Outpatient Day-care Neuroangiography and Neurointervention of Unruptured Intracranial Aneurysms / 신경중재치료의학

PURPOSE: Day-care management of unruptured intracranial aneurysms can shorten hospital stay, reduce medical cost and improve outcome. We present the process, outcome and duration of hospital stay for the management of unruptured intracranial aneurysms via a neurointervention clinic in a single center during the past four years. MATERIALS AND METHODS: We analyzed 403 patients who were referred to Neurointervention Clinic at Asan Medical Center for aneurysm evaluation between January 1, 2011 and December 31, 2014. There were 141 (41%) diagnostic catheter angiographies, 202 (59%) neurointerventional procedures and 2 (0.6%) neurointerventional procedures followed by operation. We analyzed the process, outcome of angiography or neurointervention, and duration of hospital stay. RESULTS: There was no aneurysm in 58 patients who were reported as having an aneurysm in MRA or CTA (14 %). Among 345 patients with aneurysm, there were 283 patients with a single aneurysm (82%) and 62 patients with multiple aneurysms (n=62, 18%). Aneurysm coiling was performed in 202 patients (59%), surgical clipping in 14 patients (4%), coiling followed by clipping in 2 patients (0.6%) and no intervention was required in 127 patients (37%). The hospital stay for diagnostic angiography was less than 6 hours and the mean duration of hospital stay was 2.1 days for neurointervention. There were 4 procedure-related adverse events (2%) including 3 minor and 1 major ischemic strokes. CONCLUSION: Our study revealed that day-care management of unruptured intracranial aneurysms could be performed without an additional risk. It could enable rapid patient flow, shorten hospital stay and thus reduce hospital costs.

Shared decision-making in the context of unruptured intracranial aneurysms management / Decisão médica compartilhada no contexto do tratamento dos aneurismas cerebrais não-rotos

Shared decision-making practice has been encouraged in several clinical settings. In this model, clinical decisions are defined by doctors and patients based on the principle of patient autonomy. Shared decisions have been argued as an ethical clinical practice during complex and uncertain clinical situations. The best management of unruptured intracranial aneurysms (UIA) remains controversial. Despite the fact that shared decisions has probably been practiced, as far as we are aware it has not yet been evaluated, nor has it been standardized for patients presenting UIA. We aim to discuss possible roles, pros and cons of shared decision-making on the management of UIA.

A decisão médica compartilhada tem sido estimulada em várias situações clínicas. Por este modelo, as decisões clínicas são definidas por pacientes e médicos em conjunto, baseado no princípio da autonomia dos pacientes. A decisão médica compartilhada tem sido apontada como uma prática ética para situações clínicas complexas ou incertas. O melhor manejo dos aneurismas cerebrais não rotos continua controverso. Apesar da decisão médica compartilhada ser provavelmente praticada, esta prática ainda não foi avaliada, nem padronizada, para o atendimento de pacientes com aneurisma cerebral não roto. Nós discutiremos os possíveis papéis da decisão médica compartilhada no manejo dos aneurismas cerebrais não rotos.

Imaging features and treatments of ischemic cerebrovascular disease with unruptured intracranial aneurysms / 临床神经病学杂志

Objective To investigate the imaging features and the treatments of ischemic cerebrovascular disease with unruptured intracranial aneurysms.Methods The clinical data of 23 patients of ischemic cerebrovascular disease with unruptured intracranial aneurysms ( unruptured group) and 147 patients of hemorrhagic cerebrovascular with ruptured intracranial aneurysms ( ruptured group) were retrospectively analyzed.Results There were no statistical significances between the two groups baselines such as age, gender, hypertension, diabetes, hyperlipidemia, heart disease, smoking, drinking alcohol (all P>0.05).There were 16 patients (69.6%) with single intracranial aneurysm and 7 patients (30.4%) with multi-intracranial aneurysms in the unruptured group, and the number of intracranial aneurysms were 34.There were 125 patients (85%) with single intracranial aneurysm and 22 patients ( 15%) with multi-intracranial aneurysms in the ruptured group, and the number of intracranial aneurysms were 170.There was no statistical significance of single aneurysm and multi-aneurysms percentage between the two groups (P>0.05).The maximum aneurysm diameter and the percentage of large aneurysms, dissecting aneurysms of the unruptured group were significantly greater than the ruptured group; and the percentage of small-middle aneurysms and saccular aneurysms were significantly smaller than the ruptured group ( all P<0.05 ) .In the unruptured group, 5 cases were treated with intervention treatment and 1 case was treated with aneurysm clip surgery, all of which recovered well after surgery;6 cases were treated with Plavix antiplatelet therapy, 5 cases were treated with Aspirin antiplatelet therapy, cerebrovascular disease events were not found of which followed-up for 6 months;6 cases were not taken antiplatelet therapy, and 1 case of which followed-up and occurred cerebral infarction.In the ruptured group, 46 cases were treated with intervention treatment, 2 cases of which were died;101 cases were treated with aneurysm clip surgery, 6 cases of which were died.Conclusions Small-middle aneurysms are more commonly occurred in patients of ischemic cerebrovascular disease with unruptured intracranial aneurysm, however, the maximum aneurysm diameter of which is significantly bigger than patiehts of hemorrhagic cerebrovascular with ruptured intracranial aneurysms.Most of unruptured aneurysms which had duty relationship with cerebral ischemic events are dissecting aneurysms and saccular aneurysms.Intervention treatment of unruptured intracranial aneurysms is relatively safe and effective.

Benefits of Surgical Treatment for Unruptured Intracranial Aneurysms in Elderly Patients

OBJECTIVE: Due to longer life spans, patients newly diagnosed with unruptured intracranial aneurysms (UIAs) are increasing in number. This study aimed to evaluate how management of UIAs in patients age 65 years and older affects the clinical outcomes and post-procedural morbidity rates in these patients. METHODS: We retrospectively reviewed 109 patients harboring 136 aneurysms across 12 years, between 1997 and 2009, at our institute. We obtained the following data from all patients : age, sex, location and size of the aneurysm(s), presence of symptoms, risk factors for stroke, treatment modality, and postoperative 1-year morbidity and mortality. We classified these patients into three groups : Group A (surgical clipping), Group B (coil embolization), and Group C (observation only). RESULTS: Among the 109 patients, 56 (51.4%) underwent clipping treatment, 25 (23%) patients were treated with coiling, and 28 observation only. The overall morbidity and mortality rates were 2.46% and 0%, respectively. The morbidity rate was 1.78% for clipping and 4% for coiling. Factors such as hypertension, diabetes mellitus, hypercholesterolemia, smoking, and family history of stroke were correlated with unfavorable outcomes. Two in the observation group refused follow-up and died of intracranial ruptured aneurysms. The observation group had a 7% mortality rate. CONCLUSION: Our results show acceptable favorable outcome of treatment-related morbidity comparing with the natural history of unruptured cerebral aneurysm. Surgical clipping did not lead to inferior outcomes in our study, although coil embolization is generally more popular for treating elderly patients. In the treatment of patients more than 65 years old, age is not the limiting factor.