Large and giant ventral paraclinoid carotid aneurysms: surgical techniques, complications and outcomes

Objectives

Surgical treatment of large and giant ventral paraclinoid carotid aneurysms (vPCAs) continues to be challenging and technically demanding for vascular neurosurgeons. Due to both physiological barriers and limitations of current surgical technology in the treatment of vPCAs, higher rates of morbidity and mortality are a given. To improve the current available data and assess the most effective microsurgical management techniques with the goal of decreased morbidity and mortality, we present this retrospective study of a series of 15 consecutive patients with large and giant vPCAs.

Materials and methods

Between January 2005 and December 2010, fifteen patients presented with large or giant vPCAs were surgically treated at West China Hospital and were included in this study. The data was retrospectively analyzed.

Results

Five men and ten women with an averaging 50 years of age (ranged 32–70 years) were included in this study. The average aneurysm size was 21 mm (ranged 13–36 mm). All patients were treated microsurgically. Twelve patients (80%) had desirable surgical outcomes (Glasgow Outcome Score 4–5) at follow-up for a mean of 32 months (range 3–72 months). One patient (7%) died of severe vasospasm after surgery. The surgical mortality was 7%; overall morbidity was 27%, including the hemiplegia, oculomotor paresis and visual deficit. None of the 14 following patients had rebleeding or regrowth of residual aneurysm during this follow-up period. Age and Hunt–Hess grade were significantly correlated with clinical outcome.

Conclusions

Despite the difficulties presented by large and giant vPCAs, our increased knowledge of anatomy and refinements in operative techniques and intraoperative monitoring have greatly improved the clinical outcome with a more acceptable mortality and morbidity.     

Treatment of recurrent and residual aneurysms with the low-profile Acandis Acclino stent: Multi-center review of 19 patients

ObjectiveTo evaluate the safety and efficacy of the low-profile Acandis Acclino microstent for embolization of recurrent and residual intracranial aneurysms.MethodsConsecutive patients treated with the Acclino for aneurysm remnants at three German neurovascular centers were enrolled. The technical success, complications, angiographic and clinical outcome were investigated.ResultsNineteen patients (median age: 53 years) with 19 aneurysm remnants (median size: 5 mm, anterior circulation: 14) were included. Initial aneurysm treatment consisted of stand-alone coiling in 14 cases, stent-assisted coiling in 4 and clipping in 1. Acclino stent-assisted coil embolization was performed technically successfully in all patients. Morbidity occurred in one patient (5.3%) due to aneurysm perforation. At the angiographic follow-up with a median follow-up duration of 21 months (range: 5–37 months), complete occlusion was obtained in 76.9%. The retreatment rate was 7.7%.ConclusionsRetreatment of aneurysm remnants with the Acclino microstent was associated with high aneurysm occlusion rates and acceptable morbidity. Further studies will be necessary to draw a definite conclusion.     

Surgical Treatment of Subependymal Giant Cell Astrocytoma in Tuberous Sclerosis Complex Patients

BackgroundSubependymal giant cell astrocytoma is a brain tumor associated with tuberous sclerosis complex. There are two treatment options for subependymal giant cell astrocytomas: surgery or mammalian target of rapamycin inhibitor. The analysis of outcome of subependymal giant cell astrocytoma surgery may help characterize the patients who may benefit from pharmacotherapy.MethodsSixty-four subependymal giant cell astrocytoma surgeries in 57 tuberous sclerosis complex patients with at least a 12-month follow-up were included in the study. The tumor size, age of the patients, mutation in the TSC1 or TSC2 gene, indication for the surgery, and postsurgical complications were analyzed.ResultsThe mean age of patients at surgery was 9.7 years. Mean follow-up after surgery was 63.7 months. Thirty-seven (57.8%) tumors were symptomatic and 27 (42.2%) were asymptomatic. Patients with TSC2 mutations developed subependymal giant cell astrocytoma at a significantly younger age than individuals with TSC1 mutations. Four patients (6.2% of all surgeries) died after surgery. Surgery-related complications were reported in 0%, 46%, 83%, 81%, and 67% of patients with tumors <2 cm, between 2 and 3 cm, between 3 and 4 cm, >4 cm, and bilateral subependymal giant cell astrocytomas, respectively, and were most common in children younger than 3 years of age. The most common complications included hemiparesis, hydrocephalus, hematoma, and cognitive decline.ConclusionsOur study indicates that subependymal giant cell astrocytoma surgery is associated with significant risk in individuals with bilateral subependymal giant cell astrocytomas, tumors bigger than 2 cm, and in children younger than 3 years of age. Therefore, tuberous sclerosis complex patients should be thoroughly screened for subependymal giant cell astrocytoma growth, and early treatment should be considered in selected patients.     

Subarachnoid hemorrhage rebleeding in the first 24 h is associated with external ventricular drain placement and higher grade on presentation: Cohort study

BackgroundRebleeding after aneurysmal subarachnoid hemorrhage (aSAH) confers a poor prognosis; however, risk factors and differential outcomes associated with early rebleeding in the first 24 h after symptom presentation are incompletely understood.MethodsA retrospective cohort study of all aSAH presenting to our institution between 2001 and 2016 was performed. Early rebleeding events were defined as clinical neurologic decline with radiographically confirmed acute intracranial hemorrhage within 24 h after symptom presentation. Univariate and multivariate logistic regression analyses were used to assess clinical associations, with a specific focus on baseline Glasgow Coma Score (GCS), World Federation of Neurosurgical Societies (WFNS), and modified Fisher scores.ResultsOf 471 aSAH cases, 33 (7%) experienced early rebleeding. Multivariate regression identified extraventricular drain (EVD) placement (OR = 2.16, P = 0.04) and WFNS 3–5 (OR = 2.69, P = 0.02) as significant predictors of early rebleeding. Good functional outcomes were observed in 8 patients with early rebleeding (24%), all of whom underwent aneurysm treatment. Higher SAH grade prior to rebleeding (WFNS 3–5) was significantly associated with increased odds of an unfavorable functional outcome (OR = 8.09, P < 0.01). Anticoagulation, aneurysm size and location were not significantly associated with either early rebleeding incidence or functional outcome.ConclusionsEarly rebleeding in aSAH is associated with unfavorable functional outcomes. EVD placement and higher SAH grade on presentation appear to be significantly and independently associated with increased risk of rebleeding within first 24 h, as well as unfavorable long-term functional outcome; however, the clinical benefit of hyper-acute aneurysm treatment requires further investigation.     

Tratamiento del neurinoma acústico gigante

Introduction and objectivesTo analyze the treatment modality and outcome of a series of patients with giant acoustic neuromas, a particular type of tumour characterised by their size (extracanalicular diameter of 4 cm or more) and high morbidity and mortality.Materials and methodsThis was a retrospective unicentre study of patients with acoustic neuromas treated in a period of 12 years. In our institutional series of 108 acoustic neuromas operated on during that period, we found 13 (12%) cases of giant acoustic neuromas. We reviewed the available data of these cases, including presentation and several clinical, anatomical, and microsurgical aspects.ResultsAll patients were operated on by the same neurosurgeon and senior author (EU) using the suboccipital retrosigmoid approach and complete microsurgical removal was achieved in 10 cases. In one case, near total removal was deliberately performed, in another case a CSF shunt was placed as the sole treatment measure, and in the remaining case no direct treatment was given. One patient died in the immediate postoperative period. One year after surgery, 4 patients showed facial nerve function of iii or more in the House-Brackman scale.ConclusionsThe 4 most important prognostic characteristics of giant acoustic neuromas are size, adhesion to surrounding structures, consistency and vascularity. Only the first of these is evident in neuroimaging.Giant acoustic neuromas are characterised by high morbidity at presentation as well as after treatment. Nevertheless, the objective of complete microsurgical removal with preservation of cranial nerve function is attainable in some cases through the suboccipital retrosigmoid approach.     

Vagus nerve stimulation for medically refractory absence epilepsy

PurposeA proportion of patients with childhood and juvenile absence epilepsies (CAE, JAE) are likely to be classified as medically refractory. In view of evidence gap for the treatment of such patients, this series is reported to generate estimate for efficacy of vagus nerve stimulation (VNS) in this patient population.MethodsPatients were identified by a chart review of all VNS recipients between January 1, 2006 and December 31, 2011. The diagnosis of CAE and JAE was based on conventional criteria. Details of demography, epilepsy phenomenology, management and outcomes were extracted. The outcome measures included reduction in daily seizure frequency measured as a percentage of pre-VNS seizure frequency and classified on International League Against Epilepsy (ILAE) outcome scale.ResultsNine patients (7 CAE, 2 JAE) with a mean age of seizure onset of 5.4 years (±3.9) were identified. Mean duration of epilepsy prior to VNS implant was found to be 3.9 years (±1.4). These patients had failed a median of 5 anti-epileptic drugs before being referred for consideration of surgical treatment. After a mean follow-up of 33.9 months (±25.5, minimum 4 months), 1 patient attained complete seizure freedom (ILAE class 1), 6 had ILAE class 4 and 2 had ILAE class 5 outcomes, respectively. Mean reduction in daily seizure frequency was found to be 53.5 ± 60.3% (1-sided p-value for paired t-test = 0.04), with a 50% responder rate of 55.6%.ConclusionVNS may be considered as a therapeutic option in patients with medically refractory absence epilepsy.     

Prognostic Value of Initial Standard EEG and MRI in Patients with Herpes Simplex Encephalitis

MethodsWe retrospectively analyzed patients who were diagnosed with HSE by applying the polymerase chain reaction to cerebrospinal fluid and who received intravenous acyclovir at our hospital from 2000 to 2014. We evaluated the clinical outcomes at 6 months after onset and their correlations with initial and clinical findings, including the volume of lesions on MRI, the severity of EEG findings, and the presence of epileptic seizures at the initial presentation.ResultsTwenty-nine patients were enrolled (18 men and 11 women). Univariate analysis revealed that the presence of severe EEG abnormality and epileptic seizures at the initial presentation were significant correlated with a poor clinical outcome at 6 months (p=0.005 and p=0.009, respectively). In multivariate analysis, the presence of severe EEG abnormality was the only independent predictor of a poor outcome at 6 months (p=0.006).ConclusionsIn cases of HSE, the initial EEG severity and seizure presentation may be useful predictive factors for the outcome at 6 months after acyclovir treatment.     

Three-Year Outcomes After Dorsal Root Ganglion Stimulation in the Treatment of Neuropathic Pain After Peripheral Nerve Injury of Upper and Lower Extremities

ObjectivesTraumatic peripheral nerve injuries (PNI) often result in severe neuropathic pain which typically becomes chronic, is recalcitrant to common analgesics, and is associated with sleep disturbances, anxiety, and depression. Pharmacological treatments proven to be effective against neuropathic pain are not well tolerated due to side effects. Neuromodulative interventions such as peripheral nerve or spinal cord stimulation have generated mixed results and may be limited by reduced somatotopic specificity. Dorsal root ganglion (DRG) stimulation may be more effective in this etiology.Materials and MethodsTwenty-seven patients were trialed with a DRG neurostimulation system for PNI; trial success (defined as ≥50% pain relief) was 85%, and 23 patients received a permanent stimulator. However, 36-month outcome data was only available for 21 patients. Pain, quality of life, mental and physical function, and opioid usage were assessed at baseline and at 3-, 6-, 12-, 18-, 24-, and 36 months post-permanent implant. Implant-related complications were also documented.ResultsCompared to baseline, we observed a significant pain relief (p < 0.001) at 3 (58%), 12 (66%), 18 (69%), 24 (71%), and 36 months (73%) in 21 patients (52.5 ± 14.2 years; 12 female), respectively. Mental and physical function showed immediate and sustained improvements. Participants reported improvements in quality of life. Opioid dosage reduced significantly (p < 0.001) at 3 (30%), 12 (93%), 18 (98%), 24 (99%), and 36 months (99%), and 20 of 21 patients were completely opioid-free after 36 months. There were five lead migrations and two electrode fractures (corrected by surgical intervention) and one wound infection (conservatively managed).ConclusionsDRG neuromodulation appears to be a safe, effective, and durable option for treating neuropathic pain caused by PNI. The treatment allows cessation of often ineffective pharmacotherapy (including opioid misuse) and significantly improves quality of life.     

Results of endovascular treatment of aneurysms depending on their size,volume and coil packing density

Background and purposeIn contrast to neurosurgery, which is more efficient, endovascular treatment (EVT) is less invasive. The main purpose of EVT is complete occlusion of the aneurysm and protection from subarachnoid haemorrhage. Accurate measurements of the aneurysm (size, volume) obtained using a 3D digital subtraction angiography (DSA) workstation can assist in the proper assessment of coil packing density (CPD), which affects possible distant recanalization. The main disadvantage of endovascular treatment of intracranial aneurysms compared to neurosurgery is the high recurrence rate. We evaluated the results of endovascular treatment of aneurysms depending on their size, volume and coil packing density.Material and methodsThirty-five patients with intracranial aneurysms underwent endovascular embolization with bare platinum coils. Three-dimensional DSA was used to evaluate aneurysms’ morphology. Eighteen patients underwent 3D DSA follow-up 6-45 months after treatment. Initial and follow-up results of embolization were assessed with the Raymond-Montreal scale. The impact of aneurysms’ morphology, volume and initial CPD on endovascular treatment was evaluated.ResultsAmong 35 patients, complete initial embolization was achieved in 74%. Mean initial aneurysm volume in 3D DSA was 0.517 mL and decreased significantly after embolization. Initial CPD varied from 74% to 2% depending on aneurysm diameter (12.1% for aneurysms ≥ 10 mm, 22.5% for aneurysms < 10 mm). Results of embolization on the Raymond-Montreal scale significantly depended on aneurysms’ CPD. Aneurysms’ recanalization rate on 3D DSA follow-up was 36%, with complete recanalization in 3.3%.ConclusionsWe can achieve a better outcome if size and volume of the aneurysm sac is smaller and if CPD is higher.     

Outcomes for a case series of unruptured anterior communicating artery aneurysm surgery

Surgical outcomes following repair of unruptured anterior communicating artery (AcomA) aneurysms have not been adequately addressed in the literature. We present our operative experiences in a consecutive series of 103 patients with 115 unruptured AcomA aneurysms. Clinical results, operative complications, angiographic outcomes and prognostic factors associated with surgery are presented. Of the 115 aneurysm repairs attempted, 114 were treated by clipping or excision and suture. One aneurysm, less than 2 mm, was wrapped. Six patients (5.8%; 95% confidence interval [CI], 2.5–12.4) experienced a new permanent neurological deficit. There was no postoperative mortality. Transient morbidity occurred in 11 patients (10.7%; 95% CI, 5.9–18.3), including transient anosmia (four patients), acute postoperative confusion and memory disturbances (four patients), extradural haematoma requiring surgery (two patients) and cerebrospinal fluid rhinorrhea (one patient). Of the 84 aneurysms (73.0%) that had documented postoperative angiography, 82 (97.6%) had complete obliteration of the aneurysm and two (2.4%) had neck remnants (mean angiographic follow-up 28.0 months; range, 1.6–146.4 months). Retreatment was performed in one patient (1.0%). Logistic regression analysis of risk factors revealed that aneurysm size (p < 0.01) was a significant predictor of outcome. There was no incidence of subarachnoid haemorrhage in the 272 person years of follow-up. In the current study, surgical treatment of unruptured AcomA aneurysms resulted in 5.8% morbidity and no mortality. The robustness of aneurysm repair achieved by open microsurgery is an important consideration when considering the option between endovascular and microsurgical treatment for unruptured AcomA aneurysms.     

Mechanical thrombectomy in patients with proximal occlusions and low NIHSS: Results from a large prospective registry

BackgroundMechanical thrombectomy is now standard of care for treatment of acute ischemic stroke secondary to large vessel occlusion in the setting of high NIHSS. We analysed a large nationwide registry focusing on patients with large vessel occlusion and low NIHSS on admission to evaluate the efficacy and safety of thrombectomy in this patient populationMethods2826 patients treated with mechanical thrombectomy were included in a multicentre registry from January 1, 2011 to December 31, 2015. We included patients with large vessel occlusion and NIHSS ≤ 6 on admission. Baseline characteristics, imaging, clinical outcome, procedure adverse events and positive and negative outcome predictors were analysed.Results134 patients were included. 90/134 had an anterior circulation and 44 a posterior circulation stroke. One patient died before treatment. Successful revascularization (mTICI 2b-3) was achieved in 73.7% (98/133) of the patients. Intraprocedural adverse event was observed in 3% (4/133) of cases. Symptomatic intracranial haemorrhage rate was 5.3% (7/133). At three months, 70.9% (95/134) of the patients had mRS score 0-2, 15.7% (21/134) mRS 3-5 and 13.4% (18/134) mRS 6. Age and successful recanalization were significant predictors of a good clinical outcome on both univariate (p= 0.005 and p=0.007) and multivariable (p=0.0018 and p=0.009 [nat log]) analysis. Absence of vessel recanalization and symptomatic intracranial hemorrhage were independent predictors of poor outcome (p=0.021) .ConclusionsOur study suggests that patients with large vessel occlusion and low NIHSS score on admission can benefit from mechanical thrombectomy. Randomized trials are warranted.     

LVIS支架辅助栓塞治疗颅内动脉瘤20例的临床分析

目的探讨LVIS支架辅助栓塞颅内动脉瘤的安全性及有效性。方法选取应用LVIS支架辅助栓塞治疗20例患者的颅内动脉瘤20个。并对其临床资料、血管内治疗方法及效果进行回顾性分析,根据Raymond分级评价动脉瘤栓塞程度,改良Rankin量表(modified Rankin Scale,mRS)评估其预后效果。结果所有患者支架释放满意。术后即刻造影见Raymond分级Ⅰ级栓塞15例(75%),Ⅱ级栓塞4例(20%),Ⅲ级栓塞1例(5%)。经术后3~12月随访的18个动脉瘤中,均未见复发,其中16个动脉瘤影像学治愈(88.9%),2个瘤颈残留但稳定(11.1%)。在访的18位患者中15位预后良好(mRS:0-2分)。结论 LVIS支架辅助弹簧圈栓塞安全可行,可提高动脉瘤的栓塞率和降低复发率,远期临床效果还有待大样本随访和临床经验的总结。     

Efficacy of vagus nerve stimulation as a treatment for medically intractable epilepsy in brain tumor patients. A case-controlled study using the VNS therapy Patient Outcome Registry

PurposeVagus nerve stimulation (VNS) therapy is a procedure to control seizure frequency in patients with medically intractable epilepsy. However, there is no data on efficacy in the subset of these patients with brain tumors. The purpose of this study is to evaluate the efficacy of VNS therapy in patients with brain tumor-associated medically intractable epilepsy.MethodsData from the VNS therapy Patient Outcome Registry, maintained by the manufacturer of the device, Cyberonics Inc. (Houston, TX, USA), was queried to characterize the response of patients in whom a brain tumor was listed as the etiology of epilepsy. A case–control analysis was implemented and patient outcome was measured by Engel classification, median seizure response and responder rate (≥50% seizure reduction) using t-tests and chi-squared tests.ResultsIn 107 patients with an epilepsy etiology related to a brain tumor, seizure reduction was 45% at 3 months and 79% at 24 months with a responder rate of 48% at 3 months and 79% at 24 months. There was no statistical difference in seizure reduction compared with 326 case–control patients from the registry without brain tumors. There was no significant difference in anti-epileptic drug (AED) usage from baseline to 24 months post implant in either group.ConclusionsVNS therapy is equally effective in patients who suffer seizures secondary to brain tumors as in patients without history of a brain tumor. VNS therapy is a viable treatment option for patients with brain tumor associated medically intractable epilepsy, assuming cytoreductive and other adjuvant therapies have been fully explored.     

Aneurysmal acute subdural hemorrhage: Prognostic factors associated with treatment

Acute subdural hematoma is an uncommon presentation of aneurysmal hemorrhage that has been identified as a poor prognostic sign. Current series are small, have short follow-up, or were collected over a long period during which treatment evolved. To evaluate prognostic factors, we analyzed a large modern series of aneurysmal subdural hematoma (aSDH) with long-term follow-up. A prospectively maintained database was queried for patients presenting with aSDH from 2001–2013. Thirty patients met the study criteria. Statistical analysis was performed with unpaired t-test or Fisher’s exact test. Aneurysm treatment involved open clipping (n = 18), endosaccular coiling (n = 8), both (n = 1), or no treatment (n = 3). Good Glasgow Outcome Scale score at discharge was present in 20% and increased to 40% at 6–12 months postoperatively. Good clinical presentation was associated with good final outcome in 75%, whereas poor clinical presentation correlated with good outcome in 30%. Good outcome correlated with younger age (p = 0.04), smaller aneurysm (p = 0.04), and lower Hunt-Hess score (HH) at intervention (p = 0.04). Favorable outcome did not correlate with sex, race, presence of subarachnoid or intraparenchymal hemorrhage, size or laterality of hemorrhage, midline shift, aneurysm treatment modality, or HH at admission (p > 0.15). There was no difference between good and poor outcomes in terms of time to treatment or hematoma evacuation. Poor clinical presentation may be exaggerated by mass effect of hematoma; aggressive treatment is not futile. Presenting neurological status, age, and aneurysm size are predictors of outcome, while laterality and size of hematoma and extent of midline shift are not, suggesting that clinical status is more important than radiographic findings.     

Operative strategy of complex internal carotid artery- posterior communicating artery aneurysms Defensive effect on perioperative nerve injury

BACKGROUND: The two problems in treating intracranial aneurysm are the vascular reconstruction and brain protection, especially for complex internal carotid artery-posterior communicating artery (ICA-PComA) aneurysms. OBJECTIVE: To analyze the anatomic features and operative technique of complex ICA-PComA aneurysms, and investigate how to better protect the brain tissue. DESIGN: A retrospective case analysis. SETTING: Department of Neurosurgery, Dalian Central Hospital. PARTICIPANTS: Totally 154 inpatients with ICA-PComA aneurysms were selected from the Department of Neurosurgery, Dalian Central Hospital from January 1998 to December 2006, including 19 cases (12.3%) of complex ICA-PComA aneurysms, 8 males and 11 females, 38–67 years of age. Informed contents for surgery and observation were obtained from all the patients or their relatives. METHODS: The clinical manifestations, including initial symptoms and Hunt&Hess grading, were observed. Corresponding strategies were selected for different types of ICA-PComA aneurysms. The patients were followed up at 3 months postoperatively. According to the results of Glasgow scoring, the curative effects were classified as good (4–5 points), bad (2–3 points) and dead (1 point). The results at discharge were taken as early results, whereas the follow-up results as late results. MAIN OUTCOME MEASURES: Clinical manifestations and curative effects of the patients. RESULTS: All the 19 patients with ICA-PComA were involved in the analysis of results. For clinical manifestations, the initial symptoms were subarachnoid hemorrhage (n =15), paralysis of oculomotor nerve (n =3), and occasional attack (n =1); The Hunt&Hess grading was grade Ⅰ in 4 cases, grade Ⅱ in 6 cases, grade Ⅲ in 6 cases, grade Ⅳ in 2 cases, and grade Ⅴ in 1 case. The curative effects were that aneurysm breakage and bleeding occurred in 6 cases perioperatively, uncomplete clipping of aneurysm in 2 cases and constriction of parent artery in 1 case. The complications were nervous and ischemic ones. The early outcome was good in 12 cases and bad in 7 cases, no one died. The late outcome was good in 17 cases and bad in 2 cases. CONCLUSION: Complex ICA-PComA aneurysm is a particular aneurysm, thus different operative strategies should be adopted according to the conditions to improve the operative outcome and reduce ischemic and nervous injuries.     

Ticagrelor versus clopidogrel dual antiplatelet therapy for unruptured intracranial aneurysms treated with flowdiverter

Background and purposeAntiplatelet therapy (APT) is a key element limiting the risk of thromboembolic events (TEE) in neuroendovascular procedures, including aneurysm treatment with flowdiverter. Clopidogrel combined with aspirin is the mostly reported dual APT (DAPT). However, resistance phenomenon and intraindividual efficacy fluctuation are identified limitations. In recent years, ticagrelor has been increasingly used in this indication. We compared these two DAPT regimens for intracranial aneurysm treated with flowdiverter.MethodsWe conducted a multicentric retrospective study from prospectively maintained databases in two high volume centers extracting consecutive patients presenting unruptured intracranial aneurysm treated with flowdiverter and receiving DAPT (May 2015 to December 2019).  Two groups were compared according to their DAPT regimen: “ticagrelor+aspirin” and “clopidogrel+aspirin”. Clopidogrel group was systematically checked with platelet test inhibition before endovascular procedure. The primary endpoint was composite, defined as any thrombo-embolic event (TEE) or major hemorrhagic event occurring the first 6 months during and after embolizationResults260 patients met our inclusion criteria. Baseline patients and aneurysms characteristics were comparable between groups, except for aneurysm location, median size and pre-treatment modified Rankin scale. No significant difference was observed regarding the primary composite outcome: 11.5% (12/104) in the ticagrelor group versus 10.9% (17/156) in the clopidogrel group (p = 1.000). There was also no significant difference in secondary outcomes including TEE (10.5 vs 9.0%; p = 0.673), major hemorrhage (0.9 vs 1.2%; p = 0.651) and clinical outcome (at least 1-point mRS worsening during follow up: 6.7% vs 8.3%; p = 0.813).ConclusionFirst-line DAPT with ticagrelor+aspirin seems as safe and effective as clopidogrel+aspirin regimen.     

Clinical Outcomes of Large (>10 mm) Unruptured Posterior Circulation Aneurysms and Their Predictors

ObjectiveThe treatment of large aneurysms of the posterior circulation is complicated and remains challenging. We here analyzed our institutional clinical outcomes of large unruptured aneurysms of the posterior circulation. MethodsThis study included 56 patients who presented with a large (>10 mm) unruptured aneurysm of the posterior circulation between 2002 and 2018. ResultsThere were 18 (32.1%) male and 38 (67.9%) female patients, with a mean age of 53.4 years. The most common location was the vertebral artery, followed by the basilar tip and posterior cerebral artery. The median follow-up duration was 29 months. Eighteen patients (32.1%) were treated by transcranial surgery and 38 (67.9%) were treated by endovascular treatment (EVT). Posttreatment complications occurred in 16 patients (28.6%), with there being no significant difference between the transcranial surgery and EVT groups. Complete obliteration was achieved in 30 patients (53.6%), with there being no statistically significant difference between the transcranial surgery and EVT groups. Recurrence occurred in 17 patients (30.4%), and the rate of recurrence was higher in the EVT group than in the transcranial surgery group (39.5% vs. 11.1%, p=0.03). Forty-four (84%) of 56 patients showed a favorable functional outcome. In saccular aneurysm, EVT was negative predictor of worsening of functional status. ConclusionTreatment of these aneurysms harbors an inherent high risk of morbidity. No superiority was found between transcranial surgery and EVT in terms of complications and complete obliteration, but transcranial surgery showed a higher treatment durability than EVT.     

Surface-modified flow diverter p48-MW-HPC: Preliminary clinical experience in 28 patients treated in two centers

Background and purposeFlow diversion is increasingly used for endovascular treatment of distal intracranial aneurysms and has led to the development of small diameter flow diverters such as p48-MW (phenox, Bochum, Germany). Use of flow diverters is limited, however, as patients require dual antiplatelet treatment to avoid thromboembolic complications. Hydrophilic Polymer Coating was developed to reduce platelet aggregation on the p48-MW (p48-MW-HPC). This study reports preliminary experience with p48-MW-HPC in aneurysm treatment in two centers.Materials and methodsPatients with ruptured, unruptured, and recanalized aneurysms treated with p48-MW-HPC were prospectively included and retrospectively analyzed for safety and efficacy. Safety was evaluated by analyzing intra- and postoperative complications as well as thromboembolic events depicted by DWI in the 72 h post-procedure. Efficacy was evaluated at 6 months based on aneurysm occlusion.ResultsFrom April 2019 to May 2020, 28 patients aged 25–82 years with 29 aneurysms were treated. Two thromboembolic events (7.1%) were reported with good clinical outcome. Final morbidity and mortality were both 0.0%. Post-operative DWI-MRI was depicting lesions in 70.0% of patients. Short-term (6 months) anatomical results were complete aneurysm occlusion in 87.0% of aneurysms, neck remnant in 8.7%, and aneurysm remnant in 4.3%.ConclusionThis preliminary clinical evaluation conducted in a relatively small sample size shows high feasibility (100.0%) of p48-MW-HPC aneurysm treatment, without morbidity or mortality, and high efficacy (complete occlusion in 90.0%). Additional larger comparative studies are needed to confirm these results and optimize perioperative antiplatelet treatment.     

Strategy for the treatment of inaccessible unruptured giant and large aneurysms of the internal carotid artery

Abstract

Our goal was to clarify the optimum management of the inaccessible unruptured giant and large aneurysms of the internal carotid artery (ICA). Since 1981, we have treated 18 patients with unclippable unruptured giant or large aneurysms of the ICA. Aneurysms were classified as either intracavernous or intradural. We performed proximal carotid occlusion in 12 patients and conservatively treated six patients. We retrospectively analyzed long-term outcomes in these patients. Four of seven patients with intradural aneurysm underwent proximal carotid occlusion, with good long-term outcomes. The three patients with intradural aneurysm, who were treated conservatively, died of subarachnoid hemorrhage. Eight of 11 patients with intracavernous aneurysm underwent proximal carotid occlusion, one dying of massive nasal bleeding 25 months after the procedure. In this case, the aneurysm was partially thrombosed, and residual lumen growth was revealed 22 months after proximal carotid occlusion. Cranial nerve paresis improved in five of the eight patients (63%), and two patients had a minor ischemic attack. Neurological problems failed to occur in the three patients with intracavernous aneurysm who were treated conservatively. The risk of rupture is relatively high in intradural giant and large aneurysms. Proximal carotid occlusion can effectively prevent bleeding from intradural aneurysms. Aggressive management is justified for intradural aneurysms with poor collateral circulation. Operative procedures in the management of an intracavernous aneurysm require careful consideration.