Treatment of ruptured intracranial aneurysms yesterday and now.

OBJECTIVE: This prospective study is designed to detect changes in the treatment of ruptured intracranial aneurysms over a period of 17 years. METHODS: We compared 361 treated cases of aneurysm occlusion after subarachnoid hemorrhage from 1997 to 2003 with 281 cases from 2006 to 2014. Specialists of neuroradiology and vascular neurosurgery decided over the modality assignment. We established a prospective data acquisition in both groups to detect significant differences within a follow-up time of one year. With this setting we evaluated the treatment methods over time and compared endovascular with microsurgical treatment. RESULTS: When compared to the earlier group, microsurgical treatment was less frequently chosen in the more recent collective because of neck-configuration. Endovascular treatment was chosen more frequently over time (31.9% versus 48.8%). Occurrence of initial symptomatic ischemic stroke was significantly lower in the clipping group compared to the endovascular group and remained stable over time. The number of reinterventions due to refilled treated aneurysms significantly decreased in the endovascular group at one-year follow-up, but the significantly better occlusion- and reintervention-rate of the microsurgical group persisted. The rebleeding rate in the endovascular group at one year follow-up decreased from 6.1% to 2.2% and showed no statistically significant difference to the microsurgical group, anymore (endovascular 2.2% versus microsurgical 0.0%, p = 0.11). CONCLUSION: Microsurgical clipping still has some advantages, however endovascular treatment is improving rapidly.

Efficacy and Safety of Treatment of Ruptured Intracranial Aneurysms.

OBJECTIVE: To compare the treatment results of ruptured aneurysms treated endovascularly with aneurysms treated with microsurgical clipping. METHODS: This prospective multicenter study recorded and analyzed 661 cases of ruptured intracranial aneurysms with consecutive subarachnoid hemorrhage treated between 1997 and 2014 at 2 large medical centers. Endovascular treatment was performed in 271 cases, and microsurgical treatment was performed in 390 cases. The treatment modality was chosen by neuroradiologists and vascular neurosurgeons and was classified by predetermined decision criteria. RESULTS: Symptomatic ischemic stroke occurred in 46 patients (17.0%) in the endovascular group versus 26 patients (6.7%) in the microsurgery group (odds ratio [OR] = 2.86; 95% confidence interval [CI], 1.72-4.76; P < 0.0001). There was a significantly better occlusion rate (OR = 11.48; 95% CI, 5.10-25.83; P < 0.0001) in the microsurgery group compared with the endovascular group. The rebleeding rate was significantly lower in the microsurgery group (OR = 14.90; 95% CI, 1.90-117.13; P = 0.00085). No patient required retreatment in the microsurgery group, whereas 23 patients required retreatment in the endovascular group (P < 0.0001). There was no significant difference regarding the low direct mortality rate of coil embolization versus microsurgical clipping (P = 0.21). CONCLUSIONS: Microsurgical clipping shows a lower rate of treatment-associated complications and a higher occlusion rate of ruptured intracranial aneurysms than coil embolization. The individual evaluation and decision process for choice of treatment modality in this study is very effective.

Cerebrospinal fluid rhinorrhea and seizure caused by temporo-sphenoidal encephalocele.

This case report describes the symptoms and clinical course of a 35-year-old female patient who was diagnosed with a temporo-sphenoidal encephalocele. It is characterized by herniation of cerebral tissue of the temporal lobe through a defect of the skull base localized in the middle fossa. At the time of first presentation the patient complained about recurrent nasal discharge of clear fluid which had begun some weeks earlier. She also reported that three months earlier she had for the first time suffered from a generalized seizure. In a first therapeutic attempt an endoscopic endonasal approach to the sphenoid sinus was performed. An attempt to randomly seal the suspicious area failed. After frontotemporal craniotomy, it was possible to localize the encephalocele and the underlying bone defect. The herniated brain tissue was resected and the dural defect was closed with fascia of the temporalis muscle. In summary, the combination of recurrent rhinorrhea and a first-time seizure should alert specialists of otolaryngology, neurology and neurosurgery of a temporo-sphenoidal encephalocele as a possible cause. Treatment is likely to require a neurosurgical approach.