Intrasaccular Flow Disruption in Acutely Ruptured Aneurysms: A Multicenter Retrospective Review of the Use of the WEB.

BACKGROUND AND PURPOSE: Use of the WEB intra-aneurysmal flow-disruption device in unruptured wide-neck bifurcation aneurysms has proven safety and efficacy. However, ruptured aneurysms are underrepresented in existing studies. This retrospective multicenter study describes the use of the WEB in patients with a ruptured intracranial aneurysm. MATERIALS AND METHODS: Ten centers contributed to this study. Clinical and procedural data of 47 patients with 52 aneurysms were analyzed retrospectively together with follow-up angiographies. RESULTS: There were 37 anterior and 15 posterior circulation aneurysms with a neck size of ≥4 mm in 49 of 52 (94%) aneurysms; 45 (87%) aneurysms were <10 mm, and 2 were partially thrombosed. Successful placement of the WEB was possible in every case. Adjunctive devices were used in 8 of 52 (15%) aneurysms. Thromboembolic events were observed in 4 of 52 (8%) patients. Adverse events occurred in 15 patients with 16 aneurysms, 9 of which were potentially related to the WEB procedure (3 thromboembolic events, 5 protrusions, and 1 perforations; 2 perforations were caused by the wire or catheter), but none had a clinical impact. Four patients were retreated. Short-term follow-up in 25 of 39 patients revealed complete occlusion in 15 of 25 (60%), 5 of 25 (20%) with residual neck, and 5 of 25 (20%) with residual aneurysm filling. Short- to midterm imaging in 9 of 25 patients revealed complete occlusion in 5 (55.6%), residual neck in 2 (22%), and residual aneurysm filling in 2 (22%). Of 47 patients, 23 (49%) had an mRS score of 0, 1, or 2; 13 (28%) had an mRS score of 3 or 4; and none had an mRS score of 5 at discharge. CONCLUSIONS: This retrospective series showed good procedural safety, feasibility, and stability of midterm occlusion in ruptured wide-neck bifurcation aneurysms.

The impact of interventional neuroradiology on service in a neurosurgical unit.

Endovascular treatment of cerebral aneurysms has rapidly evolved and has transformed neurosurgical practice. We evaluated the influence of an interventional neuroradiology service on cerebral aneurysm management. We performed a retrospective analysis of all aneurysms treated in our unit before and after the establishment of endovascular treatment. All patients (n = 248: 78M: 170F aged 10-78 years) who underwent aneurysm treatment between 1996 and 1999 were included in the analysis. Length of in-patient stay on neurosurgical ward, GOS at 6-month follow-up and complications of treatment were the factors chosen for the analysis. Definitive treatment was attempted in 306 of 374 aneurysms detected (203 surgical and 103 endovascular). During the last 2 years of the study period, 46% of all aneurysms were coiled. Endovascular treatment of ruptured aneurysms tended to be sooner than surgery, but in-patient stay following treatment was the same. No significant difference in GOS at 6-month follow-up was found (chi2 = 0.18). Coiling of unruptured aneurysms reduced in-patient stay when compared with surgery (t-test, p < 0.001), fewer complications occurred, but no difference in outcome was seen at follow up (chi2 = 1.09). Our data suggest that the long-term morbidity following subarachnoid haemorrhage is not related to treatment modality. Coiling is the preferred treatment for unruptured aneurysms. The GOS is insensitive to the detection of the perceived benefits of coiling. The increasing role of interventional neuroradiology has direct effects on many aspects of neurosurgical practice.

The impact of interventional neuroradiology on neurosurgical training.

Aneurysmal subarachnoid haemorrhage carries a high mortality and morbidity. Surgical treatment (craniotomy and clipping of the aneurysm) has been, until recently, the gold standard treatment. Endovascular embolisation treatment has rapidly evolved and the evidence available suggests that the results are as good as surgery. Endovascular treatment successfully occludes the aneurysm to prevent re-haemorrhage, whilst reducing the procedural morbidity when compared to craniotomy and clipping. It is perceived to be of particular benefit for aneurysms in the posterior cerebral circulation where operative morbidity and mortality are significantly higher than for aneurysms on the anterior circle of Willis. The establishment of endovascular treatment has reduced the number of cases being treated surgically, and this has had a significant effect on surgical training. We analysed the management of all ruptured aneurysms treated in our unit over a 4-year period. During the same period, an endovascular service was established in the unit. We devised a novel system for the angiographic grading of aneurysms in order to evaluate the impact that coiling has had on surgical training. The results show that as few as four aneurysms per year would be appropriate for specialist registrars to operate upon. We propose some mechanisms for maintaining high quality surgical training.

Hydrocephalus: comparison of clipping and embolization in aneurysm treatment.

OBJECT: In this retrospective study conducted at Atkinson Morley's Hospital and Middlesbrough General Hospital, the authors analyzed 100 matched patients who had suffered subarachnoid hemorrhage (SAH) to determine whether the technical procedure by which aneurysms are treated affects the development of chronic hydrocephalus. METHODS: Four hundred seventy-five patients presented with SAH between 1995 and 1998. Exclusion criteria included posterior circulation aneurysms, multiple aneurysms, electively clipped or embolized aneurysms, angiographically undetected SAH, patients who died within 1 month of neurosurgical intervention, and patients with the same aneurysm location but a different Fisher grade. The authors matched 50 patients who underwent embolization of their aneurysms with another 50 who had similar Fisher grades and aneurysm types and underwent clipping of their aneurysms. The maximum incidence of ruptured aneurysms occurred in patients who were between 41 and 60 years of age, with women preponderant in both study groups. In each group, 27 patients had anterior communicating artery aneurysm, 13 had posterior communicating artery aneurysm, seven had middle cerebral artery aneurysm, and three had internal carotid artery aneurysm. The lesions in three patients in each group were Fisher Grade I, in 23 patients they were Fisher Grade II, in 14 they were Fisher Grade III, and 10 patients had Fisher Grade IV SAH. Nine patients among those with clipped aneurysms and eight of the patients who underwent embolization had hydrocephalus for which they needed intervention. These interventions included lumbar puncture, ventricular drainage, and ventriculoperitoneal (VP) shunt placement; three patients in each group needed VP shunt placement. CONCLUSIONS: The technical procedure used to treat aneurysms, whether clipping or embolization, does not significantly affect the development of chronic hydrocephalus. However, a larger sample of patients is needed for accurate comparisons and stronger conclusions.

Ectasia of arteries beyond the circle of Willis.

Isolated fusiform ectasia involving branches of the carotid and vertebral arteries is very rare, only two cases have been recorded. Recently we have encountered two cases affecting the right posterior and left middle cerebral arteries. Both patients were young and there was no evidence of acquired arterial pathology. It is considered likely that the condition is a local congenital abnormality which may be related to an abnormality of the elastic substance in the arterial wall. In the first case, a selective injection of the right posterior cerebral artery clarified the nature of the lesion and provided an example of the value of the relatively new superselective technique.

CT findings in orbital tumours of nerve sheath origin.

The clinical and CT features of orbital nerve sheath tumours (13 neurofibromas and 17 neurilemmomas, including one malignant neurilemmoma) have been reviewed. The commonest clinical findings were proptosis, mild impairment of visual acuity and disorders of eye movements. No significant correlation with intra- or extraconal location and these symptoms was found. The two types of tumour were morphologically similar, most being smooth retrobulbar masses, elongated in the long axis of the orbit; lobulation was slightly more common with neurofibromas. The neurilemmomas were generally larger than the neurofibromas. The distribution of neurilemmomas in the retrobulbar space, and in its intra- and extraconal compartments appeared random, but most neurofibromas occurred in the upper orbit and three quarters lay extraconally. The apex of the orbit was seen to be clear of tumour in all intraconal neoplasms (except the one case of malignant neurilemmoma); this observation may be useful in differentiation from intrinsic optic nerve tumours and pseudotumour. Focal or generalised enlargement of the bony orbit was common, being seen in four-fifths of neurilemmomas and three-quarters of neurofibromas. Tumour density was homogeneous for all the neurilemmomas and in the majority of neurofibromas: attenuation coefficients were slightly higher for the neurofibromas. Subcutaneous extension was more common in neurofibromas, occurring in approximately one third of cases but was observed in about a tenth of the neurilemmomas. Enhancement with intravenous contrast medium was variable; contrast medium was helpful in showing intracranial extension. Although the CT findings did not allow unequivocal presurgical diagnosis, they were suggestive in many cases and facilitated biopsy.

A simple system for image directed stereotaxis.

A simple system for CT directed stereotaxis has been developed. This technique represents a true three-dimensional solution to the problems of CT stereotaxis and is therefore free of positional constraints relating to the orientation of the patient/stereotactic instrument/CT scan plane, but is not dependent on the relatively complicated mathematical methods required by existing techniques. The preliminary series of 17 procedures are presented, 13 of these were designed to obtain tissue diagnosis. One patient had effective stereotactic aspiration of a colloid cyst of the third ventricle. The stereotactic instrument itself is lightweight and easy to use, a wide range of target trajectories including low sites are possible. The design of this instrument would be particularly well suited for MR directed stereotaxis.

Feasibility of 105-cm flexible sigmoidoscopy in family practice.

The 105-cm flexible sigmoidoscope was studied for the feasibility of its use in a family practice setting in screening for colorectal cancers and polyps. A total of 49 examinations were performed. The average length of colon examined was 71 cm. Insertion to 105 cm was accomplished in 14 patients (29 percent) and exceeded 65 cm in 28 patients (57 percent). No complications of the procedure were encountered. The study indicated that some patients, with no special preparation or medications and no additional discomfort, might benefit by the more thorough screening afforded by 105-cm flexible sigmoidoscope. What is not yet known is the efficacy of large-scale screening for cancers and polyps utilizing the 105-cm flexible sigmoidoscope in the family practice setting.

Development of an analogue method to link stereotactic surgery to computed tomography.

The mathematical problems involved in linking computed tomography with stereotactic surgery are complicated. The use of an analogue has provided a simple, precise solution to the problems and gives the neurosurgeon a clearer understanding of the complexities of stereotactic target location. The feasibility and accuracy of this technique has been demonstrated in preclinical trials. A prototype stereotactic instrument compatible with any CT scanner has been suggested and used in the preclinical trials. The analogue method of linking computed tomography and stereotactic surgery requires no modification of the CT scanner.