BackgroundThromboembolic complications (TECs) are frequent during the endovascular treatment of unruptured aneurysms. To prevent TECs, dual antiplatelet therapy using aspirin and clopidogrel is recommended for the perioperative period. In patients with a poor response, clopidogrel is a risk factor for TECs. To prevent TECs, our study assessed the stratified use of prasugrel.MethodsPatients who underwent endovascular therapy for unruptured cerebral aneurysms from April 2017 to August 2019 were enrolled in this clinical study and given premedication with aspirin and clopidogrel for 2 weeks prior to the procedure. P2Y12 reaction units (PRU) were measured using the VerifyNow assay on the day before the procedure (tailored group). In subgroups with PRU <240, the clopidogrel dose was maintained (CPG subgroup). In subgroups with PRU ≥240, clopidogrel was changed to prasugrel (PSG subgroup). We compared the occurrence of TECs with retrospective consecutive cases from January 2015 to March 2017 without PRU assessments (non-tailored group). The frequency of TECs within 30 days was assessed as the primary endpoint.ResultsThe tailored and non-tailored groups comprised 167 and 50 patients, respectively. TECs occurred in 11 (6.6%) and 8 (16%) patients in the tailored and non-tailored groups (P=0.048), respectively. The HR for TECs was significantly reduced in the tailored group (HR 0.3, 95% CI 0.11 to 0.81); P=0.017) compared with the non-tailored group.ConclusionThe results suggest that tailored dual antiplatelet therapy medication with PRU significantly reduces the frequency of TECs without increasing hemorrhagic complications.

No abstract

Introduction:Microsurgical clipping and Endovascular coiling (EC) are both effective alternatives in the management of intracranial aneurysms. EC has been shown to be associated with the risk of recurrent aneurysm (RA) growth. Considering the minimally invasive nature of this procedure, the management of intracranial aneurysms has been skewed toward EC, especially in the developed world. In this scenario, there has been an upsurge of RAs after EC. Since the optimal management of these RAs has not been defined, they pose a unique challenge to the treating surgeons.Aims and Objectives:The aim of this study is to elucidate the optimal management of RAs after EC.Materials and Methods:Medical records of all patients who underwent surgery for RAs were reviewed from the period January 2014 to March 2019. The demographic and angiographic patterns of the patients and operative techniques and complications were studied. The outcome was dichotomized into good and bad depending on the Glasgow outcome scale (GOS).Results:There were four cases of RAs operated in our institution between the above-mentioned period. There were varied differences between the initial coiling and time to recurrences. All four patients were operated under neuromonitoring. Three underwent clipping and one patient underwent clipping with bypass. All four patients had good outcome with a GOS of 5/5.Conclusion:Operations for RAs constitute many technical challenges and require a lot of expertise. Such surgeries are recommended in high-volume centers, with sufficient experience in both clipping and cerebral bypass.

Introduction: The surgical strategies for clipping of paraclinoid aneurysms are diverse. These aneurysms are unique in their location, as they closely abut the anterior clinoid process (ACP) and the optic nerve. The ultimate goal of clipping encompasses the exposure of neck of the aneurysm which is seldom complete without the manipulation of optic nerve and the ACP. This manipulation may result in disturbances of vision postoperatively. We analyze our results of visual outcomes in the surgery for paraclinoid aneurysms in this retrospective study. Materials and Methods: All patients with paraclinoid aneurysms who underwent surgery from June 2014 to June 2019 were included in the study. Surgical procedure was uniform in all patients which included anterior clinoidectomy and clipping of aneurysms as per the Bantane protocol. Glasgow Outcome Scale as well as vision was assessed at discharge and at 1 month and 6 months. Results: There were 77 cases of paraclinoid aneurysms operated during the abovementioned period. All patients had no symptoms related to vision preoperatively. Visual deterioration was noted in two patients. All patients were discharged with a good outcome on the Glasgow Outcome Scale. Conclusion: Paraclinoid aneurysm has a good outcome when treated with surgery. The visual deterioration following surgery can be minimized with extradural anterior clinoidectomy and careful handling of the vessels and nerve.

Basilar apex aneurysms constitute 5%–8% of all intracranial aneurysms. Microsurgical clipping of basilar tip aneurysms is still advocated for as it is safe, especially for unruptured basilar tip aneurysms which have a low risk of postoperative mortality or morbidity. Careful patient preparation is needed preoperatively because the risk of intraoperative rupture is significant. Good surgical techniques should be applied. The skill will need to be preserved as endovascular surgery becomes more popular. This is a case of basilar tip aneurysm managed by clipping through the anterior temporal approach, followed by a review of the literature.