Basilar tip aneurysms: a microsurgical and endovascular contemporary series of 100 patients.

BACKGROUND: Endovascular therapy has largely replaced microsurgical clipping for the treatment of basilar tip aneurysms. OBJECTIVE: We describe the variables our center evaluates when choosing to clip or coil basilar tip aneurysms and our outcomes. Four case illustrations are presented. METHODS: All patients with ruptured or unruptured basilar tip aneurysms from 2005 to April 2012 were examined. The patients were treated by 2 interventional neuroradiologists and 2 dually trained neurosurgeons. RESULTS: There were 63 ruptured (clipped 38%, coiled 62%) and 37 unruptured (clipped 35%, coiled 65%) aneurysms in this 100-patient study. Seventy percent of the patients with ruptured aneurysms and 92% of the patients with unruptured aneurysms had a good outcome (modified Rankin scale 0-2) at 3 months. For ruptured aneurysms, there was a statistically significant difference in clipping and coiling with respect to age and treatment modality (clip 48.8 years, coil 57.6 years). Patients in the coiled group had higher dome-to-neck (1.3 vs 1.1) (P = .01) and aspect ratios (1.6 vs 1.2) (P = .007). In the ruptured coiling group, 69.5% achieved a Raymond 1 radiographic outcome, 28% Raymond 2, and 2.5% Raymond 3. Eleven (17.4%) patients required re-treatment, and 3 (4.4%) patients were re-treated more than twice. Coiling of unruptured aneurysms resulted in 75% Raymond 1. There were no residual lesions for unruptured clipped aneurysms. There were no differences in outcome between clipping and coiling in the ruptured and unruptured group. CONCLUSION: In our current management of basilar tip aneurysms, the majority can be treated via endovascular means, albeit with the expectation of a higher percentage of residual lesions and recurrences. Microsurgery is still appropriate for aneurysms with complex neck morphologies and in young patients desiring a more durable treatment.

Motor vehicle crash brain injury in infants and toddlers: a suitable model for inflicted head injury?

OBJECTIVE: Children involved in motor vehicle crash (MVC) events might experience angular accelerations similar to those experienced by children with inflicted traumatic brain injury (iTBI). This is a pilot study to determine whether the progression of signs and symptoms and radiographic findings of MVC brain injury (mvcTBI) in children of the age at greatest risk of iTBI could be evaluated with retrospective data. The ultimate goal was to examine the association of subdural hematoma (SDH) with initial loss of consciousness (LOC) and outcome. METHODS: Retrospective review of records was conducted of 51 patients involved in a MVC, between birth and 36 months, admitted to Harborview Medical Center between January 1996 and December 2001. Radiographs were reviewed. Simple descriptive statistics and Fisher's exact test were used. RESULTS: Ambulance reports were available for 57% of the patients, while Glasgow Coma Scale (GCS) scores (from any source) were only available for 76% of patients. Thirty-nine percent of patients sustained skull fractures, 8% long bone fractures, 20% thoracic injuries, and 8% intra-abdominal injuries. Twenty-four percent of the patients had SDHs; half of these experienced LOC. SDH patients without initial LOC had computed tomography findings and clinical courses indicative of focal impact injury, not angular acceleration. CONCLUSIONS: Initial LOC and subsequent evolution of GCS scores are inconsistently documented in retrospective records. Seven of the 12 patients with SDHs had simple contact injuries, while 5 exhibited diffuse brain injury. Initial LOC was associated with diffuse brain injury and poor outcome. Due to the high rate of simple contact injury, mvcTBI may be a difficult model for iTBI.