Comparative Effectiveness of Unruptured Cerebral Aneurysm Therapies

McDonald, Jennifer S.; McDonald, Robert J.; Fan, Jiaquan; Kallmes, David F.; Lanzino, Giuseppe; Cloft, Harry J.

doi:10.1161/strokeaha.111.000196

Cited by 105 publications

(40 citation statements)

References 28 publications

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“…38 From this database, morbidity rates ranging from 13.5% to 27.6% and mortality rates ranging from 0.7% to 3.5% have been reported. 2,3,4,5,6,15,18,19,22,28,41 The objective of this institutional review board-approved prospective study was to assess the feasibility and efficacy of the addition of direct neurological testing during both temporary and permanent clipping of UIAs.…”

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confidence: 99%

“Awake” clipping of cerebral aneurysms: report of initial series

Abdulrauf¹,

Vuong²,

Patel³

et al. 2017

Journal of Neurosurgery

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ABBREVIATIONS ACoA = anterior communicating artery; CVA = cerebrovascular accident; EEG = electroencephalography; ICA = internal carotid artery; LOS = length of stay; MCA = middle cerebral artery; MEP = motor evoked potential; mRS = modified Rankin Scale; NIS = National Inpatient Sample; SSEP = somatosensory evoked potential; UIA = unruptured intracranial aneurysm; VA = vertebral artery. OBJECTIVE Risk of ischemia during aneurysm surgery is significantly related to temporary clipping time and final clipping that might incorporate a perforator. In this study, the authors attempted to assess the potential added benefit to patient outcomes of "awake" neurological testing when compared with standard neurophysiological testing performed under general anesthesia. The procedure is performed after the induction of conscious sedation, and for the neurological testing, the patient is fully awake. METHODS The authors conducted an institutional review board-approved prospective study of clipping unruptured intracranial aneurysms (UIAs) in 30 consecutive adult patients who underwent awake clipping. The end points were the incidence of stroke/cerebrovascular accident (CVA), death, discharge to a long-term facility, length of stay, and 30-day modified Rankin Scale score. All clinical and neurophysiological intraoperative monitoring data were recorded. RESULTS The median patient age was 52 years (range 27-63 years); 19 (63%) female and 11 (37%) male patients were included. Twenty-seven (90%) aneurysms were anterior, and 3 (10%) were posterior circulation aneurysms. Five (17%) had been coiled previously, 3 (10%) had been clipped previously, 2 (7%) were partially calcified, and 2 (7%) were fusiform aneurysms. Three patients developed synchronous clinical neurological and neurophysiological changes during temporary clipping with consequent removal of the temporary clip and reversal of those clinical and neurophysiological changes. Three patients developed asynchronous clinical neurological and neurophysiological changes. These 3 patients developed hemiparesis without changes in neurophysiological monitoring results. One patient developed linked clinical neurological and neurophysiological changes during final clipping that were not reversed by reapplication of the clip, and the patient had a CVA. Four patients with internal carotid artery ophthalmic segment aneurysms underwent visual testing with final clipping, and 1 of these patients required repositioning of the clip. Three patients who required permanent occlusion of a vessel as part of their aneurysm treatment underwent a 10-minute intraoperative clinical respective-vessel test occlusion. The median length of stay was 3 days (range 1-5 days). The median modified Rankin Scale score was 1 (range 0-3). All of the patients were discharged to home from the hospital except for 1 who developed a CVA and was discharged to a rehabilitation facility. There were no deaths in this series. CONCLUSIONS The 3 patients who developed neurological deterioration without a concomitant neurophysi...

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confidence: 99%

“Awake” clipping of cerebral aneurysms: report of initial series

Abdulrauf¹,

Vuong²,

Patel³

et al. 2017

Journal of Neurosurgery

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“…These retrospective database studies have reported mortality from surgical treatment ranging from 0.7% to 3.5% and morbidity ranging from 13.5% to 27.6%. [199][200][201][202][203][204][205][206][207][208] Because of the lack of specific outcome information available in such databases, morbidity has generally been defined as discharge status to a facility other than home (including rehabilitation facilities). No longer-term outcome data past the time of discharge can be assessed, and assumptions that discharge status is a reliable surrogate for longerterm outcome are not well validated.…”

Section: Surgical Clipping Outcomesmentioning

confidence: 99%

Guidelines for the Management of Patients With Unruptured Intracranial Aneurysms

Thompson¹,

Brown²,

Amin‐Hanjani³

et al. 2015

Stroke

834

352

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Purpose— The aim of this updated statement is to provide comprehensive and evidence-based recommendations for management of patients with unruptured intracranial aneurysms. Methods— Writing group members used systematic literature reviews from January 1977 up to June 2014. They also reviewed contemporary published evidence-based guidelines, personal files, and published expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulated recommendations using standard American Heart Association criteria. The guideline underwent extensive peer review, including review by the Stroke Council Leadership and Stroke Scientific Statement Oversight Committees, before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee. Results— Evidence-based guidelines are presented for the care of patients presenting with unruptured intracranial aneurysms. The guidelines address presentation, natural history, epidemiology, risk factors, screening, diagnosis, imaging and outcomes from surgical and endovascular treatment.

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“…2,3 Endovascular coil embolization is occasionally preferred in the management of unruptured intracranial aneurysms because it is less invasive than surgical clipping. [5][6][7][8] However, the longterm risk and durability of coil embolization are unknown. 9,10 The frequencies of aneurysm rests or recurrences are higher after coil embolization than that after surgical clipping.…”

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Blood Flow Into Basilar Tip Aneurysms

Sugiyama

Niizuma

Sato

et al. 2016

Stroke

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We retrospectively investigated the clinical and radiological data from 111 consecutive patients who underwent endovascular treatment Background and Purpose-Hemodynamic forces may play a role in the recanalization of coiled aneurysms. The purpose of this study was to investigate the influence of presurgical hemodynamics on the efficacy of coil embolization for basilar tip aneurysms. Methods-We identified 82 patients who underwent endovascular coil embolization for basilar tip aneurysms with a followup of >1 year. Presurgical hemodynamics were investigated using computational fluid dynamics with 3-dimensional data derived from rotational angiography. During postprocessing, we quantified the rate of net flow entering the aneurysm through its neck and calculated the proportion of the aneurysmal inflow rate to the basilar artery flow rate. In addition, we investigated the correlation between the basilar bifurcation configuration and the hemodynamics. Results-Twenty-five of the 82 patients were excluded because of difficult vascular geometry reconstruction. Among the 57 examined patients, angiographic recanalization was observed in 19 patients (33.3%). The proportion of the aneurysmal inflow rate to the basilar artery flow rate and a coil packing density <30% were independent and significant predictors for the recanalization of coiled aneurysms. Additional investigation revealed that a small branch angle formed by the basilar artery and the posterior cerebral artery increased blood flow into the aneurysm. Conclusions-The proportion of the aneurysmal inflow rate to the basilar artery flow rate, influenced by the basilar bifurcation configuration, was an independent and significant predictor for recanalization after coil embolization in basilar tip aneurysms.

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Comparative Effectiveness of Unruptured Cerebral Aneurysm Therapies

Cited by 105 publications

References 28 publications

“Awake” clipping of cerebral aneurysms: report of initial series

“Awake” clipping of cerebral aneurysms: report of initial series

Guidelines for the Management of Patients With Unruptured Intracranial Aneurysms

Blood Flow Into Basilar Tip Aneurysms

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