Saccular aneurysms in the post–Barrow Ruptured Aneurysm Trial era

2021 ◽  
pp. 1-8
Author(s):  
Joshua S. Catapano ◽  
Mohamed A. Labib ◽  
Visish M. Srinivasan ◽  
Candice L. Nguyen ◽  
Kavelin Rumalla ◽  
...  
Keyword(s):  
Aneurysmal Subarachnoid Hemorrhage ◽  
Endovascular Embolization ◽  
Endovascular Intervention ◽  
Ruptured Aneurysm ◽  
Endovascular Coiling ◽  
Neurological Outcomes ◽  
Microsurgical Clipping ◽  
Poor Neurological Outcome ◽  
Technical Advances ◽  
Saccular Aneurysms

OBJECTIVE The Barrow Ruptured Aneurysm Trial (BRAT) was a single-center trial that compared endovascular coiling to microsurgical clipping in patients treated for aneurysmal subarachnoid hemorrhage (aSAH). However, because patients in the BRAT were treated more than 15 years ago, and because there have been advances since then—particularly in endovascular techniques—the relevance of the BRAT today remains controversial. Some hypothesize that these technical advances may reduce retreatment rates for endovascular intervention. In this study, the authors analyzed data for the post-BRAT (PBRAT) era to compare microsurgical clipping with endovascular embolization (coiling and flow diverters) in the two time periods and to examine how the results of the original BRAT have influenced the practice of neurosurgeons at the study institution. METHODS In this retrospective cohort study, the authors evaluated patients with saccular aSAHs who were treated at a single quaternary center from August 1, 2007, to July 31, 2019. The saccular aSAH diagnoses were confirmed by cerebrovascular experts. Patients were separated into two cohorts for comparison on the basis of having undergone microsurgery or endovascular intervention. The primary outcome analyzed for comparison was poor neurological outcome, defined as a modified Rankin Scale (mRS) score > 2. The secondary outcomes that were compared included retreatment rates for both therapies. RESULTS Of the 1014 patients with aSAH during the study period, 798 (79%) were confirmed to have saccular aneurysms. Neurological outcomes at ≥ 1-year follow-up did not differ between patients treated with microsurgery (n = 451) and those who received endovascular (n = 347) treatment (p = 0.51). The number of retreatments was significantly higher among patients treated endovascularly (32/347, 9%) than among patients treated microsurgically (6/451, 1%) (p < 0.001). The retreatment rate after endovascular treatment was lower in the PBRAT era (9%) than in the BRAT (18%). CONCLUSIONS Similar to results from the BRAT, results from the PBRAT era showed equivalent neurological outcomes and increased rates of retreatment among patients undergoing endovascular embolization compared with those undergoing microsurgery. However, the rate of retreatment after endovascular intervention was much lower in the PBRAT era than in the BRAT.

scholarly journals Analysis of overlapping surgery in patients undergoing microsurgical aneurysm clipping: acute and long-term outcomes from the Barrow Ruptured Aneurysm Trial

2018 ◽  
Vol 129 (3) ◽  
pp. 711-717 ◽  
Author(s):  
Michael A. Mooney ◽  
Scott Brigeman ◽  
Michael A. Bohl ◽  
Elias D. Simon ◽  
John P. Sheehy ◽  
...  
Keyword(s):  
Smoking Status ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Ruptured Aneurysm ◽  
Long Term Outcomes ◽  
Microsurgical Clipping ◽  
Fisher Grade ◽  
Medicine Today ◽  
Saccular Aneurysms

OBJECTIVEOverlapping surgery is a controversial subject in medicine today; however, few studies have examined the outcomes of this practice. The authors analyzed outcomes of patients with acutely ruptured saccular aneurysms who were treated with microsurgical clipping in a prospectively collected database from the Barrow Ruptured Aneurysm Trial. Acute and long-term outcomes for overlapping versus nonoverlapping cases were compared.METHODSDuring the study period, 241 patients with ruptured saccular aneurysms underwent microsurgical clipping. Patients were separated into overlapping (n = 123) and nonoverlapping (n = 118) groups based on surgical start/stop times. Outcomes at discharge and at 6 months, 1 year, 3 years, and 6 years after surgery were analyzed.RESULTSPatient variables (e.g., age, smoking status, cardiovascular history, Hunt and Hess grade, Fisher grade, and aneurysm size) were similar between the 2 groups. Aneurysm locations were similar, with the exception of the overlapping group having more posterior circulation aneurysms (18/123 [15%]) than the nonoverlapping group (8/118 [7%]) (p = 0.0495). Confirmed aneurysm obliteration at discharge was significantly higher for the overlapping group (109/119 [91.6%]) than for the nonoverlapping group (95/116 [81.9%]) (p = 0.03). Hospital length of stay, discharge location, and proportions of patients with a modified Rankin Scale (mRS) score > 2 at discharge and up to 6 years postoperatively were similar. The mean and median mRS, Glasgow Outcome Scale, Mini–Mental State Examination, National Institutes of Health Stroke Scale, and Barthel Index scores at all time points were not statistically different between the groups.CONCLUSIONSCompared with nonoverlapping surgery, overlapping surgery was not associated with worse outcomes for any variable at any time point, despite the complexity of the surgical management in this patient population. These findings should be considered during the discussion of future guidelines on the practice of overlapping surgery.

scholarly journals Neurological outcomes following intraprocedural rerupture during coil embolization of ruptured intracranial aneurysms

2015 ◽  
Vol 122 (1) ◽  
pp. 128-135 ◽  
Author(s):  
Christopher J. Stapleton ◽  
Brian P. Walcott ◽  
William E. Butler ◽  
Christopher S. Ogilvy
Keyword(s):  
Coil Embolization ◽  
Intracranial Aneurysms ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
External Ventricular Drain ◽  
Endovascular Coiling ◽  
Neurological Outcomes ◽  
Symptomatic Vasospasm ◽  
Increased Risk ◽  
Ruptured Intracranial Aneurysms

OBJECT Intraprocedural rerupture (IPR) of intracranial aneurysms during coil embolization is associated with significant periprocedural disability and death. However, whether this morbidity and mortality are secondary to an increased risk of vasospasm and hydrocephalus is unknown. The authors undertook this study to determine the in-hospital and long-term neurological outcomes for patients with aneurysmal subarachnoid hemorrhage (SAH) treated with coil embolization who suffer aneurysm rerupture during treatment. METHODS The records of 156 patients admitted with SAH from previously untreated, ruptured, intracranial aneurysms and treated with endovascular coiling between January 2007 and January 2014 were retrospectively reviewed. Twelve patients (7.7%) experienced IPR during coil embolization. RESULTS Compared with the cohort of patients with uncomplicated coil embolization procedures, patients with aneurysm rerupture were more likely to require external ventricular drain (EVD) placement (91.7% vs 58.3%, p = 0.02) and postprocedural EVD placement (36.4% vs 7.1%, p = 0.01), to undergo permanent ventriculoperitoneal shunt placement (50.0% vs 18.8%, p = 0.02), to develop symptomatic vasospasm (50.0% vs 18.1%, p = 0.02), and to have longer lengths of hospital stay (median 21.5 days vs 15.0 days, p = 0.04). Admission Hunt and Hess, modified Fisher, and Barrow Neurological Institute grades did not differ between the 2 cohorts, nor did long-term functional neurological outcomes as assessed by the modified Rankin Scale. CONCLUSIONS Intraprocedural rerupture during coil embolization for ruptured intracranial aneurysms is associated with an increased risk of symptomatic vasospasm and need for temporary and permanent cerebrospinal fluid diversion for hydrocephalus.

Accuracy in Identifying the Source of Subarachnoid Hemorrhage in the Setting of Multiple Intracranial Aneurysms

Neurosurgery ◽  
2017 ◽  
Vol 83 (1) ◽  
pp. 62-68 ◽  
Author(s):  
Jennifer L Orning ◽  
Sophia F Shakur ◽  
Ali Alaraj ◽  
Mandana Behbahani ◽  
Fady T Charbel ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Subarachnoid Hemorrhage ◽  
Cerebral Aneurysms ◽  
Endovascular Embolization ◽  
Ruptured Aneurysm ◽  
Multiple Aneurysms ◽  
Microsurgical Clipping ◽  
Computed Tomography Scans ◽  
Rupture Site

Abstract BACKGROUND Subarachnoid hemorrhage cases with multiple cerebral aneurysms frequently demonstrate a hemorrhage pattern that does not definitively delineate the source aneurysm. In these cases, rupture site is ascertained from angiographic features of the aneurysm such as size, morphology, and location. OBJECTIVE To examine the frequency with which such features lead to misidentification of the ruptured aneurysm. METHODS : Records of patients who underwent surgical clipping of a ruptured aneurysm at our institution between 2004 and 2014 and had multiple aneurysms were retrospectively reviewed. A blinded neuroendovascular surgeon provided the rupture source based on the initial head computed tomography scans and digital subtraction angiography images. Operative reports were then assessed to confirm or refute the imaging-based determination of the rupture source. RESULTS One hundred fifty-one patients had multiple aneurysms. Seventy-one patients had definitive hemorrhage patterns on initial computed tomography scans and 80 patients had nondefinitive hemorrhage patterns. Thirteen (16.2%) of the cases with nondefinitive hemorrhage patterns had discordance between the imaging-based determination of the rupture source and intraoperative findings of the true ruptured aneurysm, yielding an imperfect positive predictive value of 83.8%. Of all multiple aneurysm cases with subarachnoid hemorrhage treated by surgical or endovascular means at our institution, 4.3% (13 of 303) were misidentified. CONCLUSION Morphological features cannot reliably be used to determine rupture site in cases with nondefinitive subarachnoid hemorrhage patterns. Microsurgical clipping, confirming obliteration of the ruptured lesion, may be preferentially indicated in these patients unless, alternatively, all lesions can be contemporaneously and safely treated with endovascular embolization.

Systemic metabolism and energy consumption after microsurgical clipping and endovascular coiling for aneurysmal subarachnoid hemorrhage

2017 ◽  
Vol 160 (2) ◽  
pp. 261-268 ◽  
Author(s):  
Hiroya Shimauchi-Ohtaki ◽  
Masahiko Tosaka ◽  
Toshiyuki Ohtani ◽  
Keiya Iijima ◽  
Nobuo Sasaguchi ◽  
...  
Keyword(s):  
Energy Consumption ◽  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Endovascular Coiling ◽  
Microsurgical Clipping

Mitigation of Blood Load Impact in Patients with Subarachnoid Hemorrhage by Cisternal Lavage

2022 ◽  
pp. 1-7
Author(s):  
Panagiotis Fistouris ◽  
Christian Scheiwe ◽  
Juergen Grauvogel ◽  
István Csók ◽  
Juergen Beck ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Prognostic Significance ◽  
Study Groups ◽  
Neurological Outcomes ◽  
Poor Neurological Outcome ◽  
Risk Patients ◽  
Multivariable Regression ◽  
Comorbidity Index ◽  
Multivariable Regression Models

<b><i>Object:</i></b> The initial amount of subarachnoid and ventricular blood is an important prognostic factor for outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). In this comparative study of an unselected aSAH-population, we assess the modifiability of these factors by implementation of blood clearance by cisternal lavage. <b><i>Methods:</i></b> All patients with aSAH treated in our department between October 2011 and October 2019 (8 years, <i>n</i> = 458) were included in our study. In the first 4-year period (BEFORE, <i>n</i> = 237), patients were treated according to international guidelines. In the second 4-year period (AFTER, <i>n</i> = 221), cisternal lavage methods were available and applied in 72 high-risk patients (32.5%). The cisternal and ventricular blood load was recorded by the Hijdra score. Multivariable regression models were used to assess the prognostic significance of risk factors, including blood load, in relation to common aSAH characteristics in both study groups. <b><i>Results:</i></b> Worse neurological outcomes (mRS &#x3e; 3) occurred in the BEFORE population with 41.45% versus 30.77% in the AFTER cohort, 6 months after aSAH (HR: 1.59, 95% CI 1.08–2.34, <i>p</i> = 0.01). Admission WFNS grade, comorbidities (Charlson Comorbidity Index), herniation signs, concomitant intracerebral hemorrhage, and the development of delayed cerebral infarction were strongly associated with poor outcome in both study groups. Intraventricular and cisternal blood load and, particularly, a cast fourth ventricle (Cast 4) represented strong prognosticators of poor neurological outcome in the BEFORE cohort. This effect was lost after implementation of cisternal lavage (AFTER cohort). <b><i>Conclusion:</i></b> Cisternal and ventricular blood load – in particular: a Cast 4 – represent important prognosticators in patients with aSAH. They are, however, amenable to modification by blood clearing therapies.

Coiling Versus Microsurgical Clipping in the Treatment of Unruptured Middle Cerebral Artery Aneurysms: A Meta-Analysis

Neurosurgery ◽  
2018 ◽  
Vol 83 (5) ◽  
pp. 879-889 ◽  
Author(s):  
Meshal Alreshidi ◽  
David J Cote ◽  
Hormuzdiyar H Dasenbrock ◽  
Michael Acosta ◽  
Anil Can ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Meta Analysis ◽  
Pooled Analysis ◽  
Endovascular Coiling ◽  
Neurological Outcomes ◽  
Microsurgical Clipping ◽  
Unruptured Intracranial Aneurysms ◽  
The Status ◽  
Middle Cerebral Artery Aneurysms

Abstract BACKGROUND Open microsurgical clipping of unruptured intracranial aneurysms has long been the gold standard, yet advancements in endovascular coiling techniques have begun to challenge the status quo. OBJECTIVE To compare endovascular coiling with microsurgical clipping among adults with unruptured middle cerebral artery aneurysms (MCAA) by conducting a meta-analysis. METHODS A systematic search was conducted from January 2011 to October 2015 to update a previous meta-analysis. All studies that reported unruptured MCAA in adults treated by microsurgical clipping or endovascular coiling were included and cumulatively analyzed. RESULTS Thirty-seven studies including 3352 patients were included. Using the random-effects model, pooled analysis of 11 studies of microsurgical clipping (626 aneurysms) revealed complete aneurysmal obliteration in 94.2% of cases (95% confidence interval [CI] 87.6%-97.4%). The analysis of 18 studies of endovascular coiling (759 aneurysms) revealed complete obliteration in 53.2% of cases (95% CI: 45.0%-61.1%). Among clipping studies, 22 assessed neurological outcomes (2404 aneurysms), with favorable outcomes in 97.9% (95% CI: 96.8%-98.6%). Among coiling studies, 22 examined neurological outcomes (826 aneurysms), with favorable outcomes in 95.1% (95% CI: 93.1%-96.5%). Results using the fixed-effect models were not materially different. CONCLUSION This updated meta-analysis demonstrates that surgical clipping for unruptured MCAA remains highly safe and efficacious. Endovascular treatment for unruptured MCAAs continues to improve in efficacy and safety; yet, it results in lower rates of occlusion.

Early clinical course after aneurysmal subarachnoid hemorrhage: comparison of patients treated with Woven EndoBridge, microsurgical clipping, or endovascular coiling

2019 ◽  
Vol 161 (9) ◽  
pp. 1763-1773 ◽  
Author(s):  
Thomas Sauvigny ◽  
Marie Teresa Nawka ◽  
Nils Schweingruber ◽  
Marius Marc-Daniel Mader ◽  
Jan Regelsberger ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Clinical Course ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Endovascular Coiling ◽  
Microsurgical Clipping ◽  
Woven Endobridge

scholarly journals Anterior communicating artery aneurysm clipping versus coiling: a comparative study of 50 cases

2017 ◽  
Vol 31 (3) ◽  
pp. 368-377
Author(s):  
Pradeep Kumar ◽  
Shashi K. Jain ◽  
Virendra D. Sinha ◽  
Trilochan Srivastava
Keyword(s):  
Aneurysmal Subarachnoid Hemorrhage ◽  
Artery Aneurysm ◽  
Endovascular Coiling ◽  
Anterior Communicating Artery ◽  
Medical College ◽  
Microsurgical Clipping ◽  
Significant Difference ◽  
Fatal Form ◽  
Larger Sample

Abstract Introduction: Aneurysmal Subarachnoid Hemorrhage (aSAH) remains a devastating and often fatal form of stroke. The aneurysm is targeted for obliteration to prevent re-bleeding and to manage the possible complications from the event. Endovascular coiling has emerged as a less invasive alternative to conventional surgical clipping to treat aneurysms. Patients and methods: This study was done in 50 cases of anterior communicating (Acommm) aneurysm presented in the department of neurosurgery, SMS medical college, Jaipur from November 2015 to August 2016 to evaluate the outcome of both modalities used in the treatment of ruptured Acommm aneurysm. 50 patients with Hunt and Hess (H&H) grade I, II or III were classified into two groups of microsurgical clipping and endovascular coiling. Results: Mortality rate was comparable in both groups that were 21. 21% in the clipping group and 23. 52% in the coiling group. Good Glasgow outcome score (GOS) were found in 60. 60% of clipping and 58. 58% of coiling group. All the complications found to be more in clipping group but that were not statistically significant except for hyponatremia which was significantly higher in clipping group(P=0. 007). Conclusion: There was no statistically significant difference in GOS at 6 month of follow up between the two groups. We recommend further interventional studies with larger sample sizes and longer follow up for better evaluation of the modalities.

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