Thomas J. Leipzig

Analysis of Intraoperative Rupture in the Surgical Treatment of 1694 Saccular Aneurysms

OBJECTIVE:Intraoperative rupture (IOR) of an aneurysm is a known risk in the surgical management of intracranial aneurysms. The purpose of this study was to determine the incidence of IOR in a modern surgical series and to assess which factors bear upon it. METHODS:This study retrospectively examined 1269 patients with saccular aneurysms treated surgically between 1986 and 1998. Three vascular neurosurgeons performed 1435 operations on 1694 aneurysms. Multiple factors, including the magnitude and time of occurrence of IOR, aneurysm location, subarachnoid hemorrhage, timing of surgery, and use of temporary occlusion, were analyzed. RESULTS:There were 113 instances of IOR (7.9% per surgery; 6.7% per aneurysm; 8.9% per patient). If the 59 “minor leaks” are excluded (as in previously published reports), the incidence becomes 3.8% per surgery, 3.2% per aneurysm, and 4.3% per patient. Posteroinferior cerebellar artery and anterior and posterior communicating artery aneurysms were more liable to rupture intraoperatively. The IOR rate was greater in ruptured than unruptured aneurysms (10.7 versus 1.2%, P < 0.0001). There was a lower rate of IOR in operations using temporary arterial occlusion (3.1 versus 8.6%, P < 0.0001). The occurrence of IOR for early surgery was not significantly higher than for surgery performed more than 3 days after subarachnoid hemorrhage (11.1 versus 10.0%, P = 0.6234). CONCLUSION:The rate of significant IOR can be kept low. Aneurysm location, subarachnoid hemorrhage, and temporary arterial occlusion seem to be important factors affecting the incidence of IOR.

The tortuous or kinked carotid artery: pathogenesis and clinical considerations: a historical review

The significance and management of cervical carotid artery tortuosity are controversial. One hundred eighteen cases of angulation of the common carotid artery and over 800 cases of elongation of the internal carotid artery have been reported. The etiology, presentation, diagnosis, and treatment of each entity are reviewed. Angulation of the common carotid artery is often managed conservatively. For clarity, elongations of the internal carotid artery should be classified as either tortuosities or kinks. Some patients with kinks of the internal carotid artery will have episodes of cerebrovascular insufficiency related to the position of their heads. Such patients merit thorough diagnostic evaluation. When other etiologic factors have been eliminated, patients in this group may benefit from a surgical procedure directed at the vascular abnormality. Applicable surgical techniques are discussed.

Results, outcomes, and follow-up of remnants in the treatment of ophthalmic aneurysms: a 16-year experience of a combined neurosurgical and endovascular team.

OBJECTIVEOphthalmic aneurysms present unique challenges to a vascular team. This study reviews the 16-year experience of a multidisciplinary neurovascular service in the treatment, complications, outcomes, and follow-up of patients with ophthalmic aneurysms from 1990 to 2005. METHODSA retrospective analysis of prospectively collected data of 134 patients with 157 ophthalmic aneurysms is presented. Subgroup analysis is performed based on treatment and clinical presentation of the patients. RESULTSClinical outcomes are reported using the Glasgow Outcome Scale. A “good” outcome is defined as a Glasgow Outcome Scale score of 4 or 5, and a “poor” outcome is defined as a Glasgow Outcome Scale score of 1 to 3. Outcome was related to patient age (P = 0.0002) and aneurysm size (P = 0.046). Outcomes for patients with ruptured aneurysms were related to hypertension (P < 0.0001) and clinical admission grade (P = 0.001). In patients with unruptured aneurysms, a good clinical outcome was noted in 103 (92.7%) of 111 patients at discharge and 83 (94.3%) of 88 patients at the time of the 1-year follow-up evaluation. Complete clipping was attained in 89 (79.5%) of 112 patients with angiographic follow-up. Patients with aneurysm remnants from both coiling and clipping had a low risk of regrowth, and there were no rehemorrhages. One of 25 patients with angiographic follow-up (average, 4.3 ± 4.1 years) after “complete” clipping showed recurrence of the aneurysm. CONCLUSIONDespite the difficulties presented by ophthalmic aneurysms, these lesions can be successfully managed by a multidisciplinary team. Imaging follow-up of patients is important, as there is a risk of aneurysm regrowth after either coiling or clipping.

Endovascular retrograde suction decompression as an adjunct to surgical treatment of ophthalmic aneurysms: analysis of risks and clinical outcomes.

OBJECTIVE Endovascular retrograde suction decompression with balloon occlusion of the internal carotid artery is a useful adjunct in the surgical treatment of ophthalmic aneurysms. This technique helps establish proximal control, facilitates intraoperative angiography, and may aid dissection by evacuating blood and softening the aneurysm. Although the technical aspects of this procedure have been described, the published data on its safety are scant. This study analyzed 2 groups of patients who underwent craniotomies for treatment of ophthalmic aneurysms, comparing a group who received suction decompression with a group who did not. METHODS A retrospective analysis of prospectively collected data on 118 craniotomies for ophthalmic aneurysms performed from 1990 to 2005 is presented. A group of 63 patients treated with endovascular suction decompression during surgery is compared with 55 patients who did not undergo this technique. RESULTS In our overall analysis of ophthalmic aneurysms, the clinical outcome was statistically related to aneurysm size (P = 0.046). The endovascular suction decompression group in this study had overall larger aneurysms (P < 0.0001) compared with the other group. There was no statistical difference between the 2 groups in rates of complications, stroke, new visual deficit, or death. The clinical outcomes were statistically similar at discharge and at 1 year. CONCLUSION Endovascular balloon occlusion and suction decompression did not increase the complication rate in a large cohort of craniotomy patients with ophthalmic aneurysms. This technique may be used to augment surgical capabilities without significantly increasing the operative risk.

Heart Rate Variability in Neurosurgical Patients

Cardiac monitors determine heart rate by counting the number of beats in a given time interval. The normal heart, however, does not beat at a constant rate. Instead, there is a continuous change in heart rate on a beat-by-beat basis. This is termed the instantaneous heart rate and it represents the projected rate per minute that the heart would beat if only one R-R interval (the time between sequential R waves) was repeated throughout a 60-second period. Calculation of the instantaneous heart rate for each heart beat (R-R interval) produces a pattern that demonstrates the variability in heart rate. This instantaneous heart rate pattern was prospectively studied in 102 patients admitted to a neurosurgical intensive care unit. Short-term (STV) and long-term (LTV) heart rate variability were compared to the Glasgow coma scale as a method for patient assessment. LTV seems to be the most useful heart rate parameter in the clinical setting, and both STV and LTV performed better in the serial evaluation of patients. Two postulations found in the heart rate literature were not borne out in this study. First, we did not find a strong correlation between elevated intracranial pressure and decreases in heart rate or variability, as previously reported by Lowensohn et al. Second, the morphological classification of heart rate patterns described by Evans in his study of head-injured patients did not carry the same prognostic value when applied to this broad spectrum of patients with a variety of acute neurological disorders. Heart rate and its variability is a simple parameter to monitor.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of Mycotic Aneurysms

Mycotic intracranial aneurysms may be treated by antibiotic therapy alone. Careful evaluation of this mode of treatment has been hampered by inadequate angiographic and microbiological documentation. The present case details the successful conservative management of one of these lesions in a patient who had previously undergone craniotomy for a separate mycotic aneurysm.

Risk of hemorrhage from de novo cerebral aneurysms.

OBJECT A small percentage of patients will develop a completely new or de novo aneurysm after discovery of an initial aneurysm. The natural history of these lesions is unknown. The authors undertook this statistical evaluation a large cohort of patients with both ruptured and unruptured de novo aneurysms with the aim of analyzing risk factors for rupture and estimating a risk of subarachnoid hemorrhage (SAH). METHODS A review of a prospectively maintained database of all aneurysm patients treated by the vascular neurosurgery service of Goodman Campbell Brain and Spine from 1976-2010 was performed. Of the 4718 patients, 611 (13%) had long-term follow-up imaging. The authors identified 27 patients (4.4%) with a total of 32 unruptured de novo aneurysms from routine surveillance imaging. They identified another 10 patients who presented with a new SAH from a de novo aneurysm after treatment of their original aneurysm. The total study group was thus 37 patients with a total of 42 de novo aneurysms. The authors then compared the 27 patients with incidentally discovered aneurysms with the 10 patients with SAH. A statistical analysis was performed, comparing the 2 groups with respect to patient and aneurysm characteristics and risk factors. RESULTS Thirty-seven patients were identified as having true de novo aneurysms. This group had a female predominance and a high percentage of smokers. These 37 patients had a total of 42 de novo aneurysms. Ten of these 42 aneurysms hemorrhaged. De novo aneurysms in both the SAH and non-SAH group were anatomically small (< 10 mm). The estimated risk of hemorrhage over 5 years was 14.5%, higher than the expected SAH risk of small, unruptured aneurysms reported in the ISUIA (International Study of Unruptured Intracranial Aneurysms) trial. There was no statistically significant correlation between hemorrhage and any of the following risk factors: hypertension, diabetes, tobacco and alcohol use, polycystic kidney disease, or previous SAH. There was a statistically significant between-groups difference with respect to patient age, with the mean patient age being significantly older in the SAH aneurysm group than in the non-SAH group (p = 0.047). This is likely reflective of longer follow-up and discovery time, as the mean length of time between initial treatment and discovery of the de novo aneurysm was longer in the SAH group (p = 0.011). CONCLUSIONS While rare, de novo aneurysms may have a risk for SAH that is comparatively higher than the risk associated with similarly sized, small, initially discovered unruptured saccular aneurysms. The authors therefore recommend long-term follow-up for all patients with aneurysms, and they consider a more aggressive treatment strategy for de novo aneurysms than for incidentally discovered initial aneurysms.

Trends over time in the management of 2253 patients with cerebral aneurysms: A single practice experience

Background: To better understand the longitudinal trend in the proportion of techniques employed for cerebral aneurysm treatment, we reviewed our experience with 2253 patients over the last 11 years. Methods: We reviewed data in our prospective aneurysm database for all consecutive patients treated from January 1998 through December 2009. Data regarding age, sex, aneurysm location, presence or absence of hemorrhage, Fisher grade, clinical grade, treatment methods, length of hospitalization, and mortality rates by the time of discharge were retrieved and retrospectively analyzed. The most common aneurysm types were subsequently classified and analyzed separately. Results: The patient population included 663 males (29%) and 1590 females (71%). A total of 2253 patients presented with 3413 aneurysms; 1523 (63%) of the aneurysms were diagnosed as aneurysmal subarachnoid hemorrhage. A total of 2411 (71%) aneurysms were treated. Overall, 645 (27%) of the 2411 aneurysms underwent endosaccular coiling and 1766 (73%) underwent clip ligation; 69 (3%) of these aneurysms required both treatment modalities. The percentage of all aneurysms treated by endosaccular coiling increased from 8% (21) in 1998 to 28% (87) in 2009. There was no statistical difference between the average length of hospitalization for patients who underwent endosaccular coiling and clip ligation for their ruptured (P = 0.19) and unruptured (P = 0.80) aneurysms during this time period. Conclusions: In our practice, endovascular treatment has continued to be more frequently employed to treat cerebral aneurysms. This technique has had the greatest proportional increase in the treatment of posterior circulation aneurysms.