Treatment of ruptured intracranial aneurysms since the International Subarachnoid Aneurysm Trial: practice utilizing clip ligation and coil embolization as individual or complementary therapies

2006 ◽  
Vol 104 (3) ◽  
pp. 344-349 ◽  
Author(s):  
Giuseppe Lanzino ◽  
Kenneth Fraser ◽  
Yassine Kanaan ◽  
Anne Wagenbach
Keyword(s):  
Functional Outcome ◽  
Coil Embolization ◽  
Endovascular Embolization ◽  
Treatment Modalities ◽  
World Federation ◽  
Subspecialty Training ◽  
Surgical Clip ◽  
Number Of Patients ◽  
International Subarachnoid Aneurysm Trial ◽  
Clip Application

Object The aim of this study was to analyze the therapeutic decision-making process and outcome in 100 consecutive patients with aneurysmal subarachnoid hemorrhage (SAH) treated since the completion of the International Subarachnoid Aneurysm Trial (ISAT). All patients were evaluated and treated by a neurosurgeon with subspecialty training in both cerebrovascular and neuroendovascular surgery. Methods One hundred consecutive patients with aneurysmal SAH who had been admitted within 1 week posthemorrhage and who had been treated using either surgical clip application or endovascular coil embolization were included in this analysis. All patients underwent a uniform perioperative protocol. All surviving patients were given a questionnaire to assess their modified Rankin Scale score (mRS) and to grade themselves at 6 months and 1 year postintervention. The cohort consisted of 73 women and 27 men with a mean age of 57.27 years (range 27–87 years). Twenty-nine percent of the patients had a World Federation of Neurosurgical Societies (WFNS) Grade IV or V SAH. Forty-seven patients underwent direct surgical clip application, 41 endovascular embolization, and 12 a combination of the two procedures. Good functional outcome—indicated by mRS scores of 0 to 2 after at least 6 months—was achieved in 71% of patients. Conclusions Data from the ISAT demonstrated a better functional outcome following endovascular embolization in a selected group of patients with aneurysmal SAH. In routine clinical practice, however, a significant number of patients still benefit from direct surgical clip ligation. Excellent functional results can be realized in a complementary clip ligation and coil occlusion practice in which each patient and aneurysm is evaluated and the two treatment modalities are used individually or, when needed, in combination.

Could late rebleeding overturn the superiority of cranial aneurysm coil embolization over clip ligation seen in the International Subarachnoid Aneurysm Trial?

2008 ◽  
Vol 108 (3) ◽  
pp. 437-442 ◽  
Author(s):  
Patrick Mitchell ◽  
Richard Kerr ◽  
A. David Mendelow ◽  
Andy Molyneux
Keyword(s):  
Life Expectancy ◽  
Coil Embolization ◽  
Cerebral Aneurysms ◽  
Absolute Difference ◽  
Poor Outcome ◽  
International Subarachnoid Aneurysm Trial ◽  
Clip Application ◽  
The Difference ◽  
Clip Occlusion

Object The present purpose is to define the sensitivity of the superiority of coil embolization observed in the International Subarachnoid Aneurysm Trial (ISAT) according to the rate of late rebleeding over a reasonable range, and to find the range of rebleeding rates for which it may be overturned. In the ISAT, coil embolization appears to be safer than clip ligation at 1 year, and clip occlusion has better long-term efficacy at preventing rebleeding. This leaves open the question of which is better in the longer term. Methods The authors calculate the life expectancy of patients following a subarachnoid hemorrhage (SAH) and compare the life expectancy of those who underwent coil embolization with those who underwent clip ligation in the ISAT cohort. Results The 1-year poor outcome rate following treatment climbs rapidly with advancing age. A consequence is that the absolute difference between the poor outcome rates after coil embolization and clip occlusion is lower in those < 50 years of age (3.3%) than it is for those > 50 years of age (10.1%). This difference may be enough to give clip application the advantage in the < 40-year-old group despite the small size of the difference in 1-year rebleeding rates thus far observed (0.152%). Conclusions When treating ruptured cerebral aneurysms, the advantage of coil embolization over clip ligation cannot be assumed for patients < 40 years old. In this age range the difference in the safety of the 2 procedures is small, and the better long-term protection from SAH afforded by clip placement may give this treatment an advantage in life expectancy for patients < 40 years of age.

Complementary management of partially occluded aneurysms by using surgical or endovascular therapy

2002 ◽  
Vol 97 (4) ◽  
pp. 843-850 ◽  
Author(s):  
Siamak Asgari ◽  
Arnd Doerfler ◽  
Isabel Wanke ◽  
Beate Schoch ◽  
Michael Forsting ◽  
...  
Keyword(s):  
Endovascular Therapy ◽  
Intracranial Aneurysms ◽  
Endovascular Embolization ◽  
Content Type ◽  
Aneurysm Neck ◽  
Surgical Clip ◽  
Clip Application ◽  
Detachable Coils ◽  
Partially Occluded ◽  
Fine Print

Object. The authors present a series of patients in whom partially occluded aneurysms were retreated using complementary surgical or endovascular therapy. Methods. During a period of 18 months, 301 patients with intracranial aneurysms were treated using either clip application (171 patients) or endovascular embolization with Guglielmi Detachable Coils ([GDCs] 130 patients). Routine posttreatment angiography studies revealed residual aneurysms in 21 of these patients, nine of whom were retreated using an endovascular or surgical method, with a mean treatment latency of 1.2 months. Four patients underwent primary surgical clip application, whereas five patients experienced GDC packing first. Among patients in the surgical group, the residual aneurysm neck was small and total elimination of the aneurysm was achieved by packing in GDCs. In patients in the endovascular group the authors incompletely packed the aneurysm because of its wide neck or fusiform component in two patients, perforation of a very small aneurysm in one patient, and coil dislocation in another patient. Typical coil compaction occurred in one case. Complete clip application was achieved in all patients. There was no complication in any patient due to the second treatment modality. Final outcome was excellent or good in six and fair in three. Conclusions. Following clip application or endovascular embolization of intracranial aneurysms, the use of complementary surgical or endovascular management is successful and associated with low morbidity.

Effectiveness of neurosurgical clip application in patients with aneurysmal subarachnoid hemorrhage

2002 ◽  
Vol 97 (5) ◽  
pp. 1036-1041 ◽  
Author(s):  
Eva H. Brilstra ◽  
Ale Algra ◽  
Gabriel J. E. Rinkel ◽  
Cornelis A. F. Tulleken ◽  
Jan van Gijn
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Treatment Modalities ◽  
Content Type ◽  
Poor Outcome ◽  
Number Of Patients ◽  
Operative Complications ◽  
Clip Application ◽  
Poor Outcomes ◽  
Fine Print

Object. Neurosurgical clip application is the standard method used to prevent rebleeding in patients with aneurysmal subarachnoid hemorrhage (SAH). The authors assessed the magnitude of the reduction in poor outcomes that accompanies a strategy aimed at surgery. Methods. Three hundred forty-six consecutive patients with aneurysmal SAH were studied. The authors estimated the number of surgically treated patients with good outcomes who would have had poor outcomes as a consequence of rebleeding if clip application had not been performed (A). They also assessed the number of patients whose poor outcomes were exclusively caused by operative complications (B). Without an operation some of these patients would have had poor outcomes because of rebleeding (C). The authors represented the number of patients in whom poor outcome was prevented by surgery with the following formula: A − B + C. They assessed the relationships between baseline characteristics of patients and aneurysms and the likelihood that a patient underwent surgery, the risk of operative complications, and the risk of rebleeding. The absolute reduction in the risk of poor outcome found in patients who undergo surgery was 9.7%. This implies that to prevent a poor outcome in one patient, surgery had to be performed in 10. The relative risk of poor outcome following surgery compared with that after conservative treatment was estimated to be 0.81. Logistic regression analysis showed a statistically significant relationship between patient age older than 65 years and the occurrence of operative complications (odds ratio [OR] 2.49; 95% confidence interval [CI] 1.03–6.03), between age older than 65 years and the likelihood of undergoing surgery (OR 0.12; 95% CI 0.07–0.2), and between a poor clinical condition at admission and the likelihood of undergoing surgery (OR 0.26; 95% CI 0.14–0.47). The authors did not identify any predictive factors for rebleeding when the Cox proportional hazard model was used. Conclusions. The beneficial effect of a treatment strategy in which the goal is surgery is substantial. If new treatment modalities such as embolization with coils are explored, these should carefully be compared with surgery before they are generally introduced.

Shunt-dependent hydrocephalus after rupture of intracranial aneurysms: a prospective study of the influence of treatment modality

2004 ◽  
Vol 101 (3) ◽  
pp. 402-407 ◽  
Author(s):  
Amir R. Dehdashti ◽  
Bénédict Rilliet ◽  
Daniel A. Rufenacht ◽  
Nicolas de Tribolet
Keyword(s):  
Coil Embolization ◽  
Clinical Grade ◽  
Content Type ◽  
Acute Hydrocephalus ◽  
Treatment Groups ◽  
Surgical Clip ◽  
Fisher Grade ◽  
Significant Difference ◽  
Clip Application ◽  
Fine Print

Object. This study was designed to determine whether the frequency of shunt-dependent hydrocephalus in patients suffering from aneurysmal subarachnoid hemorrhage (SAH) differs when comparing surgical clip application with endovascular obliteration of ruptured aneurysms. Methods. In this prospective nonrandomized study, 245 patients with aneurysmal SAH treated using either surgical clip application or endovascular coil embolization were studied at our institution between September 1997 and March 2003. One hundred eighty patients underwent clip application and 65 had coil embolization. In those patients who underwent clip application of anterior circulation aneurysms, the lamina terminalis was systematically fenestrated. The occurrence of acute, asymptomatic, and shunt-dependent hydrocephalus was analyzed in both treatment groups. A subgroup analysis of patients with good clinical grade (World Federation of Neurosurgical Societies [WFNS] Grades I–III) and better Fisher Grade (1–3) and of patients with Fisher Grade 4 hemorrhage was performed. Acute hydrocephalus was observed in 19% of surgical cases and 46% of endovascular ones. The occurrence of asymptomatic hydrocephalus was similar in both treatment groups (p = 0.4). Shunt-dependent hydrocephalus occurred in 14% of surgical cases and 19% of endovascular cases. This difference did not reach statistical significance (p = 0.53). Logistic regression models controlling for patient age, WFNS grade, Fisher grade, and acute hydrocephalus in patients with good clinical grade and better Fisher grade revealed no significant difference in the rate of shunt-dependent hydrocephalus in both therapy groups (odds ratio [OR] 0.8, 95% confidence interval [CI] 0.2–2.65). Results of similar models indicated that among patients with intraventricular hemorrhage (IVH), surgical clip application carried a lower risk of shunt-dependent hydrocephalus (OR 0.32, 95% CI 0.14–0.75) compared with that for endovascular embolization. Conclusions. Shunt-dependent hydrocephalus was comparable in the two treatment groups, even in patients with better clinical and radiological grades on admission. Only patients in the endovascular therapy group who had experienced IVH showed a higher likelihood of shunt-dependent hydrocephalus.

scholarly journals Treatment of Cerebral Aneurysms: Surgical Clipping and Coil Embolization

2007 ◽  
Vol 13 (1_suppl) ◽  
pp. 68-72 ◽  
Author(s):  
Y. Kaku ◽  
H. Watarai ◽  
J. Kokuzawa ◽  
T. Tanaka ◽  
T. Andoh
Keyword(s):  
Coil Embolization ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Cerebral Aneurysms ◽  
Endovascular Embolization ◽  
Favorable Outcome ◽  
Treatment Modalities ◽  
Team Approach ◽  
Complication Rates ◽  
Surgical Clipping ◽  
Significant Difference

The present series provides a balanced overview of the treatment of aneurysms in surgical clipping and coil embolization. Between January 2004 and March 2006, 76 consecutive patients with cerebral aneurysms underwent endovascular embolization and/or surgical clipping. Of these, 42 patients suffered an aneurysmal subarachnoid hemorrhage (SAH), while the remaining 34 patients had nonruptured cerebral aneurysms. Of the 23 surgically treated patients, 17 (73.9%) achieved a favorable outcome. Of the 19 patients who underwent endovascular embolization, 12 (63.2%) achieved a favorable outcome. Three patients (15.8%) who underwent endovascular embolization needed to undergo re-treatments, while no re-treatment was needed in the surgically treated patients. Of the 34 nonruptured aneurysms, 12 (35.3%) were treated using surgical clipping, while 22 (64.7%) underwent endovascular embolization. The complication rates of the two treatment modalities demonstrated no significant difference. A combined microsurgical-endovascular team approach is thus considered to provide the most effective means to achieve favorable outcomes for patients with cerebral aneurysms.

New Trends and Developments in Patients with Severe Aortic Stenosis – Towards Optimal Treatment?

2009 ◽  
Vol 5 (2) ◽  
pp. 81 ◽  
Author(s):  
Martijn WA van Geldorp ◽  
Johanna JM Takkenberg ◽  
Ad JJC Bogers ◽  
A Pieter Kappetein ◽  
◽  
...  
Keyword(s):  
Aortic Stenosis ◽  
Severe Aortic Stenosis ◽  
Surgical Techniques ◽  
Treatment Strategies ◽  
Tissue Doppler ◽  
Doppler Imaging ◽  
Treatment Modalities ◽  
Diagnostic Tools ◽  
Number Of Patients ◽  
Transcatheter Valve

Over the next few decades the number of patients diagnosed with aortic stenosis is expected to rise as the population ages and the use of several diagnostic tools expands. This will result in a growing need for both medical and surgical treatment and stimulate the development of new diagnostic and surgical techniques. This article briefly describes the prevalence, pathogenesis and clinical presentation of patients with aortic stenosis and focuses on developments in diagnostic tools, treatment strategies and treatment modalities: the use of echocardiography, tissue Doppler imaging, stress testing and biomarkers is discussed, as well as timing of surgery and the role microsimulation can play in prosthesis selection. Furthermore, newly developed transcatheter valve implantation techniques and their possible role in treating ‘inoperable’ or ‘elderly’ patients are discussed.

scholarly journals Endovascular embolization versus surgical clipping in a single surgeon series of basilar artery aneurysms: a complementary approach in the endovascular era

2021 ◽  
Vol 163 (5) ◽  
pp. 1527-1540
Author(s):  
Ethan A. Winkler ◽  
Anthony Lee ◽  
John K. Yue ◽  
Kunal P. Raygor ◽  
W. Caleb Rutledge ◽  
...  
Keyword(s):  
Basilar Artery ◽  
Open Surgery ◽  
Endovascular Embolization ◽  
Neurologic Outcome ◽  
Endovascular Coiling ◽  
Surgical Clip ◽  
Complementary Approach ◽  
Complete Obliteration ◽  
Good Neurologic Outcome ◽  
Appropriate Therapy

Abstract Background Currently, most basilar artery aneurysms (BAAs) are treated endovascularly. Surgery remains an appropriate therapy for a subset of all intracranial aneurysms. Whether open microsurgery would be required or utilized, and to what extent, for BAAs treated by a surgeon who performs both endovascular and open procedures has not been reported. Methods Retrospective analysis of prospectively maintained, single-surgeon series of BAAs treated with endovascular or open surgery from the first 5 years of practice. Results Forty-two procedures were performed in 34 patients to treat BAAs—including aneurysms arising from basilar artery apex, trunk, and perforators. Unruptured BAAs accounted for 35/42 cases (83.3%), and the mean aneurysm diameter was 8.4 ± 5.4 mm. Endovascular coiling—including stent-assisted coiling—accounted for 26/42 (61.9%) treatments and led to complete obliteration in 76.9% of cases. Four patients in the endovascular cohort required re-treatment. Surgical clip reconstruction accounted for 16/42 (38.1%) treatments and led to complete obliteration in 88.5% of cases. Good neurologic outcome (mRS ≤ 2) was achieved in 88.5% and 75.0% of patients in endovascular and open surgical cohorts, respectively (p = 0.40). Univariate logistic regression analysis demonstrated that advanced age (OR 1.11[95% CI 1.01–1.23]) or peri-procedural adverse event (OR 85.0 [95% CI 6.5–118.9]), but not treatment modality (OR 0.39[95% CI 0.08–2.04]), was the predictor of poor neurologic outcome. Conclusions Complementary implementation of both endovascular and open surgery facilitates individualized treatment planning of BAAs. By leveraging strengths of both techniques, equivalent clinical outcomes and technical proficiency may be achieved with both modalities.

scholarly journals POS1274 THERAPEUTIC MANAGEMENT OF RHEUMATOLOGISTS VERSUS OTORHINOLARYNGOLOGISTS OF CERVICOGENIC DIZZINESS

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 921.2-922
Author(s):  
M. Yasmine ◽  
K. Maatallah ◽  
H. Ferjani ◽  
W. Triki ◽  
D. Ben Nsib ◽  
...  
Keyword(s):  
Physical Therapy ◽  
Treatment Approach ◽  
Cross Sectional Study ◽  
Treatment Modalities ◽  
Sectional Study ◽  
Cross Sectional ◽  
Standard Assessment ◽  
Number Of Patients ◽  
Cervicogenic Dizziness ◽  
No Gold Standard

Background:The treatment of patients presenting with cervicogenic dizziness (CGD) may be challenging. Indeed, there is no consensual treatment approach for CGD, nor is there no gold-standard assessment for diagnosis.Objectives:Our study aimed to assess the management of CGD by rheumatologists versus otorhinolaryngologists.Methods:We conducted a cross-sectional study including Tunisian doctors dealing with CGD. Rheumatologists (RTO) and otorhinolaryngologists (ORL) were invited to answer a questionnaire via google form about CGD daily management. Outcomes of interest were treatment modalities.Results:The study included 30 RTO and 32 ORL. Most of the doctors (RTO, vs ORL) were females (88.3%, vs 56.3%), aged between 35 and 45 (43.3%, vs 62.5%), and worked at a private practice (33.3%, vs 59.4%). The number of patients diagnosed with CGD by RTO was as follows: 1-2 per year (33.3%), 1-2 per month (18.8%), 1-2 per week (20%), less than one patient a year (10%) and none in 3.3% of cases. The number of patients diagnosed with CGD by ORL was as follows: 1-2 per year (50%), 1-2 per month (33.3%), 1-2 per week (6.2%), less than one patient a year (15.7%) and none (9.4%). Most patients presenting with CGD were females in both groups (93.1%, vs 82.8% respectively) with a mean age between 36 and 65 (79.3%, vs 82.1%). Most of the respondents declared treating patients with CGD (93.1%, vs 79.1%). Regarding treatment modalities, physical therapy was the most prescribed in both specialties (81.5% and 48.3%, respectively). Only RTO (18.5%) prescribed manual therapy. Concerning medical treatment, anti-inflammatory were the most prescribed drugs in both groups (92.6, and 34.5%, respectively). Sixty-seven percent of RTO prescribed anti-vertigo medication. Interestingly, it was the least prescribed drug by ORL (6.9%). Only RTO (59.3%) prescribed Muscle relaxants.Conclusion:Despite the disparities in the management of CGD, physical therapy remains the first prescribed treatment by Tunisian doctors. Further studies are needed to establish a consensus to treat CGD.Disclosure of Interests:None declared

scholarly journals Opioid Induced Hyperalgesia, a Research Phenomenon or a Clinical Reality? Results of a Canadian Survey

2020 ◽  
Vol 10 (2) ◽  
pp. 27
Author(s):  
Grisell Vargas-Schaffer ◽  
Suzie Paquet ◽  
Andrée Neron ◽  
Jennifer Cogan
Keyword(s):  
Chronic Pain ◽  
Nmda Antagonist ◽  
Treatment Modalities ◽  
Clinical Test ◽  
Physician Practice ◽  
Clinical Tests ◽  
Opioid Rotation ◽  
Number Of Patients ◽  
Opioid Induced Hyperalgesia ◽  
Age Range

Background: Very little is known regarding the prevalence of opioid induced hyperalgesia (OIH) in day to day medical practice. The aim of this study was to evaluate the physician’s perception of the prevalence of OIH within their practice, and to assess the level of physician’s knowledge with respect to the identification and treatment of this problem. Methods: An electronic questionnaire was distributed to physicians who work in anesthesiology, chronic pain, and/or palliative care in Canada. Results: Of the 462 responses received, most were from male (69%) anesthesiologists (89.6%), in the age range of 36 to 64 years old (79.8%). In this study, the suspected prevalence of OIH using the average number of patients treated per year with opioids was 0.002% per patient per physician practice year for acute pain, and 0.01% per patient per physician practice year for chronic pain. Most physicians (70.2%) did not use clinical tests to help make a diagnosis of OIH. The treatment modalities most frequently used were the addition of an NMDA antagonist, combined with lowering the opioid doses and using opioid rotation. Conclusions: The perceived prevalence of OIH in clinical practice is a relatively rare phenomenon. Furthermore, more than half of physicians did not use a clinical test to confirm the diagnosis of OIH. The two main treatment modalities used were NMDA antagonists and opioid rotation. The criteria for the diagnosis of OIH still need to be accurately defined.

Results of Embolization Used as the First Treatment Choice in a Consecutive Nonselected Population of Ruptured Aneurysms: Clinical Results of the Clarity GDC Study

Neurosurgery ◽  
2011 ◽  
Vol 69 (4) ◽  
pp. 837-842 ◽  
Author(s):  
◽  
Christophe Cognard ◽  
Laurent Pierot ◽  
René Anxionnat ◽  
Frédéric Ricolfi
Keyword(s):  
Clinical Results ◽  
Morbidity And Mortality ◽  
World Federation ◽  
Consecutive Series ◽  
Ruptured Aneurysms ◽  
First Choice ◽  
International Subarachnoid Aneurysm Trial ◽  
Treatment Morbidity ◽  
Intraoperative Rupture ◽  
The Impact

Abstract BACKGROUND: The International Subarachnoid Aneurysm Trial (ISAT) showed that for ruptured aneurysms suitable for both techniques, coiling should be the first-choice treatment. Only a small proportion of patients (22%) with ruptured aneurysms were included in that trial. Operators were selected on their experience. One could then criticize the impact of the ISAT on clinical practice as a result of recruitment biases and operators' selection. OBJECTIVE: To evaluate the morbidity and mortality of coiling when used as first-choice treatment in a consecutive population of patients with ruptured aneurysms treated by nonselected operators. METHODS: Thirty-four operators from 19 French centers treated 405 patients with GDC coils from November 2006 to July 2007. The method of treatment was not prespecified. RESULTS: World Federation of Neurological Societies grade at admission was I/II in 65.7% and IV/V in 30.6% of patients. At the 3- to 6-month follow-up, 23.3% of patients were dependent or dead. Thromboembolic events and intraoperative rupture resulted in permanent deficit in 13 (3.2%) and 2 (0.5%), respectively, and death in 4 (1.0%) and 0. Early rebleeding occurred in 2 patients (0.5%) with 2 subsequent deaths. Permanent treatment morbidity and mortality were 3.7 % and 1.5 %, respectively. CONCLUSION: Clinical results of the multicenter prospective Clarity registry show that when coiling is performed as first-intention treatment in a consecutive series of nonselected ruptured aneurysms by nonselected operators, clinical results are similar to those of the ISAT.

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