Vallabh Janardhan

Comparison of endovascular and surgical treatments for intracranial aneurysms: an evidence-based review

Intracranial aneurysms can be treated with endovascular or surgical techniques. We provide an objective comparison of these treatments, using data from single-centre studies, multicentre studies with and without independent outcome ascertainment, and randomised clinical trials. We compared the outcomes of patients who were candidates for endovascular treatment, surgical treatment, or both. In patients with ruptured intracranial aneurysms, rates of aneurysm obliteration were higher, and need for second treatment was lower, after surgery than after endovascular treatment. However, in observational studies and randomised trials, outcome at discharge, at 2-6 months, and at 1 year, and later survival, were all better after endovascular treatment than after surgery. The results suggest that the higher rates of incomplete obliteration and retreatment after endovascular treatment do not affect patients clinical outcome. In observational studies of patients with unruptured intracranial aneurysms, discharge outcomes were better and hospital costs were lower after endovascular treatment than after surgery. These patients showed no difference between the two treatments in 1-year outcomes and later rebleeding, although few data were available for this comparison.

Initial experience in establishing an academic neuroendovascular service: program building, procedural types, and outcomes.

To report our initial experience in setting up a neuroendovascular service in a university‐based comprehensive stroke center.

The Value of Computed Tomography Angiography in Determining Treatment Allocation for Aneurysmal Subarachnoid Hemorrhage

Background and PurposeComputed tomography (CT) and CT angiography (CTA) are frequently the initial imaging modalities used in the evaluation of patients with suspected aneurysmal subarachnoid hemorrhage (SAH). It remains unclear whether CTA can provide adequate information to determine best treatment modality (endovascular versus surgical) for ruptured intracranial aneurysms.MethodsPertinent clinical and radiological information of consecutive patients with aneurysmal SAH who underwent CTA on a 64-slice multidetector CT (MDCT) scanner were independently reviewed by five endovascular specialists. Subsequently, the interobserver reliability was calculated.ResultsA total of 21 consecutive patients with aneurysmal SAH detected on CTA were reviewed. Of the total of 105 reviews, in 65% a treatment allocation decision was made. Responses were, 26% either treatment; 18% endovascular only; 18% surgical only; and 3% neither treatment. In the remaining 35% it was considered that CTA images were inadequate to make a decision for treatment allocation and more information was requested. Interobserver reliability was poor between endovascular specialists (kxa0=xa00.2). The reliability was higher among endovascular/vascular neurosurgeons (kxa0=xa00.34) and physicians with >5xa0years of faculty experience (kxa0=xa00.55).ConclusionWhen 64-slice MDCT angiography is used in the evaluation of aneurysmal SAH, the information obtained is adequate to determine treatment modality allocation in two-thirds of the cases. The agreement on best treatment modality varied across primary specialty, practice experience, and site of fellowship completion.

Advances in Interventional Neuroimaging

SummaryAdvances in neuroimaging have aided in the development of useful diagnostic modalities for neurological disease and have helped improve existing therapies and pioneer newer therapies in the field of interventional neurology, a new subspecialty of neurology. In this chapter, the authors discuss the advances in various neuroimaging modalities, such as digital subtraction angiography, transcranial and intravascular ultrasonography, interventional dynamic computed tomography and 64-slice computed tomographic scanners, magnetic resonance image-guided interventions and intravascular magnetic resonance imaging, and molecular and cellular neuroimaging tools using microbubbles. The authors also summarize the clinical usefulness of these advances and their role in improving the diagnostic and therapeutic potential of neurointerventional procedures.