Aneurysmal Neck Clipping as the Primary Treatment Option for Both Ruptured and Unruptured Middle Cerebral Artery Aneurysms

OBJECTIVE: Although middle cerebral artery (MCA) aneurysms are less amenable to coil embolization, an increasing number of studies support favorable endovascular treatment for them. The purpose of this study is to compare the outcomes of two different treatments (surgery versus coiling) and evaluate the benefits of surgical clipping for MCA aneurysms. METHODS: Here we retrospectively analyzed the outcomes of 178 ruptured and unruptured MCA aneurysms treated in patients between September 2008 and April 2012. Parameters assessing treatment outcomes include degree of aneurysm occlusion, presence of regrowth, clinical status, and complications. RESULTS: Among 178 MCA aneurysms, 153 were treated surgically. After a mean follow-up of 12 months, the surgery group showed a clinically significant complete occlusion rate (98%) compared with the coiling group (56%) (p<0.001). Follow-up radiologic evaluation showed a higher regrowth rate (four of 16 cases) in the coiling group than in the surgery group (one of 49 cases) (p=0.003). There was no statistically significant difference in favorable clinical outcome rate between the two groups. The procedure-related permanent morbidity and mortality rates were 2% (three of 153 cases) in the surgery group and 0% (0 of 25 cases) in the coiling group. CONCLUSION: Compared to endovascular treatment, surgical neck clipping for both ruptured and unruptured MCA aneurysms results in a significantly higher complete obliteration rate and less regrowth. Therefore, even in this endovascular era, we still recommend surgical clipping as the primary treatment option for MCA aneurysms rather than coil embolization.

Outcomes of Ultra-Early Decompressive Craniectomy after Severe Traumatic Brain Injury-Treatment Outcomes after Severe TBI / 대한신경손상학회지

OBJECTIVE: The beneficial effect of decompressive craniectomy in the treatment of severe traumatic brain injury (TBI) is controversial, but there is no debate that decompression should be performed before irreversible neurological deficit occurs. The aim of our study was to assess the value of ultra-early decompressive craniectomy in patients with severe TBI. METHODS: Total of 127 patients who underwent decompressive craniectomy from January 2007 to December 2013 was included in this study. Among them, 60 patients had underwent ultra-early (within 4 hours from injury) emergent operation for relief of increased intracranial pressure. Initial Glasgow coma scale, brain computed tomography (CT) scan features by Marshall CT classification, and time interval between injury and craniectomy were evaluated retrospectively. Clinical outcome was evaluated, using the modified Rankin score. RESULTS: The outcomes of ultra-early decompressive craniectomy group were not better than those in the comparison group (p=0.809). The overall mortality rate was 68.5% (87 patients). Six of all patients (4.7%) showed good outcomes, and 34 patients (26.8%) remained in a severely disabled or vegetative state. Forty of sixty patients (66.7%) had died, and two patients (3.3%) showed good outcomes at last follow-up. CONCLUSION: Ultra-early decompressive craniectomy for intracranial hypertension did not improve patient outcome when compared with "early or late" decompressive craniectomy for managing severe TBI.

Risk Factors Predicting Unfavorable Neurological Outcome during the Early Period after Traumatic Brain Injury

OBJECTIVE: We aimed to identify clinico-radiological risk factors that may predict unfavorable neurological outcomes in traumatic brain injury (TBI), and to establish a guideline for patient selection in clinical trials that would improve neurological outcome during the early post TBI period. METHODS: Initial clinico-radiological data of 115 TBI patients were collected prospectively. Regular neurological assessment after standard treatment divided the above patients into 2 groups after 6 months : the Favorable neurological outcome group (GOS : good & moderate disability, DRS : 0-6, LCFS : 8-10) and the Unfavorable group (GOS : severe disability-death, DRS : 7-29 and death, LCFS : 1-7 and death). RESULTS: There was a higher incidence of age > or =35 years, low initial GCS score, at least unilateral pupil dilatation, and neurological deficit in the Unfavorable group. The presence of bilateral parenchymal lesions or lesions involving the midline structures in the initial brain CT was observed to be a radiological risk factor for unfavorable outcome. Multivariate analysis demonstrated that age and initial GCS score were independent risk factors. The majority of the Favorable group patients with at least one or more risk factors showed improvement of GCS scores within 2 months after TBI. CONCLUSION: Patients with the above mentioned clinico-radiological risk factors who received standard treatment, but did not demonstrate neurological improvement within 2 months after TBI were deemed at risk for unfavorable outcome. These patients may be eligible candidates for clinical trials that would improve functional outcome after TBI.