Symptomatic unruptured cerebral aneurysms: features and surgical outcome

Development of less invasive imaging studies, such as magnetic resonance angiography, has increased the chances that unruptured cerebral aneurysms are found. The rupture risk of "symptomatic" aneurysms is higher than for "asymptomatic" aneurysms; so "symptomatic" aneurysms are more often surgically treated. Many reviews examine "asymptomatic" unruptured cerebral aneurysms, but few evaluate "symptomatic" aneurysms. The author has treated many patients with symptomatic unruptured cerebral aneurysms and found that improved cranial nerve signs can be expected if the surgical treatment is performed before the symptoms become irreversible; the critical period is approximately 3 months. It is important to suppress the pulsation of the aneurysms compressing the cranial nerves; both a clipping procedure and endovascular coiling are effective. Cranial nerve signs are more commonly the symptoms of unruptured cerebral aneurysms, but large to giant aneurysms can also be the causes of hemiparesis, hydrocephalus, epilepsy, or even cerebral infarction. This review summarizes the features and surgical outcome of symptomatic unruptured cerebral aneurysms.     

Multifactorial analysis of surgical outcome in patients with unruptured middle cerebral artery aneurysms

OBJECTIVE: To build a predictive tool for assessing both favorable outcome and morbidity in a large series of unruptured aneurysms. SUMMARY BACKGROUND DATA: Some well-known predictors of clinical outcome for patients with ruptured aneurysms are not useful in forecasting outcome for patients with unruptured aneurysms. METHODS: The authors analyzed 93 patients with a total of 101 unruptured middle cerebral aneurysms who underwent surgical clipping. Intraoperative data was reviewed and seven factors that might influence outcome were identified: 1) aneurysm size > 10 mm, 2) presence of a broad neck, 3) presence of intraaneurysmal plaque, 4) clipping of more than one aneurysm during the same surgery, 5) temporary occlusion of the middle cerebral artery, 6) multiple clip applications and repositionings, and 7) use of multiple clips. The entire group of unruptured middle cerebral artery aneurysms was divided into two subgroups on the basis of outcome. Each patient was subsequently analyzed for the Factor Accumulation Index (FAI), the sum of different factors observed in a given patient. RESULTS: The expected outcome subgroup was represented by 86 patients, with a total of 92 aneurysms, and demonstrated the following results: no factors were found in six patients; FAI of 1: 24 patients; FAI of 2: 23 patients; FAI of 3: 12 patients; FAI of 4: 11 patients; FAI of 5: 8 patients; FAI of 6: one patient; FAI of 7: one patient. Seven patients represented the subgroup of unexpected outcomes with total morbidity of 7.5%. There were no deaths. None of the patients in this subgroup accumulated FAI of 0, 1, 2, or 5; otherwise: FAI of 3: two patients; FAI of 4: two patients; FAI of 6: one patient; FAI of 7: two patients. CONCLUSION: It is possible to predict outcome in patients with unruptured middle cerebral artery aneurysm by calculating FAI. The postoperative morbidity increases with an FAI within a range of 3 to 4.     

Long-term outcome of unruptured giant cerebral aneurysms

The long-term outcome of 39 patients with unruptured giant aneurysm (>2.5 cm) treated during the last 12 years was retrospectively reviewed. The 7 male and 32 female patients, aged 32 to 81 years, presented with symptoms related to compression of the surrounding structures by the aneurysm in 28 cases, cerebral infarction in one, and asymptomatic in 10. The locations were the internal carotid artery (ICA) in 27 cases, middle cerebral artery in three, anterior cerebral artery in one, and basilar artery in eight. Therapeutic modalities were direct clipping in 11 patients, ICA occlusion combined with extracranial-intracranial bypass in 15, and conservative treatment in 13. The follow-up period ranged from 16 to 128 months (mean 54.0 months). The mortality was 9% (1/11), 0% (0/15), and 31% (4/13), and morbidity was 18% (2/11), 20% (3/15), and 8% (1/13), respectively. Surgery reduced the mortality (from 31% to 4%) but increased the morbidity (from 8% to 19%) as compared with conservatively treated patients (p < 0.05). Giant intracranial aneurysm has a poor prognosis if left untreated, but these lesions are difficult to treat with the present management options.     

Intraoperative angiography evaluation of the microsurgical clipping of unruptured cerebral aneurysms

Intraoperative angiography evaluation of the clippings of cerebral aneurysms was investigated in a series of 38 consecutive patients with unruptured cerebral aneurysms to determine any favorable impact on the outcome. Unexpected findings including major arterial occlusion or residual aneurysm were identified. Specific variables such as the size and site of aneurysm were analyzed to determine the impact on clinical outcome and the incidence of clip modification. There were 11 large and 27 small aneurysms in this series. Mortality and permanent morbidity after microsurgical clipping were 0.0% and 2.6%, respectively. Unexpected angiographic findings necessitating clip repositioning consisted of residual aneurysm in two cases and distal branch occlusion or parent vessel stenosis in four. The need for clip modification was significantly higher for large than for small aneurysms (p = 0.007), and the rate of clip adjustment increased with increasing aneurysm size (p = 0.008). Intraoperative assessment prior to wound closure allows for the recognition and correction of defects and decreases the risk of postoperative complications. Intraoperative angiography may become important in the microsurgical clipping of unruptured cerebral aneurysms, especially large aneurysms.     

Symptomatic and silent cerebral infarction following surgical clipping of unruptured intracranial aneurysms: incidence,risk factors,and clinical outcome

Neurosurgical Review - Cerebral infarction (CI) associated with clipping of unruptured intracranial aneurysms (UIAs) has not been completely studied. The role of individual and operative...     

Co-existence of unruptured cerebral aneurysms in patients with hypertensive intracerebral hemorrhage

Summary Objective. Primary hypertensive intracerebral hemorrhage (PICH) is caused by a rupture of a small endartery, and diagnosis is made either by computed tomography (CT) or magnetic resonance imaging (MRI). Vascular abnormalities are not always evaluated in detail. In this study, we aimed to clarify the incidence of co-existing vascular abnormalities, especially unruptured cerebral aneurysms by reviewing selective intra-arterial digital subtraction angiography (DSA) images in PICH patients.Methods. The cases of 169 hypertensive PICH patients who underwent selective intra-arterial DSA were reviewed. In all cases, CT or MRI showed no abnormality other than PICH, such as subarachnoid hemorrhage, component of arterio-venous malformation or cerebral tumor. The main reason for performing DSA was to exclude other causes of intracerebral hemorrhage such as ruptured cerebral aneurysm or small arterio-venous malformation prior to surgical removal of the hematoma.Results. There were 33 patients with vascular abnormalities: unruptured cerebral aneurysm (n=24, 14.2%), major vessels occlusion or stenosis (n=8, 4.7%), and dural arterio-venous fistula (n=1). Unruptured cerebral aneurysms were found in 9.4% of men and 20.5% of women.Conclusion. Vascular abnormalities co-existing with PICH are not rare, suggesting the necessity for angiographic evaluation. Special attention should be given to female PICH patients who have a high incidence of having an unruptured cerebral aneurysm.     

Management of unruptured cerebral aneurysms in patients with polycystic kidney disease

BACKGROUND: Autosomal dominant polycystic kidney disease (PKD) is a hereditary disorder characterized by bilateral multiple renal cysts and early onset chronic renal failure. PKD patients tend to suffer their subarachnoid hemorrhage at a younger age. Unruptured aneurysms in PKD patients are not always innocuous, and proactive treatment has been indicated for these lesions. However, the management of PKD patients undergoing unruptured cerebral aneurysm surgery has been documented on only a few occasions. The purpose of this study was to better define the management of unruptured cerebral aneurysms in patients with PKD. METHODS: We present a retrospective review of the management of unruptured cerebral aneurysms in 16 patients with PKD. Eight patients were maintained through chronic hemodialysis whereas the remaining 8 patients did not require hemodialysis, at the time of treatment of their cerebral aneurysms. The mean follow-up period was 24 months. RESULTS: In the nonhemodialysis patients prophylactic hemodialysis was routinely performed after cerebral angiography to prevent deterioration of the pre-existing renal dysfunction. Microsurgical clipping of the aneurysm was performed in 15 patients (7 nonhemodialysis and 8 hemodialysis patients) and intravascular coil embolization was performed in 1 nonhemodialysis patient. One nonhemodialysis patient who underwent microsurgical clipping required a temporary hemodialysis after surgery, but the patient was not shifted to chronic hemodialysis. No patients developed postprocedural complications, and each showed an excellent recovery. CONCLUSION: PKD patients with unruptured cerebral aneurysms can be safely treated with an appropriate treatment strategy including the use of prophylactic hemodialysis.     

Importance of neuropsychological evaluation after surgery in patients with unruptured cerebral aneurysms

BACKGROUND: We evaluated neuropsychological function before and after surgery in patients with unruptured cerebral aneurysms. METHODS: Neuropsychological functions in 43 patients with unruptured cerebral aneurysms were evaluated before and 1 month after surgery. The neuropsychological examination included the Mini-Mental State examination, "Kana-hiroi" test, Kohs Block Design test, and Miyake's Memory test. Then, if scores of even a single test were decreased 1 month after surgery, the tests were performed again 5 months later. In 24 of the 43 subjects, cerebral blood flow (CBF) was measured before and 1 month after surgery by single-photon emission tomography. RESULTS: The outcome in all patients was evaluated as good according to the Glasgow Outcome Score (GOS). In 17 (40%) of the 43 patients, neuropsychological function had deteriorated 1 month after surgery. The most sensitive test applied was the Miyake's Memory test. Of 14 patients with neuropsychological deterioration 1 month after surgery, 6 showed complete recovery, 5 showed partial recovery, and 3 still showed cognitive deterioration 6 months after surgery. Patients over 65 years old, those with anterior communicating artery aneurysms, those operated by interhemispheric approach, or those with systemic diseases showed a greater tendency toward a decline in postoperative neuropsychological function than the other patients. The postoperative CBF and vascular response in the frontal lobe of affected-side was decreased in cases showing cognitive deterioration. CONCLUSIONS: These results suggested that the neuropsychological outcomes after surgery for unruptured cerebral aneurysms were not satisfactory.     

MRA volume rendering for surgical planning of unruptured intracranial cerebral aneurysms

A volume rendering (VR) three-dimensional reconstruction method was applied to magnetic resonance angiography (MRA), to investigate its usefulness for surgical planning of unruptured cerebral aneurysms (ANs). Twelve cases with anterior communicating artery (Acom) ANs and 16 cases with middle cerebral artery (MCA) ANs underwent MRA VR, preoperatively. There were 10 male and 18 female patients, whose ages were ranged from 37 to 73 (mean 58) years old. Appearance of ANs and surrounding vascular structures on MRA VR was compared with that on maximum intensity projection (MIP) image, three-dimensional digital subtraction angiogram (3D-DSA), and intraoperative findings. In all cases, MRA VR delineated aneurysms more clearly compared to MIP. In MCAANs, MRA VR provided enough information for surgical planning, compatible with 3D-DSA. In Acom ANs, MRA VR delineated bilateral A1, A2 and Acom complex simultaneously without temporary vascular occlusion. MRA VR may have a complementary role in preoperative evaluation of unruptured ANs with other modalities such as 3D-DSA.     

Clinical features and outcome in 48 patients with unruptured intracranial saccular aneurysms: a prospective consecutive study

During a 5-year period (1978-1983) the clinical features and operative morbidity/mortality were registered prospectively for all patients in Denmark with an unruptured symptomatic (27 patients) or incidental (21 patients) intracranial saccular aneurysm. A follow-up examination was performed 2 years after diagnosis of the aneurysm. Thirty symptomatic aneurysms in 27 patients most frequently involved the visual pathways or ocular motility (66%). The median diagnostic delay for patients with impaired visual acuity was 7 months but only 14 days for patients with impaired ocular motility. The localisation of the 30 symptomatic and 23 incidental aneurysms were: internal carotid artery (73% approximately 35%), anterior communicating artery (3% approximately 26%) and middle cerebral artery (7% approximately 35%). The diameters of 73% of the symptomatic aneurysms were greater than 10 mm, while the diameter of 74% of the incidental aneurysms were below 10 mm. The total operative morbidity and mortality were 15% and 4%, respectively. The mortality rate in the follow-up period was 10-11% mainly due to fatal bleeding from unoccluded aneurysms. In 21 survivors, a normal mental status was found in 43% and mild dementia was found in another 43%. The impaired visual acuity was unchanged in 67% of patients, while the ocular motility had normalised in 75%. A normal daily functional capacity was enjoyed by 57% while 43% had a moderate reduction, mostly due to visual disturbances.     

Endovascular coil placement compared with surgical clipping for the treatment of unruptured middle cerebral artery aneurysms: a consecutive series.

OBJECT: The goal of this study was to delineate the angioanatomical features that determine whether a patient with an unruptured middle cerebral artery (MCA) aneurysm is treated using endovascular coil placement or surgical clipping. METHODS: Thirty consecutive patients harboring 34 unruptured MCA aneurysms were evaluated. Patients with unruptured aneurysms are managed prospectively according to the following protocol: the primary treatment recommendation is endovascular packing with Guglielmi detachable coils (GDCs). Surgical clipping is recommended after failed attempts at coil placement or in the presence of angioanatomical features that contraindicate that type of endovascular therapy. Of 34 unruptured MCA aneurysms, two (6%) were successfully embolized and 32 (94%) were clipped. Of these 32 surgically treated aneurysms, in 11 (34%) an attempt at GDC embolization had failed, whereas in 21 (66%) primary clipping was performed because of unfavorable angioanatomy. Of the 13 aneurysms treated endovascularly, two (15%) were successfully excluded, whereas GDC treatment failed in 11 (85%). An unfavorable dome/neck ratio (< 2) and an arterial branch originating at the aneurysm base were the reasons for embolization failure. CONCLUSIONS: Careful evaluation of the angioanatomy of unruptured aneurysms allows selection of the most appropriate treatment. However, for unruptured MCA aneurysms, surgical clipping appears to be the most efficient treatment option. Series of unruptured aneurysms are ideal for comparing treatment results.     

Surgical treatment of unruptured cerebral aneurysms and complications in patients with ischemic cerebrovascular disease

Patients who have unruptured intracranial aneurysms associated with ischemic cerebrovascular disease are a high-risk group for surgery. We have done clipping surgery in 15 patients among 40 with ischemic cerebrovascular disease. The criteria for surgery included an age below 65 years, CBF of more than 35 ml/100 g/min, and favorable ADL comparable to Rankin score 0-III. Two patients received simultaneous aneurysm clipping and superficial-middle cerebral artery anastomosis. Only one patient suffered from ischemia-related permanent neurological worsening, and one had direct optic nerve injury. Surgical mortality was 0%, and morbidity was 15%. There were two patients who had transient neurological worsening. These results suggest that surgical treatment of unruptured cerebral aneurysms is not contraindicated in patients with ischemic brain disease, but careful selection and careful perioperative management are mandatory for preventing surgical complications.     

Clip ligation of unruptured intracranial aneurysms: a prospective midterm outcome study

Background

We conducted a prospective study to investigate the clinical and radiological outcome in a surgical case series of 176 patients with 203 unruptured intracranial aneurysms (UIA).

Methods

The success of aneurysm obliteration was assessed within 2 weeks after surgery by digital subtraction angiography (DSA). Patients also underwent angiography 5 years after surgery. Clinical outcomes were assessed using the modified Rankin Scale (mRS). All predictors of poor surgical outcomes were assessed using an exact logistic regression.

Results

Overall, 83 % of the patients had a good outcome (mRS score 0 or 1); 10.8 % of the patients had a slight disability (mRS score 2), and 6.2 % of the patients had a moderate or moderate-severe disability (mRS score 3 or 4). The mortality rate was 0 % overall. The most important predictors of outcome were presence of history of ischemic cerebrovascular disease and postoperative stroke. Complete aneurysm occlusion was achieved in 93.5 % of all aneurysms. Sixty percent of treated aneurysms were checked with late follow-up DSA. No cases of hemorrhage from a surgically obliterated UIA were documented in this series during the 7.3?±?1.4 (SD)-year follow-up period.

Conclusions

If patients are carefully selected and individually assigned to their optimum treatment modality, IUAs can be obliterated by surgery with a low percentage of unfavorable outcomes.

     

Microsurgical treatment of unruptured intracranial aneurysms. A consecutive surgical experience consisting of 450 aneurysms treated in the endovascular era

BACKGROUND: With the progressive refinement of endovascular techniques, fewer IAs are being treated with open microsurgery. There is limited information regarding the impact of this trend on the ability of younger neurosurgeons to achieve proficiency in the surgical management of IAs. We describe a consecutive series of patients with unruptured IAs treated by a neurosurgeon initiating a dedicated cerebrovascular practice in the "endovascular era." METHODS: We retrospectively reviewed the records of all patients who had undergone surgical repair of a saccular IA by one neurosurgeon upon completion of neurosurgical training in July 1997 until April 2005. Patients with ruptured IAs were excluded from review. RESULTS: Of the 1450 patients with IAs treated during this period, 376 underwent microsurgical repair of 450 unruptured IAs. Microsurgical aneurysm neck clipping was possible in most cases, although distal revascularization with proximal occlusion was used in many of the more complicated aneurysms. Major complications occurred in 6 (1.60%) patients, and 1 (0.27%) patient died. At the time of 6-month follow-up, 4 (1.06%) patients were left with a new focal neurologic deficit related to surgery. CONCLUSIONS: Despite the growing role of endovascular therapy in the management of IAs, it is possible for young neurovascular surgeons to achieve acceptable results with open microsurgical treatment of IAs. The factors that were deemed important in achieving success in this series included a collaborative approach with endovascular colleagues, careful surgical judgment, continual reanalysis of personal results, and early support from experienced mentors.     

Cerebral vasospasm in patients with unruptured intracranial aneurysms

Summary Intracranial arterial vasospasm is a typical sequela of subarachnoid haemorrhage. The association between symptomatic vasospasm and unruptured aneurysms has been sporadically presented in the literature. The pathogenesis of this unusual entity is unclear. The published cases were collected in this review and analysed with regard to timing, clinical presentation and possible relationship with surgical factors. We also added an illustrative case which was recently observed in our department.     

Examination of the effectiveness of DVD decision support tools for patients with unruptured cerebral aneurysms

Preventative treatments for unruptured cerebral aneurysms include craniotomy, endovascular treatment, and follow up. Since there is no agreement as to the best procedure, it is important to provide adequate information so that the patient and physician can share in the decision-making process. A multi-media DVD was created to inform patients of the facts. This study examined how effectively this DVD changes patients' recognition including knowledge of unruptured cerebral aneurysms. Forty-seven patients with unruptured cerebral aneurysms who sought neurosurgery consultation between December 2005 and February 2006 completed a questionnaire before and after watching the DVD, as well as at 3 months follow up. Before watching the DVD, the average knowledge score was 8.72 out of 15 total points. The average score increased to 12.4 after watching the DVD (p < 0.001). At 3 months follow up, the average score was 10.34, which was still higher than before watching the DVD (p < 0.01). Participants' knowledge about treatment methods also increased after watching the DVD (p < 0.001). Compared to 63.2% who were satisfied with their treatment decision before watching the DVD, 69.6% were satisfied with their decision after watching the DVD. All participants responded that the use of multi-media images was helpful in better understanding treatment options and in making informed decisions. The DVD was favorably accepted as a decision support tool by patients with unruptured cerebral aneurysm and effectively increased patients' knowledge.     

Outcome for unruptured middle cerebral artery aneurysm treatment: surgical and endovascular approach in a single center

The rupture of an intracranial aneurysm leads to subarachnoid hemorrhage (SAH). To prevent SAH, unruptured lesions can be treated by either endovascular or microsurgical approach. Due to their complex anatomy, middle cerebral artery (MCA) aneurysms represent a unique subgroup of intracranial aneurysms. Primary objective was to determine radiological and clinical outcomes in patients with middle cerebral artery aneurysms who were interdisciplinary treated by either endovascular or microsurgical approach in a single center. Secondary objective was to determine the impact of the lesions’ angiographic characteristics on treatment outcome. Clinical and radiological data of 103 patients interdisciplinary treated for unruptured MCA aneurysms over a 5-year period were analyzed in endovascular (n?=?16) and microsurgical (n?=?87) cohorts. Overall morbidity (Glasgow Outcome Score <5) after 12-month follow-up was 9 %. There was no significant difference between the two cohorts. Complete or “near complete” aneurysm occlusion was achieved in 97 and 75 % in the microsurgical, respective endovascular cohort. A “complex” aneurysm configuration had a significant impact on complete aneurysm occlusion in both cohorts, however, not on clinical outcome. Treatment of unruptured MCA aneurysms can be performed with a low risk of repair using both approaches. However, the risk for incomplete occlusion was higher for the endovascular approach in this series.     

Effects of habitual cigarette smoking on higher cortical function in patients with unruptured cerebral aneurysms

Postoperative changes in higher cortical function and cerebral blood flow (CBF) were investigated in patients with unruptured cerebral aneurysms to assess the effect of habitual smoking on the known transient changes after aneurysm surgery. Fifty-six adults with unruptured cerebral aneurysms, including 11 heavy smokers (smoking index > or = 600) and 45 non-smokers, were evaluated using three neuropsychological examinations, the Mini-Mental State Examination, the Maze test, and the Kana-hiroi test, and single photon emission computed tomography to measure CBF before and after surgery. Neuropsychological changes were assessed by reliable change indices to take into account the practice effects. The scores of at least one examination decreased in 15 of 56 patients 1 month after surgery. On the Maze test, five of 11 heavy smokers and five of 45 non-smokers deteriorated after surgery, showing a significant difference (p = 0.018). The CBF in heavy smokers often decreased after surgery, but there was no statistically significant difference in logistic regression. Three months after surgery, the neuropsychological scores of 13 of the 15 deteriorated patients recovered to the preoperative level. Higher cortical function in heavy smokers with unruptured cerebral aneurysms often decreases transiently after operation, compared to non-smokers. Therefore, surgery planning for heavy smokers with unruptured cerebral aneurysms should consider this outcome.     

Clinical factors associated with in-hospital death in pediatric surgical patients admitted to the neonatal intensive care unit: a 15-year single tertiary center experience

Background/purpose

The purpose of this study was to explore clinical characteristics and primary surgical diagnoses associated with in-hospital death in pediatric surgical patients admitted to the neonatal intensive care unit (NICU) of a tertiary hospital.