Current update on the randomized controlled trials of intracranial aneurysms

Endovascular coiling has become the primary treatment modality for the treatment of intracranial ruptured aneurysms in many centers. A multicenter randomized controlled trial (RCT), ISAT study, has demonstrated that endovascular coiling of ruptured intracranial aneurysms has benefits over surgical clipping in those patients suitable for either treatment. Because RCT comparing conservative management with surgical clipping and with endovascular coiling have not been performed to date for unruptured intracranial aneurysms, the best management for unruptured aneurysm remains unclear. A RCT is ongoing to answer the question whether active treatment can improve the outcome of patients with unruptured intracranial aneurysms as compared with observation.     

比较手术夹闭和介入栓塞治疗颅内未破裂动脉瘤安全性和有效性的Meta分析

目的比较手术夹闭和介入栓塞治疗颅内未破裂动脉瘤的安全性和有效性。方法计算机检索1990至2018年颅内未破裂动脉瘤的所有临床对照研究。两名研究员分别纳入研究、提取数据、质量评价并应用Rev Man5. 0软件进行数据处理。结果最终纳入21篇文献,病例数109114例。Meta分析结果提示:手术夹闭组动脉瘤闭塞率为88. 2%,平均住院时间7. 7天,均高于介入栓塞组的65. 3%和4. 1天,P 0. 05。介入组患者的短期死亡率和致残率分别为0. 61%和2. 1%,均低于手术组的1. 27%和4. 7%,P 0. 05。介入组患者的1年期死亡率和致残率(2. 5%、2. 5%)均与手术组(2. 2%、1. 8%)无明显差异,P 0. 05。漏斗图未发现发表偏倚。敏感性分析结果一致。结论介入栓塞相比于手术夹闭可缩短患者的住院时间,降低患者的短期不良预后发生率。但是动脉瘤的闭塞率较低,1年期预后与手术夹闭无明显差异。据此推测手术夹闭患者的长期预后可能要好于介入栓塞,手术夹闭更适合于年轻患者。     

Quality of life after treatment of unruptured intracranial aneurysms by neurosurgical clipping or by embolisation with coils. A prospective, observational study

BACKGROUND: Relatively high rates of complications occur after operation for unruptured intracranial aneurysms. Published data on endovascular treatment suggest lower rates of complications. We measured the impact of treatment of unruptured aneurysms by clipping or coiling on functional health, quality of life, and the level of anxiety and depression. METHODS: In three centres, we prospectively collected data on patients with an unruptured aneurysm who were treated by clipping or coiling. Treatment assignment was left to the discretion of the treating physicians. Before, 3 and 12 months after treatment, we used standardised questionnaires to assess functional health (Rankin Scale score), quality of life (SF-36, EuroQol), and the level of anxiety and depression (Hospital Anxiety and Depression Scale). RESULTS: Nineteen patients were treated by coiling and 32 by clipping. In the surgical group, 4 patients (12%) had a permanent complication; 36 of all 37 aneurysms (97%) were successfully clipped. Three months after operation, quality of life was worse than before operation; 12 months after operation, it had improved but had not completely returned to baseline levels. Scores for depression were higher than in the general population. In the endovascular group, no complications with permanent deficits occurred; 16 of 19 aneurysms (84%) were occluded by more than 90%. One patient died from rupture of the previously coiled aneurysm. In the others, quality of life after 3 months and after 1 year was similar to that before treatment. CONCLUSIONS: In the short term, operation of patients with an unruptured aneurysm has a considerable impact on functional health and quality of life. After 1 year, recovery occurs but it is incomplete. Coil embolisation does not affect functional health and quality of life.     

Which unruptured cerebral aneurysms should be treated? A cost-utility analysis.

OBJECTIVE: To determine which unruptured cerebral aneurysms should be treated considering the risks. benefits, and costs. BACKGROUND: Asymptomatic unruptured cerebral aneurysms are commonly treated by surgical clipping or endovascular coil embolization to prevent subarachnoid hemorrhage (SAH). METHODS: We performed a cost-utility analysis comparing surgical clipping and endovascular coil embolization with no treatment for unruptured aneurysms. Eight clinical scenarios were defined based on aneurysm size, symptoms, and history of SAH from a different aneurysm. Health outcomes of a hypothetical cohort of 50-year-old women were modeled over the projected lifetime of the cohort. Costs were assessed from the societal perspective. We compared net quality-adjusted life years (QALYs) and cost per QALY of each therapy to no treatment. RESULTS: For an asymptomatic unruptured aneurysm less than 10 mm in diameter in patients with no history of SAH from a different aneurysm, both procedures resulted in a net loss in QALYs, and confidence intervals (CI) were not compatible with a benefit from treatment (clipping, loss of 1.6 QALY [95% CI 1.1 to 2.1]; coiling, loss of 0.6 QALY [95% CI 0.2 to 0.8]). For larger aneurysms (> or = 10 mm), those producing symptoms by compressing neighboring nerves and brain structures, or in patients with a history of SAH from a different aneurysm, treatment was cost-effective. Coiling appeared more effective and cost-effective than clipping but these differences depended on relatively uncertain model parameters. CONCLUSIONS: Treatment of small, asymptomatic, unruptured cerebral aneurysms in patients without a history of SAH worsens clinical outcomes, and thus is neither effective nor cost-effective. For aneurysms that are > or = 10 mm or symptomatic, or in patients with a history of SAH, treatment appears to be cost-effective.     

颅内动脉瘤治疗措施的临床证据评价

目的 评价不同治疗方案对颅内动脉瘤的疗效及不良后果.以为颅内动脉瘤的循证治疗制定最佳治疗方案.方法 以颅内动脉瘤、治疗、血管内栓塞治疗、手术夹闭治疗等英文词组作为检索词.分别检索MEDLINE、PubMed、Cochrane图书馆等数据库,并辅助手工检索获得临床指南、随机对照临床试验、系统评价、回顾性病例分析、临床对照试验及病例观察研究等方面的相关文献,采用Jadad量表对文献质量进行评价.结果 经筛选共纳入与颅内动脉瘤治疗有关的临床指南4篇、随机对照临床试验4篇、系统评价7篇、回顾性病例分析9篇、临床对照试验1篇、病例观察研究1篇;其中20篇被评为高质量文献(2篇7分、2篇6分、4篇5分、12篇4分),6篇为低质量文献.经对各项临床试验治疗原则和不同治疗方法 的疗效及安全性评价显示:(1)血管内栓塞和手术夹闭治疗是目前治疗颅内动脉瘤的主要外科手术方法,但哪种方法 更具优势仍存在争议.(2)对于未破裂颅内动脉瘤的治疗,有症状者建议积极治疗;但对于无症状的小动脉瘤,是否需要治疗尚有争议,应根据各种影响因素如年龄、既往病史、家族史.以及动脉瘤大小、部位、形态和预期寿命等综合考虑.(3)对于已破裂的颅内动脉瘤.建议尽快施行手术治疗,除非急性期不能耐受手术者外,不宜采取延期治疗方案.手术方法 的选择也应结合患者具体情况具体分析.(4)动脉瘤破裂后的药物治疗,除尼莫地平已获得大犁随机对照临床试验证据外,其他药物治疗效果仍有待研究.结论 借助循证医学评价方法 可为颅内动脉瘤患者的治疗提供最佳的临床证据.     

Surgical nuances of clipping after coiling: looking beyond the international subarachnoid aneurysm trial

After the introduction of Guglielmi Detachable Coils (GDC), endovascular management of ruptured and unruptured aneurysms became a viable alternative to surgical clipping as a "minimally invasive" option. Endovascular management of aneurysms became even more common after the International Subarachnoid Aneurysm Trial, which was one of the first prospective, randomized trials comparing clipping and coiling, showed reduced dependency and death in patients undergoing coiling after two months and one year. As the numbers of patients treated by endovascular therapy grow neurosurgeons are facing increasing challenges of clipping difficult aneurysms not suitable for coiling, including those that are wide-necked, thrombosed or involving many perforators. In addition, treatment failures (recurrent and residual aneurysms after coiling) pose difficult treatment scenarios fraught with complications due to surrounding adhesions, coil migration and involvement of adjacent neurovascular structures. Thus, we analyzed the recent literature dealing with the nuances of clipping after coiling and reviewed the current management principles involved in treating these difficult aneurysms.     

German Society of Neurosurgery Section on Vascular Neurosurgery: Position Statement on the International Subarachnoid Hemorrhage Trial (ISAT)

The outcome after a specific treatment (clipping or coiling) of ruptured intracranial aneurysms is determined by both the periprocedural complication rate and the success of preventing re-bleeding from the treated aneurysm. The latter is associated with a cumulative risk over many years, particularly in incompletely treated aneurysms. Incomplete occlusion of the aneurysm is not infrequently seen after endovascular coiling, even in cases with a perfect anatomical configuration. Therefore, we believe that the 1-year outcome as reported in the ISAT is not an appropriate endpoint for the comparison of both methods. There has also been a tendency to apply the 1-year ISAT data to all patients harbouring intracranial aneurysms. It is inappropriate and dangerous to be less critical when selecting the endovascular approach as the method of choice for treating an aneurysm. This will ultimately result in a higher complication rate of coiling. Another striking finding is the poor surgical outcome in the ISAT. This good-grade patient population (94 % were WFNS grade 1-3 and 89 % were WFNS grade 1-2) had an almost 10 % higher rate of poor outcome compared to other good-grade patients in large prospective surgical studies or the same outcome as trials that included up to 20 % poor-grade patients.[nl]Neurosurgeons should acknowledge that endovascular coiling is a safe method associated with less complications than clipping in experienced hands (Fig. ). Endovascular radiologists should acknowledge that the success of complete obliteration is higher after surgery, that incompletely occluded aneurysms have a higher rate of re-rupture and that the definitive long-term re-rupture rate still remains unknown. Therefore, we await with interest the angiographic and clinical follow-up data that will provide evidence about the final patient outcome.     

Unruptured intracranial aneurysms

Between 3.6 and 6% of the population harbour an unruptured intracranial aneurysm. Risk of rupture is related to aneurysm site and size and whether or not the patient has already had a subarachnoid haemorrhage (SAH) from another aneurysm. In ISUIA 2, the rupture rate for anterior circulation aneurysms<7mm was 0% per year in patients with no prior SAH, and 0.3% per year in patients with previous SAH; 7-12mm aneurysms, 0.5% per year (both groups); 13-24mm aneurysms, 3% per year; and giant aneurysms 8% per year. Rupture rate for posterior circulation aneurysms is higher at all sizes:<7mm was 0.5% per year in subjects with no prior SAH, 0.7% in those with prior SAH; 7-12mm, 3% per year; 13-24mm, 3.7% per year; and giant aneurysms, 10% per year. Non-invasive tests like contrast enhanced magnetic resonance angiography (MRA) and multislice computed tomographic angiography (CTA) are alternatives to intra-arterial digital subtraction angiography (IADSA) to detect aneurysms. Although these are promising techniques, the quality of data testing their accuracy remains limited and single slice CTA and time-of-flight MRA are poorer at detecting aneurysms<5mm diameter, which account for up to 1/3 of unruptured aneurysms. For ruptured aneurysms, the only large scale randomised controlled trial comparing surgical and endovascular treatment (ISAT) by coiling, resulted in an absolute 8.8% reduction (updated figure as of June 2003 for 1888 patients) in death or dependency at 1 year compared with surgical clipping. For unruptured aneurysms, the best available data so far comparing coiling and clipping is from the prospective (but non-randomised) arm of ISUIA. Elective surgical clipping had combined morbidity and mortality at 1 year of 12.2% versus 9.5% for coiling, although the groups were not matched with more high risk patients in the endovascular treatment cohort. Nevertheless these data are encouraging for future randomised trials of elective coiling versus clipping for asymptomatic aneurysms, in particular as the unproven long-term durability of coiling treatment and the fact that complete aneurysm occlusion is not always achieved remain obstacles to its wider use in unruptured aneurysms. There is an increased risk of SAH in relatives of patients with SAH (highest in those with two or more first degree relatives affected), but most SAH is sporadic and therefore the balance of available evidence indicates that mass screening for aneurysms is not cost effective. There may be a limited role for investigation of high-risk subgroups and ideally such screening should be tested in a randomised trial. The avoidance and active management of vascular risk factors should also be part of the management of at risk subjects.     

Factors affecting rapid growth of unruptured cerebral aneurysms during the acute stage of subarachnoid hemorrhage

BACKGROUND AND PURPOSE: Several unruptured cerebral aneurysms have been reported to grow and rupture. To determine which factors affect the growth of these aneurysms during the acute stage of subarachnoid hemorrhage (SAH), a retrospective review was performed.METHODS: Between January 2000 and January 2003, 130 patients with angiographically proven ruptured cerebral aneurysms were treated at our institution. Of these patients, 32 also had simultaneous unruptured aneurysms, and the total number of the unruptured aneurysms was 40, including two neck remnants which had remained since the past clipping. Seventeen patients had 17 unruptured aneurysms and two neck remnants. The unruptured aneurysms were not treated during the acute stage of SAH but had received a complete short term follow-up.RESULTS: The rapid growth of one unruptured aneurysm and two neck remnants was confirmed by a second angiogram performed on average 40 days after the first angiogram. Several candidate factors responsible for the growth of aneurysm were selected, and the results of a statistical analysis indicate that a systolic blood pressure above 200 mmHg during the acute stage of SAH and vasospasm, confirmed by transcranial Doppler ultrasound (TCD) or neurological examination, and neck remnants, are risk factors that affect the growth.CONCLUSIONS: Short term follow-up angiography is thus important for patients with untreated unruptured cerebral aneurysms after the acute stage of SAH.     

The impact of microsurgical clipping and endovascular coiling on the outcome of cerebral aneurysms in patients over 60 years of age

A retrospective study was performed to compare the safety and efficacy in elderly patients of endovascular coiling, with clipping, for cerebral aneurysms. In total, 198 patients over 60 years of age with ruptured intracranial aneurysms were treated by microsurgical clipping (n = 122) or endovascular coiling (n = 76). Endovascular coiling achieved favorable outcome in 88.2% of patients, which was significantly higher than for the microsurgical clipping group. The occurrence of re-bleeding, infarction, and hydrocephalus was similar between the two groups. Intraoperative time for microsurgical clipping was significantly longer than that for endovascular coiling. Length of hospitalization was shorter for the coiling group than for the clipping group. Our results suggest that endovascular coiling should be considered as the first-choice therapy in elderly patients with ruptured aneurysms, as it may reduce duration of both the operation and hospitalization.     

动脉瘤外科治疗的临床研究

目的 比较开颅夹闭和介入治疗颅内动脉瘤的临床治疗效果. 方法 哈尔滨医科大学附属第二医院神经外科自2008年11月至2010年1月收治颅内动脉瘤患者73例,其中行开颅夹闭治疗30例,行介入治疗43例.回顾性分析2组患者的临床资料并比较并发症、住院时间和预后情况. 结果 脑水肿、脑梗死、颅内出血、脑积水和颅内感染的发生率2组间比较差异无统计学意义(P＞0.05);开颅夹闭组患者住院时间[(17.56±7.57)d]长于介入治疗组[(13.12±7.12)d],差异有统计学意义(P＜0.05);开颅夹闭组患者出院时预后良好25例,预后不良5例,介入治疗组患者出院时预后良好40例,预后不良3例,差异无统计学意义(P＞0.05). 结论 血管内介入治疗动脉瘤的安全性和有效性并不优于开颅夹闭治疗.     

Natural history, epidemiology and screening of unruptured intracranial aneurysms

IntroductionThe prevalence of unruptured intracranial aneurysms is around 2%; most of these aneurysms are small and located in the anterior circulation. Unruptured intracranial aneurysms may give rise to subarachnoid hemorrhage in the near or distant future and sometimes, these lesions warrant preventive intervention.State of the artMost studies, on risk of rupture, have methodological weaknesses; the overall risk of rupture found in follow-up studies is around 1% per year. Size is the most important risk factor for rupture, with smaller risks for smaller aneurysms. Other risk factors are site of the aneurysm (higher risk for posterior-circulation aneurysms), age, female gender, population (higher risks in Finland and Japan) and probably also smoking. For aneurysms smaller than 10 mm, treatment carries a risk of around 5% of complications leading to death or dependence on help for activities of daily living.PerspectivesThere are no good comparisons between clipping and coiling of unruptured aneurysms. The efficacy of coiling in the long-term is unsettled. Good-quality data are urgently needed to settle these questions.ConclusionsIn deciding whether or not to treat an aneurysm, life expectancy is a pivotal factor; other important factors are size and site of the aneurysm.     

Unruptured intracranial saccular aneurysms less than 20 mm in diameter in adults. Radical surgery in 89 cases

Between 1972 and 1989, 131 unruptured intracranial saccular aneurysms were clipped in the Neurosurgical Department of La Pitié Hospital, Paris. Only 89 of these are considered here, the remaining 42 aneurysms having been discovered and clipped during surgery for a ruptured aneurysm. All isolated unruptured aneurysms were detected by angiography, computerized tomography or magnetic resonance imaging. Twenty out of the 89 aneurysms were asymptomatic ("incidental") while 69 were accompanied by clinical symptoms indicating radiological examination. It is generally accepted that in ruptured aneurysms the mortality rate during 3 days following the rupture is about 50 percent, and for this reason many neurosurgeons are in favour of unruptured aneurysms being treated either by open surgery with clipping of the aneurysmal neck or by inserting a balloon into the aneurysmal sac. The results obtained in 377 published cases, including ours, justify this approach: no recurrent bleeding was observed after open surgery and the mortality rate was nil when the contra-indications of surgery were respected. There was a permanent morbidity of less than 2 per cent directly related to the surgeon's experience.     

椎动脉颅内段夹层动脉瘤的个体化治疗

目的 探讨椎动脉颅内段夹层动脉瘤的个体化治疗策略.方法 分别采用微弹簧圈闭塞动脉瘤和载瘤动脉、支架辅助微弹簧圈栓塞动脉瘤、单纯支架植入、手术直接夹闭动脉瘤,以及枕动脉-小脑后下动脉血管吻合术辅助微弹簧圈闭塞动脉瘤和载瘤动脉等方法 治疗18例椎动脉颅内段夹层动脉瘤患者.结果 18例患者中5例采用微弹簧圈闭塞动脉瘤和载瘤动脉,5例行支架辅助微弹簧圈栓塞动脉瘤(3例基本致密栓塞、2例非致密栓塞),4例行单纯支架植入术(术后3例动脉瘤血流动力学改善),3例经远外侧入路手术直接夹闭动脉瘤,1例行枕动脉.小脑后下动脉血管吻合术辅助微弹簧圈闭塞动脉瘤和载瘤动脉.其中2例术中动脉瘤破裂出血,1例死亡、1例中残;I例闭塞动脉瘤和载瘤动脉患者,术后出现短暂性吞咽困难和偏侧肢体麻木,其余患者术后平稳.17例获得1个月至3年随访,无一例动脉瘤复发或进展.结论 用于治疗椎动脉颅内段夹层动脉瘤的方法 有多种,选择治疗方案时需考虑动脉瘤是否破裂出血或引起脑梗死,以及动脉瘤形态(如局限性偏侧型)、是否位于优势侧、是否累及小脑后下动脉等因素,根据患者具体情况制定个体化治疗方案.     

Indications for the use of temporary arterial occlusion during aneurysm repair: an institutional experience

This study was undertaken to determine variables that could predict, in the preoperative period, the likelihood for the need for intraoperative temporary arterial occlusion using clips (temporary clipping) when surgically repairing intracranial aneurysms. Data collected prospectively between October 1989 and March 2010 of 1129 unruptured intracranial aneurysms in 934 patients who were managed surgically was examined retrospectively. Temporary clipping was used in 400 patients (35.4%). Regression analysis of putative predictive variables revealed that aneurysms of a larger size, irregular fundus shape or midline location were more likely to be treated with temporary clipping.Basilar caput aneurysms larger than 10 mm were always managed with temporary clipping. There was no combination of factors studied that consistently predicted that temporary clipping would not be needed. Therefore, the potential need for temporary clipping must be considered for every patient with an aneurysm.     

Risk of subarachnoid hemorrhage after surgical treatment of unruptured cerebral aneurysms.

BACKGROUND AND PURPOSE: Recent progress in noninvasive imaging techniques has resulted in increased detection of unruptured aneurysms. Although many neurosurgeons advocate surgical intervention for such unruptured aneurysms, the long-term results of surgery for unruptured aneurysms have not been carefully investigated. METHODS: We analyzed 173 consecutive patients who had unruptured intracranial saccular aneurysm(s) detected by angiography that was performed for reasons other than subarachnoid hemorrhage (SAH). Of those, 115 cases were surgically treated and studied. All patients were followed up for either SAH, repeat treatment of aneurysms, or death. The median follow-up period was 8.8 years. RESULTS: Four of the 115 patients suffered SAH either from a de novo aneurysm (2) or from regrowth of clipped aneurysm (1), or from regrowth after wrapping (1). Additionally, 1 patient also suffered SAH from an unstudied basilar aneurysm. One patient was incidentally found to have de novo aneurysm and underwent reoperation 14 years after the first operation. The cumulative risk for SAH for the 114 cases excluding the basilar aneurysm case was 1.4% in 10 years and 12.4% in 20 years. CONCLUSIONS: Although this study confirmed the long-term efficacy of clipping unruptured aneurysms, the risk of SAH was high compared with that in the general population, even after treatment. Considering the high mortality rate of SAH, long-term follow-up by angiography may be warranted for patients with surgically treated unruptured aneurysms.     

Benefits of Surgical Treatment for Unruptured Intracranial Aneurysms in Elderly Patients

Objective

Due to longer life spans, patients newly diagnosed with unruptured intracranial aneurysms (UIAs) are increasing in number. This study aimed to evaluate how management of UIAs in patients age 65 years and older affects the clinical outcomes and post-procedural morbidity rates in these patients.

Methods

We retrospectively reviewed 109 patients harboring 136 aneurysms across 12 years, between 1997 and 2009, at our institute. We obtained the following data from all patients : age, sex, location and size of the aneurysm(s), presence of symptoms, risk factors for stroke, treatment modality, and postoperative 1-year morbidity and mortality. We classified these patients into three groups : Group A (surgical clipping), Group B (coil embolization), and Group C (observation only).

Results

Among the 109 patients, 56 (51.4%) underwent clipping treatment, 25 (23%) patients were treated with coiling, and 28 observation only. The overall morbidity and mortality rates were 2.46% and 0%, respectively. The morbidity rate was 1.78% for clipping and 4% for coiling. Factors such as hypertension, diabetes mellitus, hypercholesterolemia, smoking, and family history of stroke were correlated with unfavorable outcomes. Two in the observation group refused follow-up and died of intracranial ruptured aneurysms. The observation group had a 7% mortality rate.

Conclusion

Our results show acceptable favorable outcome of treatment-related morbidity comparing with the natural history of unruptured cerebral aneurysm. Surgical clipping did not lead to inferior outcomes in our study, although coil embolization is generally more popular for treating elderly patients. In the treatment of patients more than 65 years old, age is not the limiting factor.     

CT血管造影在脑动脉瘤手术和栓塞中的价值

目的评估CT血管造影(CTA)在脑动脉瘤(AN)手术和栓塞中的临床价值.方法回顾211例行CTA检查并进行了手术或栓塞治疗的AN,196例患者同期接受了数字减影血管造影(DSA)检查.所有患者根据CTA的结果确定治疗方案和指导手术或栓塞的进行.结果 7例CTA出现技术性失误,其余CTA影像均被手术或栓塞所证实.CTA发现了DSA漏诊的2例小型AN.CTA提供的AN的部位、瘤体、瘤颈、瘤体/瘤颈比等参数,有利于早期确定治疗方案.66例行夹闭术,依据CTA所模拟的手术入路影像均可顺利找到AN,CTA能有效地提供AN与载瘤动脉、周围分支及颅底骨结构之间的三维关系信息.145例行栓塞治疗,CTA的结果均被DSA所证实,对前交通、基底动脉顶端AN,CTA均准确指导导引导管进入的方向,能清晰显示瘤颈的投射角度和瘤体瘤颈比,辅助确定工作角度和是否需要支架植入.结论 CTA有助于AN治疗方案地迅速确定,为早期治疗提供确切依据和指导信息,对AN手术或栓塞具有重要的价值.     

Intraoperative rupture in the surgical treatment of patients with intracranial aneurysms

Intraoperative rerupture (IOR) during clipping of cerebral aneurysms is a difficult complication of microneurosurgery. The aim of this study was to evaluate the incidence of IOR and analyze the strategies for controlling profound hemorrhage. A total of 165 patients with unruptured intracranial aneurysms and 46 patients with subarachnoid hemorrhage (SAH) treated surgically between April 2010 and March 2011, were reviewed. The data were collected with regard to age, sex, presence of symptoms, confounding factors and strategy for controlling intraoperative hemorrhage was analyzed in terms of location of aneurysms, timing of rupture and severity of IOR. 211 patients with 228 aneurysms were treated in this series. There were a total of six IORs which represented an IOR rate of 2.84% per patient and 2.63% per aneurysm. The highest ruptures rates occurred in patients with internal carotid artery aneurysms (25%). Surgeries in the group with ruptured aneurysms had a much higher rate of IOR compared with surgeries in the group with unruptured aneurysms. Of the six IOR aneurysms, one occurred during predissection, four during microdissection and one during clipping. One was major IOR, three were moderate and two were minor. Intraoperative rupture of an intracranial aneurysm can be potentially devastating in vascular neurosurgery. Aneurysm location, presence of SAH and surgical experience of the operating surgeon seem to be important factors affecting the incidence of IOR.     

Changing paradigm in the management of elderly patients with intracranial aneurysms: An institutional review

Optimal treatment of intracranial aneurysms (IAs) in elderly patients has not yet been well established. We have investigated the clinical and radiological outcomes and predictors of unfavorable outcome of IAs in elderly patients. Radiological and clinical data of 85 elderly patients from 2010 through 2015 were retrospectively reviewed. Significant differences between the groups were determined by a chi-square test. Regression analysis was performed to identify the predictors of unfavorable outcome. Among the 85 patients with IAs, the number of patients with >7 mm size aneurysm (p = 0.01), diabetes mellitus (DM) (p = 0.02), smoking (0.009) and Hunt and Hess grade 4–5 (p = 0.003) was significantly higher in the ruptured group compared to the unruptured group. Similarly, the number of patients who underwent clipping was higher in the ruptured aneurysm group (p = 0.01). The overall clinical outcome was comparatively better in the unruptured group (p = 0.03); however, microsurgical clipping of aneurysms provides a significantly higher rate of complete aneurysmal occlusion (p = 0.008). Overall, there was no significant difference in outcome in respect to treatment approach. In regression analysis, hypertension (HTN), obstructive sleep apnea (OSA), prior stroke, ruptured aneurysms and partial occlusion of aneurysms were identified as predictors of unfavorable outcome of IAs. Intracranial aneurysms in elderly patients reveals that endovascular treatment provides better clinical outcome; however, microsurgical clipping yields higher complete occlusion. Retreatment of residual aneurysms was comparatively more in the coiling group. Practice pattern has shifted from clipping to coiling for aneurysms in posterior circulation but not for aneurysms in anterior circulation.