G. Vaz

Surgical management of unruptured intracranial aneurysms that are inappropriate for endovascular treatment: experience based on two academic centers.

OBJECTIVETo analyze the results of the surgical management of unruptured intracranial aneurysms (UIA) when coil embolization (CE) was considered first but deemed inappropriate by our multidisciplinary groups. METHODIn two institutions, all UIAs recommended for treatment were considered first for a CE procedure if accessibility, neck width, and fundus-to-neck ratio were appropriate. Patients with UIAs considered inappropriate for CE were to undergo a surgical clipping procedure. We reviewed the medical records of all patients who underwent surgical clipping between February 1996 and February 2006. RESULTSA total of 325 patients with 440 UIAs were treated. Of them, 149 patients were selected by our multidisciplinary staff for treatment by CE, and 176 patients with 238 UIAs were treated by 207 surgical procedures. Angiographic studies revealed complete occlusion in 95% and near total occlusion in 2.5% of surgically treated UIAs. No deaths related to surgery occurred. Sixteen patients (9.1%) experienced postoperative complications, four of which persisted 1 year after surgery (two cases of diplopia and two aphasic disorders). The 1-year morbidity rate was 2.2% (four of 176) by patient and 1.7% (four of 238) by aneurysm. For UIAs smaller than 10 mm in patients younger than 65 years old, the morbidity rate was 0.56%. CONCLUSIONOur results gathered from two centers with the same management of UIAs show that SC remains a safe and effective treatment for UIAs even when CE is considered first.

Neurosurgical management of inadequately embolized intracranial aneurysms: a series of 17 consecutive cases.

SummaryObjective. Inadequately embolized aneurysms (IEA) are coiled aneurysms with a significant remnant (>5%), initially or after recanalisation, or with a coil extrusion deemed too thrombogenic or threatening the blood flow in the parent vessel. Our objective is to report our experience with the surgical clipping (SC) of a consecutive series of 17 IEA considered as not appropriate for an additional endovascular procedure. Methods. Between February 1996 and April 2006, we evaluated 523 ICA in 380 patients of whom 192 underwent coil embolisation (CE), 117 with complete occlusion (61%), 47 with near complete occlusion (≥95%), 9 with partial occlusion (<95%), and 19 without any coil delivery (attempted embolisation). Of the 173 ICA embolized one or two times, at their radiological follow-up 15 (8.6%) were considered as IEA and not appropriate for an additional CE. Two IEA treated endovascularly before February 1996 were added to this series. The female/male ratio was 0.47 with an average age of 54 years (range, 37–65). All cases were located on the anterior circulation except the last one. The 17 IEA were treated by SC either because of an aneurysm remnant deemed not accessible to a further CE and large enough for direct clipping or because the risks of a thromboembolic event related to extruded coils was too high. Results. SC was complete in all 17 cases, confirmed angiographically. Postoperatively, the clinical status of two patients deteriorated slightly but transiently. Our surgical experience with this series led us to classify IEA into five types, in three groups: group A (with one type: type A) was the most important group (n = 11) with IEA characterized by an aneurysm residue allowing direct SC, as assessed preoperatively; group B (n = 4) comprised aneurysms with a residue smaller than predicted and showing parent vessel stenosis when a clip was applied to the neck residue requiring the fundus full of coils to be removed followed by either clip application to the neck residue (type B1, n = 3) or suture if the remnant was too small (type B2, n = 1); and group C (n = 2) grouping cases requiring coil extraction through the parent vessel (type C2, n = 1) or through the fundus (type C2, n = 1). Conclusions. With this series of IEA, we observed that open surgery of type A and C aneurysms can be a straightforward procedure. Our experience with type B IEA encourages us to wait for a sufficient aneurysm residue before performing SC because of the potential difficulties that may be encountered by the surgeon, particularly in type B2. SC of IEA was very effective with complete occlusion and no permanent morbidity in all 17 cases.

Glioblastoma surgery with and without intraoperative MRI at 3.0T

BACKGROUND Gross total or near total resection (GTR/NTR; resection ≥95%) of glioblastoma (GBM) seems correlated with a longer survival. Intraoperative MRI (ioMRI) is one method to evaluate the extent of resection (EOR) in order to improve it during the same anesthesia. We compared GBM resections using a 3.0T ioMRI and then without considering the EOR, safety, survival and discussed the indications for using this expensive modality. METHODS Between March 2006 and November 2011, 56 GBM resections were performed using an ioMRI, and 38 without (control group). The only criterion in order to have access to the ioMRI was its availability. We compared the variables EOR, Karnofsky Performance Scale scores and survival in both groups. RESULTS In the ioMRI group, 15 patients (26.8%) underwent an immediate second resection increasing the GTR rate of 10.7% and the GTR/NTR rate of 8.9%. There was a significant difference between the use of an ioMRI and the control group in reaching a larger EOR (P=0.049, Fishers exact test). The effect of using the ioMRI or not on the overall survival, with EOR as covariate, was not significant (P=0.147, Likelihood ratio test). However, the EOR alone had a significant effect on survival (P=0.049, Wald test), with a shorter survival for the patients with a partial resection (PR) than a GTR/NTR (Hazard ratio=1.6, 95% CI HR: 1.00-2.69), with a median overall survival of 15.26 months (95% CI: 12.34-19.08) for the GTR/NTR subgroup versus 10.26 months (95% CI: 6.64-15.82) for the PR subgroup. Multivariate regression analysis also identified age, sex and adjuvant chemotherapy as factors significantly associated with overall survival. CONCLUSIONS A 3.0T ioMRI improved the quality of resection by 17.8% and increased the GTR/NTR rate by 8.9% up to 73.2% without additional morbidity. A GTR/NTR improves survival duration by about 50%. Thus, it remains reasonable to increase the EOR to reach GTR/NTR using an intraoperative control. However, ioMRI should be limited to the cases for which a GTR/NTR seems preoperatively possible.

Radiating Multiple Subpial Transection: Operative Techniques, Complications and Outcomes

Epilepsy is a neurologic disorder affecting nearly fifty million people worldwide [1]. In two thirds of the patients, seizures can be controlled with the right medication. Unfortunately, one third of the patients have drug-resistant epilepsy; for those patients, epilepsy surgery remains a possible life-transforming treatment option.

Multiple subpial transections and magnetic resonance imaging

INTRODUCTION Multiple subpial transection (MST) has been applied to the treatment of refractory epilepsy when epileptogenic zone involves eloquent areas since 1989. However, there is a lack of data evaluating the effect of this surgical technique on the cortex as measured by Magnetic Resonance Imaging (MRI). PATIENTS AND METHODS Ten consecutive patients (3F/7M, average age: 18.5 years) were operated on using radiating MST (average: 39; min: 19, max: 61) alone (n=3) or associated with another technique (n=7). Seven patients underwent a post-operative 3.0T MRI while 3 had a 1.5T MRI. Three patients had an early post-operative MRI and 7 a late MRI, among which 3 previously had an intraoperative MRI. RESULTS The MR sequences that allowed the best assessment of MST-induced changes were T2 and T2*. The traces of MST are more visible on late MRI. These discrete non-complicated stigmas of MST were observed in all 10 studied patients: on the intraoperative MRI they are seen as micro-hemorrhagic spots (hypo-T2), on the early postoperative MRI as a discreet and limited cortical edema whether associated or not with micro-hemorrhagic spots and on the late MRI as liquid micro-cavities (hyper-T2) surrounded with a fine border of hemosiderin. CONCLUSIONS MST-induced cerebral lesions are best visualized in T2-sequences, mainly on the late postoperatively MRIs. On all the MRI examinations in this study, the MST are only associated with limited modifications of the treated cortical regions.

Thrombosis and recanalization of a blister-like aneurysm: letter to the editor.

Dear Editor, We would like to report the first case of a complete thrombosis and recanalization of a blister-like aneurysm. The partial or complete spontaneous aneurysmal thrombosis is reported by multiple authors and ranges between 13 and 20 % of giant aneurysms [4]. This phenomenon has been exceptionally reported in nongiant aneurysms and has never been documented with a blister-like aneurysm. A 54-year-old man was diagnosed with a subarachnoid hemorrhage (SAH) of Fisher grade III (GCS: 14). Arteriography showed an aneurysm of the left MCA bifurcation. Four days after its complete clipping, the patient deteriorated due to a new SAH. An aneurysm on the left A1 segment was disclosed. The patient died 72 h after this second SAH. The autopsy demonstrated a ruptured blister-like aneurysm of A1, which was probably also responsible for the first SAH (Fig. 1). Blister-like aneurysms account for only 1 % of all intracranial aneurysms [1]. They are characterized by their small size and a broad base. Their very thin wall is associated with growth in short intervals and rapid evolution towards the rupture [2]. The diagnosis of blister-like aneurysms, uneasy to distinguish from normal variants, remains complicated [5]. In our case, the blister-like ICA was not visualized at the first CT angiography. The occurrence of false-negative cerebral angiography in acute non-traumatic SAH is 5 %. The main cause of SAH with negative angiogram is a nonvisualized aneurysm. The incidence of ruptured ICA disclosed at a delayed angiography is about 16 %. Five possible reasons have been reported: inadequate angiography, obliteration of aneurysm by the hemorrhage, aneurysm thrombosis, an aneurysm too small to be visualized, and lack of aneurysm filling due to vasospasm [6]. The hypothesis the most probable is thrombosis of the aneurysm shortly after its rupture preventing its visualization at the first angiography. The spontaneous aneurysmal thrombosis is well known in giant aneurysms [4]. Intrinsic factors influencing its occurrence are the aneurysm morphology (narrow neck), the presence of endothelial lesion and hemodynamic patterns in the parent artery. An extrinsic factor can be the compressive effect exerted by the hematoma around the aneurysm. In many cases, aneurysmal thrombosis has an unfavorable natural evolution with the occurrence of thromboembolic events, recanalization, and bleeding [3]. In non-giant aneurysms, such in blister-like ones, this process is poorly documented and not understood. Such an occurrence seems to be exceptional. We report, for the first time, a complete thrombosis and recanalization of a blister-like aneurysm, disclosed after a D. Tassigny :G. Vaz : C. Raftopoulos (*) Department of Neurosurgery, University Hospital St-Luc, Universite Catholique de Louvain (UCL), Avenue Hippocrate, 10, 1200 Brussels, Belgium e-mail: christian.raftopoulos@uclouvain.be

Rapport 2012 : Anévrismes intracrâniens : clip ou coilIndications et traitement chirurgical des anévrismes intracrâniens après recanalisation ou embolisation incomplèteIndications and surgical treatments for failed coiled aneurysms

The possibility of treating intra-cranial aneurysms (ICA) through an endovascular approach is a great progress. But, as any technique, it has its own limitations. Multidisciplinary neurovascular teams are regularly confronted with ICA where embolization is a poor option or even failed (a residue of more than 5% at six months follow-up or after recanalization). Another potential failure is a coil extrusion into the parent vessel with thrombo-embolic risks. Our team and others in the world developed strategies to manage these complex cases. After a brief review of the literature, we describe our experience and present a modified Gurian classification. This classification allows a better identification of the various failed coiled aneurysms types and their potential surgical treatments.

Indications et traitement chirurgical des anévrismes intracrâniens après recanalisation ou embolisation incomplète

The possibility of treating intra-cranial aneurysms (ICA) through an endovascular approach is a great progress. But, as any technique, it has its own limitations. Multidisciplinary neurovascular teams are regularly confronted with ICA where embolization is a poor option or even failed (a residue of more than 5% at six months follow-up or after recanalization). Another potential failure is a coil extrusion into the parent vessel with thrombo-embolic risks. Our team and others in the world developed strategies to manage these complex cases. After a brief review of the literature, we describe our experience and present a modified Gurian classification. This classification allows a better identification of the various failed coiled aneurysms types and their potential surgical treatments.

Intrathecal Tissue-type Plasminogen Activator Therapy after Coil Embolization or Surgical Clipping for Ruptured Intracranial Aneurysms: A Prospective Study: ISC 128

S OF ORAL PROCEEDINGS 2006 JOINT ANNUAL MEETING OF THE AANS/CNS CEREBROVASCULAR SECTION AND THE AMERICAN SOCIETY OF INTERVENTIONAL & THERAPEUTIC NEURORADIOLOGY CARIBE ROYALE ORLANDO—ORLANDO, FLORIDA FEBRUARY 17–20, 2006 ISC 127 De Novo Aneurysm Formation in Patients Younger than 40 Years of Age Terry G. Horner, M.D., Thomas Leipzig, M.D., Troy Payner, M.D. (Indianapolis, IN) INTRODUCTION: The incidence of de novo aneurysm formation is unknown. The risk of recurrent hemorrhage in treated patients with a previous aneurysmal subarachnoid hemorrhage or incidental aneurysm is reported to be higher than in the general population. It seems that the incidence in the younger age population may be higher than in the older population. We review a consecutive series of young patients to determine their risk for de novo aneurysm formation. METHODS: We report a series of 378 patients treated between 1976 and 2000 who presented with a subarachnoid hemorrhage secondary to a saccular aneurysm or an incidental aneurysm in patients ranging in age from 9 to 39 years at presentation. Thirty-nine of these patients died from initial hemorrhage or from other causes, leaving 339 patients for follow-up. RESULTS: Of 121 patients who had repeat arteriograms, new aneurysms were seen in 15 (12.4%). Findings in 16 other patients included the development of a neck remnant or growth of a known previous neck remnant, regrowth of a previously thrombosed aneurysm, rupture of a previously explored infundibulum, and recurrence of a previously clipped aneurysm. CONCLUSION: Although the follow-up of the remaining patients is ongoing, it seems that de novo aneurysm formation or recurrent growth of existing aneurysm is significant. Close angiographic follow-up in patients below the age of 40 years is recommended. ISC 128 Intrathecal Tissue-type Plasminogen Activator Therapy after Coil Embolization or Surgical Clipping for Ruptured Intracranial Aneurysms: A Prospective Study Christian Raftopoulos, M.D., Ph.D., Geraldo Vaz, M.D., Pierre Goffette, M.D., Ph.D. (Brussels, Belgium) INTRODUCTION: We aim to study the effect of tissue-type plasminogen activator (tPA) on the development of permanent delayed ischemic neurological deficit and ventriculoperitoneal shunting after coil embolization (CE) or surgical clipping (SC) for a ruptured intracranial aneurysm (RIA). METHODS: A total of 126 consecutive patients with ruptured intracranial aneurysms were prospectively divided into two groups: CE (n 50) or SC (n 76). Eleven patients in the CE group and 31 in the SC group received tPA. Five subgroups were defined according to the method of tPA administration: 1) CE with acute hydrocephalus who received tPA through a ventricular catheter; 2) CE without acute hydrocephalus who received tPA through a lumbar catheter; 3) SC with intraparenchymal hematoma who received tPA through a lumbar catheter; 4) SC with acute hydrocephalus who had tPA placed in the opened subarachnoid cisternae at the end of surgery plus tPA through the ventricular catheter; and 5) SC without intraparenchymal hematoma or acute hydrocephalus who received tPA in the basal cisterns at the end of surgery followed by tPA through a lumbar catheter. No saline irrigation was performed after tPA administration. RESULTS: The administration of tPA induced a significant reduction in the incidence of permanent delayed ischemic neurological deficit and of ventriculoperitoneal shunting after acute hydrocephalus (Fisher’s exact P value 0.02). One patient (2.3%) showed an acute spinal subdural hematoma requiring surgical decompression. CONCLUSION: Tissue-type plasminogen activator reduced the incidence of permanent delayed ischemic neurological deficit and ventriculoperitoneal shunting after acute hydrocephalus in patients with a ruptured intracranial aneurysm. These results call for a Phase III study using tPA without saline irrigation. ISC 129 Awake Carotid Endarterectomy in Patients with Contralateral Carotid Occlusion: Selective Shunting Without Increased Risk of Complications Paul K. Kim, M.D., Aaron Hoffman, B.S., John A. Wilson, M.D., F.A.C.S. (Winston-Salem, NC) INTRODUCTION: Although there is evidence that carotid endarterectomy (CEA) can be performed with low risk in patients with contralateral carotid occlusion (CCO), ongoing debate exists concerning the use of empiric versus selective shunting for CEA in patients with CCO. We reviewed our series to determine the impact of shunting on overall outcome. METHODS: Between 1995 and 2004, 325 CEA procedures were performed by the senior author. The mean length of the follow-up period was 12 months. The average age was 72 years, which did not differ significantly between patients with CCO (Group 1, 30 patients) and those without CCO (Group 2, 295 patients). Indications for shunting included deteriorating mental status and/or development of focal neurological deficits. Shunting was performed in 16 of 325 cases using a Pruitt-Inahara carotid shunt (LeMaitre Vascular, Inc., St. Petersburg, FL). In 1% of cases, permanent cranial nerve deficits (vocal cord paresis) occurred, and there was a 2% incidence of postoperative wound complications requiring reoperation, none of which involved Group 1 patients. RESULTS: Shunting was performed in 23.3% of Group 1 patients and in 3.1% of Group 2 patients. Medical complications occurred in one patient in Group 1 and in three in Group 2. Complications resulting in permanent neurological deficit or death occurred in 1.2% NEUROSURGERY VOLUME 58 | NUMBER 2 | FEBRUARY 2006 | 395 of cases overall, with only one event occurring in Group 1 patients (intracerebral hemorrhage secondary to hyperperfusion syndrome). CONCLUSION: Our study demonstrates that CEA with selective shunting in the presence of CCO can be performed without increased risk of complications. Prospective randomized studies are necessary to determine whether selective shunting demonstrates significant improvement in outcome in patients undergoing CEA with CCO. ISC 130 The Versican Gene and the Risk of Intracranial Aneurysms Ynte M. Ruigrok, M.D., Gabriel J.E. Rinkel, Cisca Wijmenga (Utrecht, The Netherlands) INTRODUCTION: We hypothesize that disruption of the extracellular matrix of the arterial wall is a likely factor in the pathogenesis of intracranial aneurysms (IAs). The proteoglycan versican is an excellent candidate gene for IAs as it plays an important role in the extracellular matrix assembly and is localized in a previously implicated locus for IAs on chromosome 5q. METHODS: We analyzed all of the common variations using tagged single nucleotide polymorphisms and haplotypes in the versican gene in 309 Dutch patients with IAs and 639 controls. Furthermore, we genotyped a small sample of 14 affected sibling pairs with IAs and analyzed allele sharing between siblings. RESULTS: We found several single nucleotide polymorphisms in strong linkage disequilibrium and haplotypes constituting these single nucleotide polymorphisms associated with IAs in the Dutch population (strongest haplotype association with odds ratio 1.40; 95% confidence interval 1.06–1.84; P 0.02). In the affected sibling pairs, we found increased allele sharing (P 0.02–0.04). CONCLUSION: Our findings suggest that variation in or near the versican gene plays a role in susceptibility to IAs, which would then confirm the hypothesis that diminished maintenance of the ECM is important in the development of IAs. ISC 131 Rate, Predictors, and Consequences of Hemodynamic Depression after Carotid Artery Stenting Rishi Gupta, M.D. (Pittsburgh, PA), Alex Abou-Chebl, M.D., Christopher T. Bajzer, M.D. (Cleveland, OH), H. Christian Schumacher, M.D. (New York, NY), Jay Yadav, M.D. (Cleveland, OH) INTRODUCTION: Hemodynamic depression (HD) has been reported after carotid artery stenting (CAS) and carotid endarterectomy. We sought to determine the frequency, predictors, and consequences of HD after CAS. METHODS: We retrospectively analyzed data on 500 consecutive CAS procedures performed over a 5-year period. HD was defined as periprocedural hypotension (systolic blood pressure 90 mmHg) or bradycardia (heart rate 60). Univariate and multivariate binary logistic regression models were used to determine the predictors and consequences of HD and persistent HD. RESULTS: The mean patient age was 70.5 years. HD occurred during 210 procedures, and persistent HD developed in 84 procedures. Features that independently predicted HD included lesions involving the carotid bulb (odds ratio [OR], 2.18 (1.46–3.26); P 0.0001) or the presence of calcified plaque (OR, 1.89 (1.25–2.84); P 0.002). Previous ipsilateral carotid endaterectomy was associated with a reduced risk of HD (OR, 0.35 (0.20–0.60); P 0.0001). Patients who developed persistent HD were at a significantly increased risk of a periprocedural major adverse clinical event (OR, 3.05 (1.35–5.23), P 0.02) or stroke (OR, 3.34 (1.13–9.90), P 0.03). CONCLUSION: Hemodynamic depression is common after CAS, particularly in patients with calcified plaque in the carotid bulb, but is easily treated with conventional methods. Patients who develop persistent HD are at an increased risk of periprocedural major adverse clinical events and stroke. ISC 132 Comparison of Recanalization during EKOS MicroLysus Catheter-Assisted versus Standard Microcatheter Thrombolysis Thomas A. Tomsick, M.D., Pooja Khatri, M.D., Janice Carrozella, R.N., Joseph Broderick, M.D. (Cincinnati, OH), Interventional Management of Stroke I & II Study Groups INTRODUCTION: The purpose of this study was to analyze the recanalization effect of EKOS MicroLysus catheter (EKOS Corp., Bothell, WA)assisted fibrinolysis compared to microcatheter thrombolysis in intravenous/intra-arterial recombinant tissue-plasminogen activator therapy in the Interventional Management of Stroke (IMS) I and II trials. METHODS: The IMS I trial enrolled 80 ischemic stroke subjects with a National Institutes of Health Stroke Scale score of 10 or g