-681 ◽

Cited By ~ 29

Author(s):

Christina Iosif ◽

Michel Piotin ◽

Suzana Saleme ◽

Xavier Barreau ◽

Jacques Sedat ◽

...

Keyword(s):

Observational Study ◽

Intracranial Aneurysms ◽

Clinical Event ◽

Morbidity Rate ◽

Complication Rates ◽

Clinical Safety ◽

Multicenter Observational Study ◽

Low Profile ◽

Unruptured Intracranial Aneurysms

Background and purposeTo evaluate the safety and effectiveness of the low-profile braided intracranial stents called the Low Profile Visualized Intraluminal Support (LVIS) devices for stent-assisted coil embolization of wide-necked intracranial aneurysms.Materials and methodsThis was a prospective, multicenter, observational study of unruptured and ruptured intracranial aneurysms treated with the LVIS devices. Imaging and clinical data were independently analyzed respectively by CoreLab and Clinical Event Committee. Primary endpoints were clinical safety, effectiveness, and angiographic stability of the results at 6 and 18 months.ResultsTen centers participated in the study; 102 patients were included and 90 patients (42.2% men, 57.8% women) were eventually analyzed, among which 27 (30.0%) had multiple aneurysms. Twenty-three (25.6%) were ruptured aneurysms, four of which (4.4%) were treated in the acute phase. One aneurysm was treated per patient; 92 LVIS and LVIS Jr devices were placed overall. The total aneurysm occlusion rate was 91.0% on immediate post-procedure angiograms, which remained unchanged at 6-month follow-up and was 92.4% at 18-month follow-up. One patient (1.1%) underwent retreatment between 6 and 18 months of follow-up. A modified Rankin score of 0 was documented for most cases immediately after the procedure (86.7%) and at 6-month (86.8%) and 18-month (83.3%) follow-up. The overall permanent morbidity rate at 18 months was 5.6% and the overall rate of events with sequelae related to the stent was 2.2%. The 18-month procedure-related mortality rate was 3.3%. No patient was deemed to require retreatment at 18-month follow-up.ConclusionThe LVIS/LVIS Jr endovascular devices are safe and effective in the treatment of ruptured and unruptured intracranial aneurysms, with acceptable complication rates, very high immediate total occlusion rates, and stable angiographic results.

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Postoperative cognitive dysfunction after endovascular treatments for unruptured intracranial aneurysms: A pilot study

Interventional Neuroradiology ◽

10.1177/15910199211039917 ◽

2021 ◽

pp. 159101992110399

Author(s):

Daizo Ishii ◽

Mario Zanaty ◽

Jorge A Roa ◽

Luyuan Li ◽

Yongjun Lu ◽

...

Keyword(s):

Confidence Interval ◽

Cognitive Dysfunction ◽

Intracranial Aneurysms ◽

Postoperative Cognitive Dysfunction ◽

Mean Difference ◽

Major Surgery ◽

Unruptured Intracranial Aneurysms ◽

Significant Difference ◽

Normal Cognition ◽

Moca Score

Objective Post operative cognitive dysfunction (POCD) has been widely observed after major surgery, particularly in elderly patients with general anesthesia (GA). However, a specific unanswered question is whether different approaches to anesthetic managements are associated with different cognitive outcomes after endovascular treatments for unruptured intracranial aneurysms (UIAs). The purpose of this study is to assess the correlation of POCD with GA versus monitored anesthesia care (MAC). Methods We performed a pragmatic, prospective study to assess the association between different anesthetic approaches and POCD. We compared the pre- and post-procedural Montreal Cognitive Assessment (MoCA) scores in patients with normal cognition who underwent treatments of UIAs with various endovascular methods, using either GA or MAC. Results A total of 23 patients with UIAs were enrolled in the study. Seven (30.4%) and sixteen (69.6%) UIAs were treated without perioperative complications under GA or MAC, respectively. There was a significant decline in the post-procedural MoCA score under GA (mean difference = 1.14; 95% confidence interval = [0.42–1.87], P < 0.01). By contrast, there was no significant difference of MoCA score between pre- and post-procedure under MAC (mean difference = 0.19; 95% confidence interval = [−0.29–0.67], P = 0.59). Conclusions Treating UIAs using MAC was associated with a decrease in POCD as compared to GA in patients undergoing endovascular treatments for UIAs with normal cognition. Larger randomized studies are needed to confirm these findings.

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