Complex intracranial aneurysms: a DELPHI study to define associated characteristics.

PURPOSE: Intracranial aneurysms present significant health risks, as their rupture leads to subarachnoid haemorrhage, which in turn has high morbidity and mortality rates. There are several elements affecting the complexity of an intracranial aneurysm. However, criteria for defining a complex intracranial aneurysm (CIA) in open surgery and endovascular treatment could differ, and actually there is no consensus on the definition of a "complex" aneurysm. This DELPHI study aims to assess consensus on variables defining a CIA. METHODS: An international panel of 50 members, representing various specialties, was recruited to define CIAs through a three-round Delphi process. The panelists participated in surveys with Likert scale responses and open-ended questions. Consensus criteria were established to determine CIA variables, and statistical analysis evaluated consensus and stability. RESULTS: In open surgery, CIAs were defined by fusiform or blister-like shape, dissecting aetiology, giant size (≥ 25 mm), broad neck encasing parent arteries, extensive neck surface, wall calcification, intraluminal thrombus, collateral branch from the sac, location (AICA, SCA, basilar), vasospasm context, and planned bypass (EC-IC or IC-IC). For endovascular treatment, CIAs included giant size, very wide neck (dome/neck ratio ≤ 1:1), and collateral branch from the sac. CONCLUSIONS: The definition of aneurysm complexity varies by treatment modality. Since elements related to complexity differ between open surgery and endovascular treatment, these consensus criteria of CIAs could even guide in selecting the best treatment approach.

Efficacy of transnasal endoscopic resection for malignant anterior skull-base tumors.

BACKGROUND: Craniofacial resection (CFR) has been the standard of care for malignant tumors of the anterior skull base (ASB). However, during the past 2 decades, transnasal endoscopic resection (TER) has gained significant popularity. The purpose of this study is to compare CFR and TER with respect to perioperative and oncologic outcomes. METHODS: Retrospective analysis at a tertiary care medical center of 82 consecutive patients undergoing resection of tumors of the ASB between 1997 and 2011. RESULTS: Thirty-four patients underwent TER, while 48 patients underwent CFR. There was no statistical difference in major complications between the two groups (p = 0.29). However, TER patients had shorter operating room times (284 minutes for TER, 620 minutes for CFR; p < 0.001), lower intraoperative blood loss (675 mL for TER, 1000 mL for CFR; p = 0.005), shorter intensive care unit (ICU) stays (0 days for TER, 3 days for CFR; p < 0.001), and shorter hospital stays (4.5 days for TER; 7 days for CFR; p < 0.001). There were no differences for the rates of en bloc resection, negative margins, or disease-specific mortality. Subanalysis yielded a median follow-up of 5 years postoperatively. There were no differences in disease-specific mortality or recurrences in this group. CONCLUSION: Patients undergoing TER for tumors of the ASB are more likely to leave the ICU and the hospital earlier than their CFR counterparts. Furthermore, for carefully selected patients undergoing TER, excellent oncologic outcomes with survival and recurrence rates similar to patients undergoing CFR may be achieved. Comparison of oncologic outcomes, however, may be limited by discrepancy in histologic grade and clinical stage between the two groups. Nonetheless, TER seems to be an excellent alternative to CFR in appropriately selected patients.