Vision outcomes in patients with paraclinoid aneurysms treated with clipping, coiling, or flow diversion: a systematic review and meta-analysis

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Patients with paraclinoid aneurysms commonly present with visual impairment. They have traditionally been treated with clipping or coiling, but flow diversion (FD) has recently been introduced as an alternative treatment modality. Although there is still initial aneurysm thrombosis, FD is hypothesized to reduce mass effect, which may decompress the optic nerve when treating patients with visually symptomatic paraclinoid aneurysms. The authors performed a meta-analysis to compare vision outcomes following clipping, coiling, or FD of paraclinoid aneurysms in patients who presented with visual impairment.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>A systematic literature review was performed using the PubMed and Web of Science databases. Studies published in English between 1980 and 2016 were included if they reported preoperative and postoperative visual function in at least 5 patients with visually symptomatic paraclinoid aneurysms (cavernous segment through ophthalmic segment) treated with clipping, coiling, or FD. Neuroophthalmological assessment was used when reported, but subjective patient reports or objective visual examination findings were also acceptable.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>Thirty-nine studies that included a total of 2458 patients (520 of whom presented with visual symptoms) met the inclusion criteria, including 307 visually symptomatic cases treated with clipping (mean follow-up 26 months), 149 treated with coiling (mean follow-up 17 months), and 64 treated with FD (mean follow-up 11 months). Postoperative vision in these patients was classified as improved, unchanged, or worsened compared with preoperative vision. A pooled analysis showed preoperative visual symptoms in 38% (95% CI 28%–50%) of patients with paraclinoid aneurysms. The authors found that vision improved in 58% (95% CI 48%–68%) of patients after clipping, 49% (95% CI 38%–59%) after coiling, and 71% (95% CI 55%–84%) after FD. Vision worsened in 11% (95% CI 7%–17%) of patients after clipping, 9% (95% CI 2%–18%) after coiling, and 5% (95% CI 0%–20%) after FD. New visual deficits were found in patients with intact baseline vision at a rate of 1% (95% CI 0%–3%) for clipping, 0% (95% CI 0%–2%) for coiling, and 0% (95% CI 0%–2%) for FD.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>To the authors’ knowledge, this is the first meta-analysis to assess vision outcomes after treatment for paraclinoid aneurysms. The authors found that 38% of patients with these aneurysms presented with visual impairment. These data also demonstrated a high rate of visual improvement after FD without a significant difference in the rate of worsened vision or iatrogenic visual impairment compared with clipping and coiling. These findings suggest that FD is an effective option for treatment of visually symptomatic paraclinoid aneurysms.</jats:p></jats:sec>

Comparison of flow diversion with clipping and coiling for the treatment of paraclinoid aneurysms in 115 patients

“…12,29,41 Our recently published meta-analysis revealed a 38% rate of visual symptoms among these patients. 42 PED placement might specifically improve visual outcomes when used to treat paraclinoid aneurysms, according to the results of our meta-analysis, in which we found a high rate of visual improvement (71%) among patients treated with a PED and similarly low rates of visual complications compared to those after clipping and coiling. 42 Among the 14% of patients in this series who presented with visual symptoms, we found a significantly higher rate of vision improvement among those treated with PED deployment than among those treated with coiling or clipping.…”

“…42 PED placement might specifically improve visual outcomes when used to treat paraclinoid aneurysms, according to the results of our meta-analysis, in which we found a high rate of visual improvement (71%) among patients treated with a PED and similarly low rates of visual complications compared to those after clipping and coiling. 42 Among the 14% of patients in this series who presented with visual symptoms, we found a significantly higher rate of vision improvement among those treated with PED deployment than among those treated with coiling or clipping. Although symptomatic visual improvement is just 1 factor to be considered when choosing a treatment modality, the findings of our study suggest that PED use might be particularly beneficial for patients with a paraclinoid aneurysm who present with visual symptoms.…”

Variation of Mass Effect After Using a Flow Diverter With Adjunctive Coil Embolization for Symptomatic Unruptured Large and Giant Intracranial Aneurysms

“…For large or giant aneurysms with compressional symptoms, a PED with adjunctive coil embolization has specific advantages. Earlier literature reported that the loss of pulsatility caused by aneurysm healing after traditional treatment had a certain probability of relieving symptoms (2, 5). However, the compression of the surrounding tissues by the aneurysm itself was considered to be unable to be resolved by the intervention, which may explain why compressional symptoms remain even after the aneurysm has been completely occluded.…”

“…Endovascular techniques have been proven effective and safe in the management of intracranial aneurysms and have thus become the preferred treatment strategy. However, traditional endovascular techniques are inferior for the treatment of large or giant aneurysms, which in some locations may induce compressional symptoms related to cranial nerves II, III, V, and VI, leading to oculomotor nerve palsy (ONP), visual loss, diplopia, and facial numbness (2–4). The classic intervention relies on coils for dense embolization in the aneurysmal sac, promoting thrombosis; however, if complete occlusion is achieved, the cranial palsy caused by the mass effect may become aggravated.…”

Microneurosurgery for Paraclinoid Aneurysms in the Context of Flow Diverters

“…A wide volume of literature confirms today the effectiveness and safety of FDs, especially for ICA aneurysms, therefore supporting them as the first-line treatment for most paraclinoid aneurysms [19][20][21][22]. Recently, FDs have also been associated with a high rate of visual improvement in symptomatic patients, without differences in terms of worsened vision or iatrogenic visual impairment as compared with clipping and coiling techniques [23]. While admitting the practical role of FDs in the treatment of a large part of ICA aneurysms as those wide-necked, fusiform, dissecting, blister-like, or ventral giant, the enthusiastic attitude toward the flow diversion ought to be counterbalanced by a series of drawbacks to be taken into account.…”