An interesting case of reruptured endovascularly coiled aneurysm managed with clipping

Endovascular treatment has proven to be effective in the management of intracranial aneurysm, and can achieve permanent occlusion in up to 85% of cases, reducing the bleeding or rebleeding rate. A paradigm shift from microsurgical clipping to endovascular intervention has been observed since the publication of the International Subarachnoid Aneurysm Trial. Aneurysm recurrence after coil embolization remains both a major shortcoming of endovascular treatment and a daunting challenge for neurosurgeons without optimal management strategies.: We present a case report of a patient with history of previously endovascularly coiled and presenting with aneurysmal bleed. Microsurgical clipping is an effective intervention for managing reruptured previously coiled intracranial aneurysm.

Comprehensive review of the recent advances in devices for endovascular treatment of complex brain aneurysms

The International Subarachnoid Aneurysm Trial (ISAT) showed superiority for endovascular treatment of ruptured aneurysms and technology has since moved on rapidly. Many approaches and technology now exist for the endovascular management of ruptured and unruptured intracranial aneurysms, which reflects their varied nature – there is no one-size-fits-all technique. We aim to provide an overview of the various classes of device and the major developments over the past decade. Coiling is the oldest of the technology and continues to demonstrate high levels of occlusion and acceptable risks, making it the default treatment choice, particularly in the acutely ruptured aneurysm setting. Advances on coiling include the use of adjuncts such as balloons, stents and fully retrievable temporary neck-bridging devices, which have facilitated the treatment of more complex aneurysms. Flow divertors have also revolutionised complex aneurysm treatment with small added risk in acute aneurysm treatment and seek to remodel the aneurysm–vessel interface without accessing the aneurysm sac. The latest development and most promising avenue appears to be intrasaccular flow disrupting devices like WEB, Contour and Neqstent that provide excellent opportunities to treat wide neck complex aneurysm with minimal mortality and morbidity and good occlusion rates and may in future replace a significant number of stent-assisted coiling too.

Endovascular Coil Embolization of a Posterior Communicating Artery Aneurysm: 2-Dimensional Operative Video

Since the International Subarachnoid Aneurysm Trial,1 endovascular treatment has been the favored treatment for appropriate ruptured intracranial aneurysms. While our endovascular technology has advanced to allow us to treat the majority of intracranial aneurysms, simple coil embolization is still the most common modality. This video demonstrates the fundamentals of aneurysm catheterization and coiling for safe treatment. In addition, the set-up and devices are detailed. This video is to add to the library of basic techniques that will aid a large number of practitioners. This patient consented to endovascular treatment. The video demonstrates endovascular coil embolization of a posterior communicating artery aneurysm in a 76-yr-old female who presented with a subarachnoid hemorrhage. Image of biplane suite in video used courtesy of Siemens Medical Solutions USA, Inc. Illustration at 5:12 reprinted from Yasargil MG, et al, Microneurosurgery IV B, p. 9, Thieme, New York, 1995.

Survival, Dependency, and Health-Related Quality of Life in Patients With Ruptured Intracranial Aneurysm: 10-Year Follow-up of the United Kingdom Cohort of the International Subarachnoid Aneurysm Trial

BACKGROUND Previous analyses of the International Subarachnoid Aneurysm Trial (ISAT) cohort have reported on clinical outcomes after treatment of a ruptured intracranial aneurysm with either neurosurgical clipping or endovascular coiling. OBJECTIVE To evaluate the long-term quality-adjusted life years (QALYs) gained of endovascular coiling compare to neurosurgical clipping in the UK cohort of ISAT. METHODS Between September 12, 1994 and May 1, 2002, patients with ruptured intracranial aneurysms who were assumed treatment equipoise were randomly allocated to either neurosurgical clipping or endovascular coiling. We followed-up 1644 patients in 22 UK neurosurgical centers for a minimum of 10 yr. Health-related quality of life (HRQoL) was collected through yearly questionnaires, measured by utilities calculated from the EQ-5D-3L. We compared HRQoL between the 2 treatment groups over a period of 10 yr. In all, 1-yr, 5-yr, and 10-yr QALYs were estimated by combining utility and survival information. RESULTS Higher average utility values were found in the endovascular group throughout the follow-up period, with mean differences between groups statistically significant in most years. The 10-yr QALYs were estimated to be 6.68 (95% CI: 6.45-6.90) in the coiling group and 6.32 (95% CI: 6.10-6.55) in the clipping group, respectively, a significant mean difference of 0.36 (95% CI: 0.04-0.66). A third of this mean QALYs gain was estimated to derive solely from HRQoL differences. CONCLUSION HRQoL after treatment of a ruptured intracranial aneurysm was better after endovascular coiling compared to neurosurgical clipping, which contributed significantly to the QALYs gained over a 10-yr period.

Impact of Treatment Delay on Outcome in the International Subarachnoid Aneurysm Trial

Background and Purpose— ISAT (International Subarachnoid Aneurysm Trial) demonstrated that 1 year after aneurysmal subarachnoid hemorrhage, coiling resulted in a significantly better clinical outcome than clipping. After 5 years, this difference did not reach statistical significance, but mortality was still higher in the clipping group. Here, we present additional analyses, reporting outcome after excluding pretreatment deaths. Methods— Outcome measures were death with or without dependency at 1 and 5 years after treatment, after exclusion of all pretreatment deaths. Treatment differences were assessed using relative risks (RRs). With sensitivity and exploratory analyses, the relation between treatment delay and outcome was analyzed. Results— After exclusion of pretreatment deaths, at 1-year follow-up coiling was favorable over clipping for death or dependency (RR, 0.77 [95% CI, 0.67–0.89]) but not for death alone (RR, 0.88 [95% CI, 0.66–1.19]). After 5 years, no significant differences were observed, neither for death or dependency (RR, 0.88 [95% CI, 0.77–1.02]) nor for death alone (RR, 0.82 [95% CI, 0.64–1.05]). Sensitivity analyses showed a similar picture. In good-grade patients, coiling remained favorable over clipping in the long-term. Time between randomization and treatment was significantly longer in the clipping arm (mean 1.7 versus 1.1 days; P <0.0001), during which 17 patients died because of rebleeding versus 6 pretreatment deaths in the endovascular arm (RR, 2.81 [95% CI, 1.11–7.11]). Conclusions— These additional analyses support the conclusion of ISAT that at 1-year follow-up after aneurysmal subarachnoid hemorrhage coiling has a better outcome than clipping. After 5 years, with pretreatment mortality excluded, the difference between coiling and clipping is not significant. The high number of pretreatment deaths in the clipping group highlights the importance of urgent aneurysm treatment to prevent early rebleeding.

Treatment and diagnosis of cerebral aneurysms in the post-International Subarachnoid Aneurysm Trial (ISAT) era: trends and outcomes

BackgroundFollowing publication of the International Subarachnoid Aneurysm Trial (ISAT), treatment paradigms for cerebral aneurysms (CAs) shifted from open surgical clipping to endovascular embolization as primary therapy in a majority of cases. However, comprehensive analyses evaluating more recent CA diagnosis patterns, patient populations and outcomes as a function of treatment modality remain rare.MethodsThe National Inpatient Sample from 2004 to 2014 was reviewed. Aneurysmal subarachnoid hemorrhages (aSAHs) and unruptured intracranial aneurysms (UIAs) with a treatment of surgical clipping or endovascular therapy (EVT) were identified. Time trend series plots were created. Linear and logistic regressions were utilized to quantify treatment changes.Results114 137 aSAHs and 122 916 UIAs were reviewed. aSAH (+732/year, p=0.014) and UIA (+2550/year, p<0.0001) discharges increased annually. The annual caseload of surgical clippings for aSAH decreased (−264/year, p=0.0002) while EVT increased (+366/year, p=0.0003). For UIAs, the annual caseload for surgical clipping remained stable but increased for EVT (+615/year, p<0.0001). The rate of incidentally diagnosed UIAs increased annually (+1987/year; p<0.0001). Inpatient mortality decreased for clipping (p<0.0001) and EVT in aSAH (p<0.0001) (2004 vs 2014—clipping 13% vs 11.7%, EVT 15.8% vs 12.7%). Mortality rates for clipped UIAs decreased over time (p<0.0001) and remained stable for EVT (2004 vs 2014—clipping 1.57% vs 0.40%, EVT 0.59% vs 0.52%).ConclusionRuptured and unruptured CAs are increasingly being treated with EVT over clipping. Incidental unruptured aneurysm diagnoses are increasing dramatically. Mortality rates of ruptured aneurysms are improving regardless of treatment modality, whereas mortality in unruptured aneurysms is only improving for surgical clipping.

Are Wikipedia statistics useful in evaluating public interest in neurosurgical diseases? (Preprint)

BACKGROUND Wikipedia, a free, semi-editable online encyclopedia, is currently the fifth most popular website worldwide. It is a leading source of medical information for the public. OBJECTIVE To evaluate to what extent Wikipedia page view statistics can assess the public interest in neurosurgical diseases. METHODS The Wikipedia Massviews statistics tool was used to find the top ten and bottom ten pages on Wikipedia under the category “Neurosurgery” from January 1, 2016 to December 31, 2018. The top ten pages were analyzed for page view correlations with time, the languages available, the top five redirects and the respective PubMed data. RESULTS The most popular neurosurgical pages on Wikipedia were: Subarachnoid hemorrhage, Neurosurgery, Idiopathic intracranial hypertension, Intracranial aneurysm and Laminectomy. The bottom pages were: International Subarachnoid Aneurysm Trial, Dandy's point, Stereotaxic atlas, Traumatic pneumorrhachis and Decerebellate. More popular pages were available in more languages with the most popular being English. Users more often accessed Wikipedia on their phone browser than on desktop; this trend was also seen over Wikipedia English overall. PubMed publications did not correlate to the page views with time. CONCLUSIONS Despite the impact of media clamor, Wikipedia statistics offer valuable insight into public health interests and show how users access this information. Our study demonstrates that the most popular neurosurgical topics on Wikipedia are for aneurysms, stroke, hydrocephalus and spine surgery. These topics align themselves with the most common neurosurgery issues. We encourage physicians clarify any questions for the common well-read patient. This allows for a more efficient physician-patient interaction and can help highlight subjects of confusion for future patients especially since the readability of articles on neurosurgery is low.

Neurointerventional Training for Neurosurgeons: Past, Present, and Future

Endovascular therapy as any other specialty has continuously been developed since 1904, but acceptability among neurosurgeons remains low despite being other subspecialties and techniques, like endoscope and for that matter microscope also, being adopted very rapidly. From injecting particles for vascular lesions to balloons for fistulas and arteriovenous malformations and embolizing agents to detachable coils for aneurysm coiling, it has come a long way. Old generations of neurosurgeons used to perform carotid puncture for diagnosing mass lesions, but once CT/MRI came in to the picture, this procedure was stopped and handed over to radiologists. A debate continues among neurosurgeons about the feasibility of aneurysm coiling since international subarachnoid aneurysm trial (ISAT) and doubts about the long-term efficacy of this novel treatment cost a subspecialty. With the recent addition of endovascular treatment of stroke and long-term efficacy of endovascular treatment of aneurysm, there is a lot of debate among clinicians and nonclinicians about who will be the true heir of this sub specialty.

Surgical or endovascular management of ruptured intracranial aneurysms: an agreement study

OBJECTIVERuptured intracranial aneurysms (RIAs) can be managed surgically or endovascularly. In this study, the authors aimed to measure the interobserver agreement in selecting the best management option for various patients with an RIA.METHODSThe authors constructed an electronic portfolio of 42 cases of RIA in which an angiographic image along with a brief clinical vignette for each patient were displayed. Undisclosed to the responders was that the RIAs had been categorized as International Subarachnoid Aneurysm Trial (ISAT) (small, anterior-circulation, non–middle cerebral artery location, n = 18) and non-ISAT (n = 22) aneurysms; the non-ISAT group also included 2 basilar apex aneurysms for which a high number of endovascular choices was expected. The portfolio was sent to 132 clinicians who manage patients with RIAs and circulated to members of an American surgical association. Judges were asked to choose between surgical and endovascular management, to indicate their level of confidence in the choice of treatment on a quantitative 0–10 scale, and to determine whether they would include the patient in a randomized trial in which both treatments are compared. Eleven clinicians were asked to respond twice at least 1 month apart. Responses were analyzed using kappa statistics.RESULTSEighty-five clinicians (58 cerebrovascular surgeons, 21 interventional neuroradiologists, and 6 interventional neurologists) answered the questionnaire. Overall, endovascular management was chosen more frequently (n = 2136 [59.8%] of 3570 answers). The proportions of decisions to clip were significantly higher for non-ISAT (50.8%) than for ISAT (26.2%) aneurysms (p = 0.0003). Interjudge agreement was only fair (kappa 0.210, 95% CI 0.158–0.276) for all cases and judges, despite high confidence levels (mean score > 8 for all cases). Agreement was no better within subgroups of clinicians with the same specialty, years of experience, or location of practice or across capability groups (ability to clip or coil, or both). When agreement was defined as > 80% of responders choosing the same option, agreement occurred for only 7 of 40 cases, all of which were ISAT aneurysms, for which coiling was preferred.CONCLUSIONSAgreement between clinicians regarding the best management option was infrequent but centered around coiling for some ISAT aneurysms. Surgical clipping was chosen more frequently for non-ISAT aneurysms than for ISAT aneurysms. Patients with such an aneurysm might be candidates for inclusion in randomized trials.