scholarly journals Rapid Ventricular Pacing as a Safe Procedure for Clipping of Complex Ruptured and Unruptured Intracranial Aneurysms

2021 ◽  
Vol 10 (22) ◽  
pp. 5406
Author(s):  
Josefin Grabert ◽  
Stefanie Huber-Petersen ◽  
Tim Lampmann ◽  
Lars Eichhorn ◽  
Hartmut Vatter ◽  
...  
Keyword(s):  
Intracranial Aneurysm ◽  
Intracranial Aneurysms ◽  
Troponin T ◽  
Surgical Reconstruction ◽  
Anesthesia Induction ◽  
Safe Procedure ◽  
Ventricular Pacing ◽  
Ruptured Intracranial Aneurysm ◽  
Unruptured Intracranial Aneurysms ◽  
Rapid Ventricular Pacing

Surgical treatment of intracranial aneurysm requires advanced technologies to achieve optimal results. Recently, rapid ventricular pacing (RVP) has been described to be an elegant technique that facilitates clip reconstruction of complex unruptured intracranial aneurysm (uIA). However, there is also a growing need for intraoperative tools to ensure safe clip reconstruction of complex ruptured intracranial aneurysm (rIA). We conducted a retrospective analysis of 17 patients who underwent RVP during surgical reconstruction of complex aneurysms. Nine patients had uIA while eight patients underwent surgery for rIA suffering from consecutive subarachnoid hemorrhage (SAH). Hemodynamic data, critical events, laboratory results, and anesthesia-related complications were evaluated. No complications were reported concerning anesthesia induction and induction times were similar between patients exhibiting uIA or rIA (p = 0.08). RVP induced a significant decline of median arterial pressure (MAP) in both groups (p < 0.0001). However, median MAP before and after RVP was not different in both groups (uIA group: p = 0.27; rIA group: p = 0.18). Furthermore, high-sensitive Troponin T (hsTnT) levels were not increased after RVP in any group. One patient in the rIA group exhibited ventricular fibrillation and required cardiopulmonary resuscitation, but has presented with cardiac arrest due to SAH. Otherwise, no arrhythmias or complications occurred. In summary, our data suggest RVP to be feasible in surgery for ruptured intracranial aneurysms.

scholarly journals Rapid ventricular pacing for clip reconstruction of complex unruptured intracranial aneurysms: results of an interdisciplinary prospective trial

2018 ◽  
Vol 128 (6) ◽  
pp. 1741-1752 ◽  
Author(s):  
Juergen Konczalla ◽  
Johannes Platz ◽  
Stephan Fichtlscherer ◽  
Haitham Mutlak ◽  
Ulrich Strouhal ◽  
...  
Keyword(s):  
Intracranial Aneurysms ◽  
Prospective Trial ◽  
Ventricular Pacing ◽  
Reconstruction Procedure ◽  
Safety And Efficacy ◽  
Surgical Clip ◽  
Unruptured Intracranial Aneurysms ◽  
Clip Application ◽  
Aneurysm Occlusion ◽  
Rapid Ventricular Pacing

OBJECTIVETo date, treatment of complex unruptured intracranial aneurysms (UIAs) remains challenging. Therefore, advanced techniques are required to achieve an optimal result in treating these patients safely. In this study, the safety and efficacy of rapid ventricular pacing (RVP) to facilitate microsurgical clip reconstruction was investigated prospectively in a joined neurosurgery, anesthesiology, and cardiology study.METHODSPatients with complex UIAs were prospectively enrolled. Both the safety and efficacy of RVP were evaluated by recording cardiovascular events and outcomes of patients as well as the amount of aneurysm occlusion after the surgical clip reconstruction procedure. A questionnaire was used to evaluate aneurysm preparation and clip application under RVP.RESULTSTwenty patients (mean age 51.6 years, range 28–66 years) were included in this study. Electrode positioning was easy in 19 (95%) of 20 patients, and removal of electrodes was easily accomplished in all patients (100%). No complications associated with the placement of the pacing electrodes occurred, such as cardiac perforation or cardiac tamponade. RVP was applied in 16 patients. The mean aneurysm size was 11.1 ± 5.5 mm (range 6–30 mm). RVP proved to be a very helpful tool in aneurysm preparation and clip application in 15 (94%) of 16 patients. RVP was used for a mean duration of 60 ± 25 seconds, a mean heart rate of 173 ± 23 bpm (range 150–210 bpm), and a reduction of mean arterial pressure to 35–55 mm Hg. RVP leads to softening of the aneurysm sac facilitating its mobilization, clip application, and closure of the clip blades. In 2 patients, cardiac events were documented that resolved without permanent sequelae in both. In every patient with successful RVP (n = 14) a total or near-total aneurysm occlusion was documented. In the 1 patient in whom the second RVP failed due to pacemaker electrode dislocation, additional temporary clipping was required to secure the aneurysm, but was not as sufficient as RVP. This led to an incomplete clipping of the aneurysm and finally a remnant on postoperative digital subtraction angiography. A pacemaker lead dislocation occurred in 3 (19%) of 16 patients, but intraoperative repositioning requires less than 20 seconds. Outcome was favorable in all patients according to the modified Rankin Scale.CONCLUSIONSTo the best of the authors’ knowledge this is the first prospective interdisciplinary study of RVP use in patients with UIAs. RVP is an elegant technique that facilitates clip reconstruction in complex UIAs. The safety of the procedure is good. However, because this procedure requires extensive preoperative cardiological workup of the patient and an experienced neurosurgery and neuroanesthesiology team with much cerebrovascular expertise, actually it remains reserved for selected elective cases and highly specialized centers.Clinical trial registration no.: NCT02766972 (clinicaltrials.gov)

scholarly journals P.114 Headache outcomes after treatment of unruptured intracranial aneurysms: systematic review and meta-analysis

2019 ◽  
Vol 46 (s1) ◽  
pp. S43-S44
Author(s):  
C Dandurand ◽  
H Parhar ◽  
F Naji ◽  
S Prakash ◽  
PA Gooderham
Keyword(s):  
Systematic Review ◽  
Intracranial Aneurysm ◽  
Intracranial Aneurysms ◽  
Rating Scale ◽  
Meta Analysis ◽  
Effect Estimate ◽  
Significant Heterogeneity ◽  
Unruptured Intracranial Aneurysm ◽  
Standard Mean Difference ◽  
Unruptured Intracranial Aneurysms

Background: Headaches are a major cause of disability and healthcare cost worldwide. When investigating headaches etiology, incidental unruptured intracranial aneurysms are often considered unrelated. We conducted a systematic review and meta-analysis to assess headaches outcomes (severity) after treatment of unruptured intracranial aneurysm. Methods: MEDLINE and EMBASE were systematically reviewed. Results: The data from eligible studies (n=7) was extracted and analyzed. 309 nonduplicated patients provided patient-level data for analysis. All studies used the 10-point numeric rating scale (NRS). 88% of patients were treated with endovascular technique. Overall, the observed effect estimate under a random effects model was found to be a standard mean difference in pre- and post-intervention headache severity of -0.448 (95% CI: -0.566 to -0.329). No significant heterogeneity was noted. No significant publication bias was demonstrated. Conclusions: This is the first and largest systematic review assessing postoperative headache outcomes after treatment of unruptured intracranial aneurysm. A significant reduction in headache intensity after treatment is observed in the current published literature. This study highlights an interesting clinical phenomenon that still warrants scientific effort before it can influence clinical practice. We encourage future study to stratify headache outcomes by aneurysm size, location and treatment modality.

scholarly journals Unruptured Cerebral Aneurysms: Evaluation and Management

2015 ◽  
Vol 2015 ◽  
pp. 1-10 ◽  
Author(s):  
Norman Ajiboye ◽  
Nohra Chalouhi ◽  
Robert M. Starke ◽  
Mario Zanaty ◽  
Rodney Bell
Keyword(s):  
Intracranial Aneurysm ◽  
Intracranial Aneurysms ◽  
Imaging Techniques ◽  
Cerebral Aneurysms ◽  
Current Evidence ◽  
Management Options ◽  
Comprehensive Overview ◽  
Aneurysmal Rupture ◽  
Unruptured Intracranial Aneurysms ◽  
Optimum Management

The evolution of imaging techniques and their increased use in clinical practice have led to a higher detection rate of unruptured intracranial aneurysms. The diagnosis of an unruptured intracranial aneurysm is a source of significant stress to the patient because of the concerns for aneurysmal rupture, which is associated with substantial rates of morbidity and mortality. Therefore, it is important that decisions regarding optimum management are made based on the comparison of the risk of aneurysmal rupture with the risk associated with intervention. This review provides a comprehensive overview of the epidemiology, pathophysiology, natural history, clinical presentation, diagnosis, and management options for unruptured intracranial aneurysms based on the current evidence in the literature. Furthermore, the authors discuss the genetic abnormalities associated with intracranial aneurysm and current guidelines for screening in patients with a family history of intracranial aneurysms. Since there is significant controversy in the optimum management of small unruptured intracranial aneurysms, we provided a systematic approach to their management based on patient and aneurysm characteristics as well as the risks and benefits of intervention.

scholarly journals Unruptured intracranial aneurysms and life insurance underwriting

2017 ◽  
Vol 7 (3) ◽  
pp. 274-277 ◽  
Author(s):  
Eugene Scharf ◽  
Sean Pelkowski ◽  
Bogachan Sahin
Keyword(s):  
Intracranial Aneurysm ◽  
Life Insurance ◽  
Intracranial Aneurysms ◽  
Morbidity And Mortality ◽  
Unruptured Intracranial Aneurysms ◽  
Negative Effect ◽  
Considerable Morbidity

AbstractUnruptured intracranial aneurysms are common. Rupture is rare, but associated with considerable morbidity and mortality. Screening for unruptured intracranial aneurysms is indicated in certain patient populations, but many patients request screening outside of established guidelines. In addition, intracranial aneurysms may be discovered incidentally. The presence of an intracranial aneurysm has a negative effect for the patient seeking life insurance. This commentary provides a perspective on insurance underwriting in individuals with unruptured intracranial aneurysms and offers points for clinicians to consider when counseling patients seeking screening.

scholarly journals Unruptured intracranial aneurysms in the Familial Intracranial Aneurysm and International Study of Unruptured Intracranial Aneurysms cohorts: differences in multiplicity and location

2012 ◽  
Vol 117 (1) ◽  
pp. 60-64 ◽  
Author(s):  
Jason Mackey ◽  
Robert D. Brown ◽  
Charles J. Moomaw ◽  
Laura Sauerbeck ◽  
Richard Hornung ◽  
...  
Keyword(s):  
Family History ◽  
Intracranial Aneurysm ◽  
Intracranial Aneurysms ◽  
Demographic Data ◽  
Positive Family History ◽  
International Study ◽  
Study Cohort ◽  
Familial Predisposition ◽  
Unruptured Intracranial Aneurysms ◽  
Patient Demographic Data

Object Familial predisposition is a recognized nonmodifiable risk factor for the formation and rupture of intracranial aneurysms (IAs). However, data regarding the characteristics of familial IAs are limited. The authors sought to describe familial IAs more fully, and to compare their characteristics with a large cohort of nonfamilial IAs. Methods The Familial Intracranial Aneurysm (FIA) study is a multicenter international study with the goal of identifying genetic and other risk factors for formation and rupture of IAs in a highly enriched population. The authors compared the FIA study cohort with the International Study of Unruptured Intracranial Aneurysms (ISUIA) cohort with regard to patient demographic data, IA location, and IA multiplicity. To improve comparability, all patients in the ISUIA who had a family history of IAs or subarachnoid hemorrhage were excluded, as well as all patients in both cohorts who had a ruptured IA prior to study entry. Results Of 983 patients enrolled in the FIA study with definite or probable IAs, 511 met the inclusion criteria for this analysis. Of the 4059 patients in the ISUIA study, 983 had a previous IA rupture and 657 of the remainder had a positive family history, leaving 2419 individuals in the analysis. Multiplicity was more common in the FIA patients (35.6% vs 27.9%, p < 0.001). The FIA patients had a higher proportion of IAs located in the middle cerebral artery (28.6% vs 24.9%), whereas ISUIA patients had a higher proportion of posterior communicating artery IAs (13.7% vs 8.2%, p = 0.016). Conclusions Heritable structural vulnerability may account for differences in IA multiplicity and location. Important investigations into the underlying genetic mechanisms of IA formation are ongoing.

Feasibility, Safety, and Periprocedural Complications of Pipeline Embolization for Intracranial Aneurysm Treatment Under Conscious Sedation: University at Buffalo Neurosurgery Experience

2015 ◽  
Vol 11 (3) ◽  
pp. 426-430 ◽  
Author(s):  
Leonardo Rangel-Castilla ◽  
Marshall C Cress ◽  
Stephan A Munich ◽  
Ashish Sonig ◽  
Chandan Krishna ◽  
...  
Keyword(s):  
Intracranial Aneurysm ◽  
General Anesthesia ◽  
Radiation Exposure ◽  
Intracranial Aneurysms ◽  
Conscious Sedation ◽  
Contrast Material ◽  
Neurological Complications ◽  
Safe Procedure ◽  
Aneurysm Treatment ◽  
The Mean

Abstract BACKGROUND Endovascular Pipeline Embolization Device (PED) placement for intracranial aneurysms is performed under general anesthesia at most centers because of perceived improved image quality and patient safety. OBJECTIVE To report the feasibility, safety, and outcomes associated with the use of the PED for intracranial aneurysms performed in awake patients after the administration of conscious sedation (CS) and a local anesthetic. METHODS Between March 2012 and September 2014, 130 patients with 139 intracranial aneurysms (8 ruptured) were treated with the PED under CS at our institution. Procedure details and time (including duration, radiation exposure, and fluoroscopy) and procedure-related complications were retrospectively reviewed. RESULTS A total of 155 PED deployment procedures were performed under CS. Treatment was successfully completed in all cases. Anesthesia was converted from CS to general anesthesia during 5 procedures. Mean interval from patient entry at the endovascular suite to procedure initiation was 18 minutes (range, 5 minutes-1 hour 10 minutes). Mean procedure length was 1 hour 25 minutes (range, 30 minutes-3 hours 51 minutes). Mean ± SD values for fluoroscopy time and radiation exposure were 36.17 ± 18.4 minutes and 1367 ± 897 mGy, respectively. The mean amount of contrast material administered was 211.37 ± 83.5 mL. Permanent neurological complications were seen in 4 patients (3%). CONCLUSION In our experience, CS for PED placement for intracranial aneurysm treatment is feasible and safe. Procedure and fluoroscopy times and amount of radiation exposure are similar to or less than described in reports of PED placement under general anesthesia. CS allows direct neurological evaluation and earlier detection of and response to intraprocedural complications.

scholarly journals Is intensive care monitoring necessary after coil embolization of unruptured intracranial aneurysms?

2016 ◽  
Vol 9 (8) ◽  
pp. 756-760 ◽  
Author(s):  
William R Stetler ◽  
Julius Griauzde ◽  
Yamaan Saadeh ◽  
Thomas J Wilson ◽  
Wajd N Al-Holou ◽  
...  
Keyword(s):  
Intracranial Aneurysm ◽  
Coil Embolization ◽  
Multivariate Regression ◽  
Intracranial Aneurysms ◽  
Cost Savings ◽  
Multivariate Regression Analysis ◽  
Unruptured Intracranial Aneurysm ◽  
Icu Admission ◽  
Telemetry Unit ◽  
Unruptured Intracranial Aneurysms

IntroductionPatients with an unruptured intracranial aneurysm treated with coil embolization are routinely admitted to the intensive care unit (ICU) after the procedure; however, this practice is questionable. The purpose of this study was to determine if routine admission to the ICU is necessary for patients undergoing coil embolization of an unruptured intracranial aneurysm.MethodsWe conducted a retrospective cohort study of all patients undergoing elective endovascular treatment of an unruptured intracranial aneurysm between 2005 and 2012 at our institution. Multivariate regression analysis was performed to identify predictors of outcome. Cost savings analysis compared ICU admission to step-down or telemetry unit admission.Results311 unruptured intracranial aneurysms were treated by coil embolization (190), balloon remodeling (13), or stent-assisted coiling (108). Eleven (3.5%) neurologic complications were noted; 5 (1.6%) of these were permanent. Multivariate regression analysis identified female sex (p=0.028), hypercoagulability (p=0.021), aneurysm size >2 cm (p=0.003), and intraoperative rupture (p<0.001) as predictors of a post-procedural neurologic complication. Cost savings were 57% for admission to a step-down unit and 32% for admission to a telemetry unit compared with ICU admission.ConclusionsNeurologic complications are rare in the treatment of unruptured intracranial aneurysms, suggesting that routine ICU admission after treatment may not be necessary. Female sex, history of hypercoagulability, aneurysm size >2 cm, and an intraprocedural rupture were predictive of a postoperative complication. ICU monitoring in these subgroups may therefore be warranted.

scholarly journals Clopidogrel response predicts thromboembolic events associated with coil embolization of unruptured intracranial aneurysms: A prospective cohort study

PLoS ONE ◽  
2021 ◽  
Vol 16 (4) ◽  
pp. e0249766
Author(s):  
Eiji Higashi ◽  
Shoji Matsumoto ◽  
Ichiro Nakahara ◽  
Taketo Hatano ◽  
Akira Ishii ◽  
...  
Keyword(s):  
Cohort Study ◽  
Intracranial Aneurysm ◽  
Coil Embolization ◽  
Intracranial Aneurysms ◽  
Thromboembolic Event ◽  
Clinical Information ◽  
Thromboembolic Events ◽  
Unruptured Intracranial Aneurysm ◽  
Clinical Model ◽  
Unruptured Intracranial Aneurysms

Objective Periprocedural thromboembolic events are a serious complication associated with coil embolization of unruptured intracranial aneurysms. However, no established clinical rule for predicting thromboembolic events exists. This study aimed to clarify the significance of adding preoperative clopidogrel response value to clinical factors when predicting the occurrence of thromboembolic events during/after coil embolization and to develop a nomogram for thromboembolic event prediction. Methods In this prospective, single-center, cohort study, we included 345 patients undergoing elective coil embolization for unruptured intracranial aneurysm. Thromboembolic event was defined as the occurrence of intra-procedural thrombus formation and postprocedural symptomatic cerebral infarction within 7 days. We evaluated preoperative clopidogrel response and patients’ clinical information. We developed a patient-clinical-information model for thromboembolic event using multivariate analysis and compared its efficiency with that of patient-clinical-information plus preoperative clopidogrel response model. The predictive performances of the two models were assessed using area under the receiver-operating characteristic curve (AUC-ROC) with bootstrap method and compared using net reclassification improvement (NRI) and integrated discrimination improvement (IDI). Results Twenty-eight patients experienced thromboembolic events. The clinical model included age, aneurysm location, aneurysm dome and neck size, and treatment technique. AUC-ROC for the clinical model improved from 0.707 to 0.779 after adding the clopidogrel response value. Significant intergroup differences were noted in NRI (0.617, 95% CI: 0.247–0.987, p < .001) and IDI (0.068, 95% CI: 0.021–0.116, p = .005). Conclusions Evaluation of preoperative clopidogrel response in addition to clinical variables improves the prediction accuracy of thromboembolic event occurrence during/after coil embolization of unruptured intracranial aneurysm.

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