G Model
ARTICLE IN PRESS
NEUCHI-659; No. of Pages 5
Neurochirurgie xxx (2014) xxx–xxx
Disponible en ligne sur
ScienceDirect www.sciencedirect.com
Original article
Multidisciplinary management of intracranial aneurysms: The experience of Lille university hospital center Prise en charge multidisciplinaire des anévrismes intracrâniens : l’expérience du CHU de Lille R. Aboukais a,∗ , F. Zairi a , L. Thines a , P. Aguettaz b , X. Leclerc b , J.-P. Lejeune a a b
Department of neurosurgery, Lille university hospital, rue E.-Laine, 59037 Lille cedex, France Department of neuroradiology, Lille university hospital, rue E.-Laine, 59037 Lille cedex, France
a r t i c l e
i n f o
Article history: Received 15 October 2013 Received in revised form 22 March 2014 Accepted 29 June 2014 Available online xxx Keywords: Aneurysm Microsurgery Clipping Endovascular
a b s t r a c t Background. – In recent years, the multidisciplinary approach has become an important concern for the management of intracranial aneurysms. Objective. – This study aims to evaluate the functional outcomes of patients treated for an intracranial aneurysm (ruptured or unruptured), when the treatment modality was defined in a multidisciplinary fashion. Materials and methods. – In this retrospective study, we included all patients (n = 209) treated for an intracranial saccular aneurysm at Lille university hospital between January 2009 and December 2009. There were 70 men and 139 women with a mean age of 50.5 years (range 24 to 73 years). The clinical data were recorded before treatment including the American Society of Anesthesiology (ASA) and the World Federation of Neurosurgical Societies (WFNS) scores. Microsurgical approach was performed in 110 patients whereas 99 patients underwent an endovascular procedure. A modified Rankin Scale (mRS) was reported at 3 months after treatment. Intracranial vascular imaging was performed before and immediately after the treatment and then renewed at 3 years in all patients to detect any recurrence. Results. – Among the 121 patients with ruptured aneurysm, the functional outcomes were similar between patients who underwent microsurgery and patients who had an endovascular treatment. In the 88 patients with an unruptured aneurysm, functional outcomes were also similar between the two treatment modalities. Among the 99 patients treated by the endovascular approach, 4 had a significant aneurysm reopening on follow-up imaging leading to additional treatment (3 clipping, 1 coiling). No aneurysm recurrence was reported among the 110 patients who underwent microsurgical treatment. Conclusion. – In a trained team, the multidisciplinary approach appears to be a valuable strategy in the management of intracranial aneurysms, to achieve good functional outcomes. © 2014 Elsevier Masson SAS. All rights reserved.
r é s u m é Mots clés : Anévrisme Microchirurgie Clippage Endovasculaire
Contexte. – Au cours des dernières années, l’approche multidisciplinaire est devenue une préoccupation importante pour la gestion des anévrismes intracrâniens. Objectif. – Cette étude vise à évaluer les résultats fonctionnels des patients traités pour un anévrisme intracrânien (rompu ou non rompu), lorsque la modalité de traitement a été définie de fac¸on multidisciplinaire. Patients et méthodes. – Dans cette étude rétrospective, nous avons inclus tous les patients (n = 209) traités pour un anévrisme sacculaire intracrânien au CHU de Lille de janvier 2009 à décembre 2009. Il y avait 70 hommes et 139 femmes avec un âge moyen de 50,5 ans (extrêmes : 24–73 ans). Les données cliniques ont été recueillies avant le traitement, dont les scores ASA (American Society of Anesthesiology) et de
∗ Corresponding author. E-mail address: [email protected] (R. Aboukais). http://dx.doi.org/10.1016/j.neuchi.2014.06.010 0028-3770/© 2014 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Aboukais R, et al. Multidisciplinary management of intracranial aneurysms: The experience of Lille university hospital center. Neurochirurgie (2014), http://dx.doi.org/10.1016/j.neuchi.2014.06.010
G Model NEUCHI-659; No. of Pages 5
ARTICLE IN PRESS R. Aboukais et al. / Neurochirurgie xxx (2014) xxx–xxx
2
la WFNS (World Federation of Neurosurgical Societies). Une exclusion microchirurgicale a été réalisée chez 110 patients alors que 99 patients ont bénéficié d’une procédure endovasculaire. L’échelle de Rankin modifiée (mRS) a été utilisée pour évaluer le statut fonctionnel à 3 mois après le traitement. Une imagerie vasculaire intracrânienne a été réalisée avant et immédiatement après le traitement, puis renouvelée à 3 ans chez tous les patients pour détecter toute récurrence. Résultats. – Parmi les 121 patients avec un anévrisme rompu, les résultats fonctionnels étaient similaires entre les patients qui ont eu un traitement microchirurgical et ceux qui ont eu un traitement endovasculaire. Parmi les 88 patients présentant un anévrisme non rompu, les résultats fonctionnels étaient également similaires pour les deux modalités de traitement. Au total, parmi les 99 patients traités par voie endovasculaire, 4 patients ont présenté une recanalisation sur l’imagerie de suivi conduisant à un traitement complémentaire (3 par microchirurgie, 1 par embolisation). Il n’a pas été noté de recanalisation parmi les 110 patients qui ont bénéficié d’un traitement par microchirurgie. Conclusion. – Dans une équipe entraînée, l’approche multidisciplinaire semble être une stratégie utile dans la gestion des anévrismes intracrâniens, pour optimiser le résultat fonctionnel. © 2014 Elsevier Masson SAS. Tous droits réservés.
1. Introduction In France, the incidence of aneurysmal subarachnoid hemorrhage (aSAH) is estimated to be 7/100,000 a year [1]. Many studies have shown that endovascular coiling and microsurgical clipping are 2 valuable treatment options [2–4]. The ISAT study, which was a prospective randomized trial, demonstrated that endovascular treatment should be preferred when the 2 options were feasible [5–7]. However, each treatment option has its own limitations [5–7]. Therefore, many clinical and anatomical criteria must be considered in order to define the optimal treatment for each patient. This multimodal evaluation requires a truly multidisciplinary approach, for best patient care. For this reason, many teams have defended the importance of the multidisciplinary management of intracranial aneurysms [8–14]. This multidisciplinary management is also valuable for unruptured intracranial aneurysms [15–17], with a prevalence estimated at 3.2% [18]. The aim of this study was to evaluate the functional outcomes of patients treated for an intracranial aneurysm (ruptured or unruptured), whatever the treatment modality when defined in a multidisciplinary fashion..
treatment and at 3 years. A conventional cerebral angiography after treatment was preferred in cases of complex aneurysm requiring multiple clips. The operated patients with a ruptured aneurysm underwent a CT angiography before treatment and a conventional angiography immediately after treatment to detect other aneurysms not observed on the CT angiography. A CT angiography was performed at 3 years. Radiological data were collected by studying the medical records. Radiological records were reviewed by the neuroradiologist for all patients who presented a recanalization. They were classified using the classification of Raymond et al. [22]. 2.3. Data analysis For statistical data analysis, the “paired samples t-test” was used for normally distributed data. For non-numerical data, the Chi2 test was used to compare the group of the operated patients to the group of the patients who had endovascular treatment. A P value < 0.05 was considered statistically significant. The analyses were performed using the SPSS statistical software, version 17 (SPSS Inc.).
2. Materials and methods 3. Results 2.1. Data collection/inclusion criteria 3.1. Population Using the hospital database, we studied the medical records of all patients admitted to our institution for the management of ruptured or unruptured intracranial aneurysm between January 2009 and December 2009 (n = 219). We excluded all patients who died before the treatment of their aneurysm (n = 5). All patients who harbored a fusiform, large (> 20 mm) or giant aneurysm (n = 5) were also excluded. 2.2. Clinical and radiological follow-up Among clinical data, the American Society of Anesthesiologists score [19] (ASA) and the World Federation of Neurosurgical Societies score [20] (WFNS) were recorded before treatment and all patients were re-evaluated 3 months after treatment using a modified Rankin Scale [21] (mRS). All patients who underwent endovascular treatment had a conventional cerebral angiography before treatment, and at the end of the procedure. Then, magnetic resonance angiography (MRA) was performed at 6 months, 18 months and 3 years after treatment. In surgically treated patients with an unruptured aneurysm, a conventional cerebral angiography was performed before treatment. In case of simple exclusion of the aneurysm using a single clip, cerebral computed tomography angiography (CT angiography) was performed immediately after
A total of 209 patients were included in this study and no patient was lost to follow-up. There were 70 men and 139 women with a mean age of 50.5 years (range 24 to 73 years; SD = 7.7). The treatment was an endovascular procedure for 99 patients and microsurgical approach for 110 patients. Fifty-six patients (27%) had multiple intracranial aneurysms. The patients with middle cerebral artery (MCA) aneurysms underwent, in most cases, microsurgery, whereas the patients with vertebro-basilar aneurysms had endovascular treatment (Tables 1A and 1B). 3.2. Patients with unruptured aneurysms There were 62 women and 26 men (sex ratio = 2.4). The mean age at diagnosis was 51 years for both the operated patients (n = 52) and patients who underwent endovascular treatment (n = 36). The ASA score was statistically comparable between the two groups. The mRS score, 3 months after the treatment, was also comparable between both groups. There were no deaths or no neurological impairments at 3 months. All patients were mRS 0–2. Only 13% of patients reported minor disorders such as memory loss and concentration problems, which have not required further investigations and treatments. After 3 years, 9 reopened aneurysms (25%) after
Please cite this article in press as: Aboukais R, et al. Multidisciplinary management of intracranial aneurysms: The experience of Lille university hospital center. Neurochirurgie (2014), http://dx.doi.org/10.1016/j.neuchi.2014.06.010
G Model
ARTICLE IN PRESS
NEUCHI-659; No. of Pages 5
R. Aboukais et al. / Neurochirurgie xxx (2014) xxx–xxx
Fig. 1. Initial neurological status of patients with treated ruptured aneurysms. État neurologique initial des patients traités d’un anévrisme rompu.
embolization were identified (4 Raymond 1; 4 Raymond 2a and 1 Raymond 3), only one patient required a further treatment by microsurgery procedure. No recanalization was recorded on the angiographic CT scan performed at 3 years after the microsurgical treatment. 3.3. Patients with ruptured aneurysms There were 76 women and 45 men (sex ratio = 1.7). The mean age at the time of diagnosis was 50 years for both patients surgically treated (n = 58) and patients who underwent endovascular treatment (n = 63). The pre-therapeutic clinical status including ASA and WFNS scores, was statistically similar between the two groups (Fig. 1). The mRS score at 3 months (Fig. 2) showed no significant difference between the two groups. Ninety-five patients (78.5%) were mRS 0–2, and only 3 of them were shunt dependant.
Fig. 2. Functional outcome (RMS) at 3 months of patients with treated ruptured aneurysms. Devenir fonctionnel (mRS) à 3 mois des patients traités d’un anévrisme rompu.
Twenty-six patients (21.5%) were mRS 3–6 and 9 of them were shunt dependant. Ischemia was considered to be the main cause of unfavourable outcomes in 22 patients. Among them, nine patients died (mRS 6). The cause of death was directly related to SAH in 6 patients (5 with severe cerebral vasospasm and 1 with rebleeding) and to multi-organ failure in 3 patients. Over 3 years, 13 aneurysmal recurrences were observed after endovascular treatment (8 Raymond 1; 1 Raymond 2a; 2 Raymond 2b and 2 Raymond 3) including 3 that required treatment by microsurgery and 1 an additional endovascular procedure. No recanalization was recorded on the angiographic CT scan performed at 3 years after the microsurgical treatment. Regarding shunt dependence, no difference (P = 0.17) was observed between endovascular treatment (n = 8) and microsurgery (n = 4). 3.4. Complementarity between microsurgery and endovascular treatment
Table 1A Location of treated ruptured aneurysms. Localisation des anévrismes rompus traités.
Paraclinoid Posterior wall ICA ICA bifurcation ACoA Pericallosa aneurysm MCA PICA Basilar artery
3
Microsurgery
Endovascular
0 6 1 17 1 32 1 0
1 13 2 35 2 1 2 7
Among the 209 treated patients, endovascular treatment was unsuccessful in 4 cases and patients were operated on. One patient had a residual aneurysm after surgery that required endovascular occlusion by coils. Three patients treated by endovascular coiling harboured a reopened aneurysm that required microsurgery. At the long-term follow-up, aneurysm recurrence was observed in 3 patients after endovascular treatment that required further microsurgical treatment. 4. Discussion
Table 1B Location of treated unruptured aneurysms. Localisation des anévrismes non rompus traités.
Paraclinoid Posterior wall ICA ICA bifurcation ACoA Pericallosa aneurysm MCA PICA Basilar artery
Microsurgery
Endovascular
2 8 3 10 1 24 1 0
12 5 2 5 1 2 0 7
In our study, the functional outcome was comparable between the operated patients and the patients who underwent endovascular treatment when a collegial decision was taken. 4.1. Population As reported in other series, women were the predominant gender with a mean age of 50 years [19,20]. Aneurysms located in the anterior circulation were more frequent, especially in the anterior communicating complex [21]. The rate of patients with multiple aneurysms was comparable to recent studies in the literature [23],
Please cite this article in press as: Aboukais R, et al. Multidisciplinary management of intracranial aneurysms: The experience of Lille university hospital center. Neurochirurgie (2014), http://dx.doi.org/10.1016/j.neuchi.2014.06.010
G Model NEUCHI-659; No. of Pages 5
ARTICLE IN PRESS R. Aboukais et al. / Neurochirurgie xxx (2014) xxx–xxx
4
but higher than previous studies, probably because of a greater sensitivity of angiography using three-dimensional reconstruction of the vascular architecture. 4.2. Choice of treatment The choice of treatment was discussed for each patient during a multidisciplinary meeting according to their clinical status and the angio-architecture of the aneurysm. Each therapeutic procedure has its limitations. Since ISAT [1], it is recognized that endovascular treatment is less invasive than microsurgery and it is the reason why we first chose endovascular treatment, if it was feasible [24]. Endovascular treatment is also more effective than microsurgery for elderly patients with basilar artery aneurysms. Microsurgery is known to be more effective than endovascular treatment for aneurysms with a high “neck diameter” to “sac diameter” ratio. Microsurgery is also more effective if the aneurysmal sac is oriented in the axis of the arterial blood flow or if the aneurysm is located on a cerebral dysplastic bifurcation [25], because it may allow, during the same procedure, a vascular reconstruction. Patients were assigned to surgery according to their medical history, clinical status, aneurysm characteristics (wide neck, arteries branched to the neck, “small” size, associated aneurysm accessible throw the same surgical approach) or unsuccessful for endovascular treatment. The main objective is of course to protect the patient from any bleeding. Using a multidisciplinary approach, half of the patients underwent microsurgical treatment and the other half endovascular procedure at our institution. By consulting the ratio “microsurgery/endovascular treatment” of the major European and American hospital centres specialized in the treatment of intracranial aneurysms, we found a similar ratio between these two treatments [1,26]. Whatever the treatment was, the follow-up is obligatory using MRA after endovascular treatment and angiography CT after microsurgery. 4.3. Functional outcome of the patients after multidisciplinary discussion After discussion, the functional outcome was similar between patients who underwent microsurgery and those who had endovascular treatment. This result was found in the group of patients with ruptured aneurysms as well as in the group of patients with unruptured aneurysms. In patient group with unruptured aneurysms, all patients had a mRS score at 3 months under 2. There were no deaths and only 13% of patients had minor cognitive disorders like moderate anterograde memory impairment which did not prevent the resumption of work and activities. These results are consistent with several studies on series of patients with unruptured aneurysms [27,28]. Concerning the patient group with SAH, the medical treatment was similar in all patients. They were hospitalized in the same neurosurgical ICU [29] and managed by the same team of intensivists, neurosurgeons and neuroradiologists. These data explain, in part, the similarity of the clinical outcome of patients operated or embolized. The medical management of their disease was also comparable [30]. Nine patients died due the SAH. Among them, 5 died from severe vasospasm after endovascular treatment in 4 and after microsurgery in 1. Nevertheless, the incidence of vasospasm has been reported to be similar between both treatments [31,32]. We also noted that the mRS score was close to the initial clinical condition, i.e. the WFNS score of the patient. The more severe the initial neurological status, the worse is the functional outcome. According to our study, with a multidisciplinary decision, the type of therapeutic procedure does not seem to interfere with the functional outcome of patients. Despite the various locations of intracranial aneurysms in the present study that differed
between clipped and coiled aneurysms, we showed that the clinical condition of patients was similar. Aneurysm location data were taken into account in the choice of treatment. The aim was to evaluate the relevance of the collegial decision on the outcome of patients with intracranial aneurysm. The goal of the treatment is to prevent bleeding or rebleeding, involving in a major way the vital and functional prognosis of the patient and also reduce the possible risk of remote recanalization as much as possible. 4.4. Angiographic outcome Of the 99 embolized patients, we noted 18 minor recanalizations requiring no further treatment and 4 significant recanalizations leading to additional treatment in 2010 and 2011 (3 by surgery and 1 by new embolization). As in several series, the occurrence of post-embolization recanalization was more frequent in the group of patients with ruptured aneurysms [33,34]. The rate of late recanalization after embolization seems to be comparable to other large series reported in the literature [35,36]. Of the 110 operated patients, we recorded no recanalization on the angiographic CT scan performed at 3 years after the microsurgical treatment. Microsurgery is known to have less recanalization after treatment [37]. Endovascular procedure can complete the procedure of a residual aneurysm after clipping and microsurgery can be used for recanalization after embolization [38]. Complementarity between neuroradiologists and neurosurgeons do not lie only on the initial decision of treatment but also in the late follow-up of patients with intracranial arterial aneurysm [39,40]. 4.5. Limitations Although, a number of radiological criteria regarding bleeding severity and aneurysm morphology are important concerns for treatment decision, they have not been all recorded. The retrospective nature of the study was also an important limitation. 5. Conclusion Multidisciplinary discussion is essential in the management of patients with intracranial ruptured or unruptured aneurysm. The goal is to obtain optimal occlusion of the aneurysmal sac, the most sustainable, with less risk of morbidity/mortality for the patient. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet 2005;366:809–17. [2] Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, et al. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 2002;360:1267–74. [3] Molyneux AJ, Kerr RS, Birks J, Ramzi N, Yarnold J, Sneade M, et al. Risk of recurrent subarachnoid haemorrhage, death, or dependence and standardised mortality ratios after clipping or coiling of an intracranial aneurysm in the International Subarachnoid Aneurysm Trial (ISAT): long-term follow-up. Lancet Neurol 2009;8:427–33. [4] Wiebers D. Unruptured intracranial aneurysms: risk of rupture and risks of surgical intervention. International Study of Unruptured Intracranial Aneurysms Investigators. N Engl J Med 1998;339:1725–33. [5] Wiebers DO, Whisnant JP, Huston 3rd J, Meissner I, Brown Jr RD, Piepgras DG, et al. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 2003;362:103–10.
Please cite this article in press as: Aboukais R, et al. Multidisciplinary management of intracranial aneurysms: The experience of Lille university hospital center. Neurochirurgie (2014), http://dx.doi.org/10.1016/j.neuchi.2014.06.010
G Model NEUCHI-659; No. of Pages 5
ARTICLE IN PRESS R. Aboukais et al. / Neurochirurgie xxx (2014) xxx–xxx
[6] Linn FH, Rinkel GJ, Algra A, van Gijn J. Incidence of subarachnoid hemorrhage: role of region, year, and rate of computed tomography: a meta-analysis. Stroke 1996;27:625–9. [7] Vlak MH, Algra A, Brandenburg R, Rinkel GJ. Prevalence of unruptured intracranial aneurysms, with emphasis on sex, age, comorbidity, country, and time period: a systematic review and meta-analysis. Lancet Neurol 2011;10:626–36. [8] Lanterna LA, Tredici G, Dimitrov BD, Biroli F. Treatment of unruptured cerebral aneurysms by embolization with guglielmi detachable coils: case-fatality, morbidity, and effectiveness in preventing bleeding: a systematic review of the literature. Neurosurgery 2004;55:767–75 [discussion 75–8]. [9] Andaluz N, Zuccarello M. Treatment strategies for complex intracranial aneurysms: review of a 12-year experience at the university of cincinnati. Skull Base 2011;21:233–42. [10] Ingelmo Ingelmo I, Fabregas Julia N, Rama-Maceiras P, Hernandez-Palazon J, Rubio Romero R, Carmona Aurioles J. [Subarachnoid hemorrhage: epidemiology, social impact and a multidisciplinary approach]. Rev Esp Anestesiol Reanim 2010;57(Suppl. 2):S4–15. [11] Kim YB, Lee JW, Huh SK, Kim BM, Kim DJ. Outcomes of multidisciplinary treatment for posterior cerebral artery aneurysms. Clin Neurol Neurosurg 2013;115:2062–8. [12] Mpotsaris A, Loehr C, Harati A, Lohmann F, Puchner M, Weber W. Interdisciplinary clinical management of high grade arteriovenous malformations and ruptured flow-related aneurysms in the posterior fossa. Interv Neuroradiol 2010;16:400–8. [13] Proust F, Gerardin E, Derrey S, Lesveque S, Ramos S, Langlois O, et al. Interdisciplinary treatment of ruptured cerebral aneurysms in elderly patients. J Neurosurg 2010;112:1200–7. [14] Sherif C, Gruber A, Dorfer C, Bavinzski G, Standhardt H, Knosp E. Ruptured carotid artery aneurysms of the ophthalmic (C6) segment: clinical and angiographic long-term follow-up of a multidisciplinary management strategy. J Neurol Neurosurg Psychiatry 2009;80:1261–7. [15] Uhl E, Zausinger S, Morhard D, Heigl T, Scheder B, Rachinger W, et al. Intraoperative computed tomography with integrated navigation system in a multidisciplinary operating suite. Neurosurgery 2009;64:231–9 [discussion 9–40]. [16] Sidi A, Lobato EB, Cohen JA. The American Society of Anesthesiologists’ Physical Status: category V revisited. J Clin Anesth 2000;12:328–34. [17] Lagares A, Alen JF, Gomez PA, Lobato RD. Re: Grading of subarachnoid hemorrhage: modification of the World Federation of Neurosurgical Societies scale on the basis of data for a large series of patients. Neurosurgery 2005;56:E629 [author reply E]. [18] Rankin J. Cerebral vascular accidents in patients over the age of 60. II. Prognosis. Scott Med J 1957;2:200–15. [19] Ghods AJ, Lopes D, Chen M. Gender differences in cerebral aneurysm location. Front Neurol 2012;3:78. [20] Clarke G, Mendelow AD, Mitchell P. Predicting the risk of rupture of intracranial aneurysms based on anatomical location. Acta Neurochir Suppl 2005;147:259–63 [discussion 63]. [21] Mira JM, Costa FA, Horta BL, Fabiao OM. Risk of rupture in unruptured anterior communicating artery aneurysms: meta-analysis of natural history studies. Surg Neurol 2006;66(Suppl. 3):S12–9 [discussion S9]. [22] Raymond J, Guilbert F, Weill A, Georganos SA, Juravsky L, Lambert A, et al. Long-term angiographic recurrences after selective endovascular treatment of aneurysms with detachable coils. Stroke 2003;34:1398–403. [23] Inagawa T. Incidence and risk factors for multiple intracranial saccular aneurysms in patients with subarachnoid hemorrhage in Izumo City, Japan. Acta Neurochir Suppl 2009;151:1623–30.
5
[24] van der Schaaf I, Algra A, Wermer M, Molyneux A, Clarke M, van Gijn J, et al. Endovascular coiling versus neurosurgical clipping for patients with aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev 2005;(4):CD003085. [25] Regli L, Dehdashti AR, Uske A, de Tribolet N. Endovascular coiling compared with surgical clipping for the treatment of unruptured middle cerebral artery aneurysms: an update. Acta Neurochir Suppl 2002;82:41–6. [26] Dorhout Mees SM, Molyneux AJ, Kerr RS, Algra A, Rinkel GJ. Timing of aneurysm treatment after subarachnoid hemorrhage: relationship with delayed cerebral ischemia and poor outcome. Stroke 2012;43:2126–9. [27] Seifert V, Gerlach R, Raabe A, Guresir E, Beck J, Szelenyi A, et al. The interdisciplinary treatment of unruptured intracranial aneurysms. Deutsches Arzteblatt Int 2008;105:449–56. [28] Gerlach R, Beck J, Setzer M, Vatter H, Berkefeld J, Du Mesnil de Rochemont R, et al. Treatment related morbidity of unruptured intracranial aneurysms: results of a prospective single centre series with an interdisciplinary approach over a 6-year period (1999–2005). J Neurol Neurosurg Psychiatry 2007;78:864–71. [29] Wijdicks EF, Kallmes DF, Manno EM, Fulgham JR, Piepgras DG. Subarachnoid hemorrhage: neurointensive care and aneurysm repair. Mayo Clin Proc 2005;80:550–9. [30] Sztark F, Petitjean ME, Thicoipe M, Dabadie P. [Subarachnoid hemorrhage caused by aneurysm rupture. Initial management of patients]. Ann Fr Anesth Reanim 1996;15:322–7. [31] Hoh BL, Topcuoglu MA, Singhal AB, Pryor JC, Rabinov JD, Rordorf GA, et al. Effect of clipping, craniotomy, or intravascular coiling on cerebral vasospasm and patient outcome after aneurysmal subarachnoid hemorrhage. Neurosurgery 2004;55:779–86 [discussion 86–9]. [32] Rabinstein AA, Friedman JA, Nichols DA, Pichelmann MA, McClelland RL, Manno EM, et al. Predictors of outcome after endovascular treatment of cerebral vasospasm. AJNR Am J Neuroradiol 2004;25:1778–82. [33] Tan IY, Agid RF, Willinsky RA. Recanalization rates after endovascular coil embolization in a cohort of matched ruptured and unruptured cerebral aneurysms. Interv Neuroradiol 2011;17:27–35. [34] Nguyen TN, Hoh BL, Amin-Hanjani S, Pryor JC, Ogilvy CS. Comparison of ruptured vs. unruptured aneurysms in recanalization after coil embolization. Surg Neurol 2007;68:19–23. [35] Starke RM, Chalouhi N, Ali MS, Penn DL, Tjoumakaris SI, Jabbour PM, et al. Endovascular treatment of very small ruptured intracranial aneurysms: complications, occlusion rates and prediction of outcome. J Neurointerv Surg 2012;4(3):196–8, http://dx.doi.org/10.1136/neurintsurg-2011-010047 [Epub 2011 Jul 7]. [36] Lum C, Narayanam SB, Silva L, Shankar J, Bussiere M, Dos Santos MP, et al. Outcome in small aneurysms (< 4 mm) treated by endovascular coiling. J Neurointerventional Surg 2012;4:196–8. [37] Kaku Y, Watarai H, Kokuzawa J, Tanaka T, Andoh T. Cerebral aneurysms: conventional microsurgical technique and endovascular method. Surg Technol Int 2007;16:228–35. [38] Waldron JS, Halbach VV, Lawton MT. Microsurgical management of incompletely coiled and recurrent aneurysms: trends, techniques, and observations on coil extrusion. Neurosurgery 2009;64:301–15 [discussion 15–7]. [39] Lawton MT, Quinones-Hinojosa A, Sanai N, Malek JY, Dowd CF. Combined microsurgical and endovascular management of complex intracranial aneurysms. Neurosurgery 2008;62:1503–15. [40] Hacein-Bey L, Connolly Jr ES, Mayer SA, Young WL, Pile-Spellman J, Solomon RA. Complex intracranial aneurysms: combined operative and endovascular approaches. Neurosurgery 1998;43:1304–12 [discussion 12–3].
Please cite this article in press as: Aboukais R, et al. Multidisciplinary management of intracranial aneurysms: The experience of Lille university hospital center. Neurochirurgie (2014), http://dx.doi.org/10.1016/j.neuchi.2014.06.010
ARTICLE IN PRESS
NEUCHI-659; No. of Pages 5
Neurochirurgie xxx (2014) xxx–xxx
Disponible en ligne sur
ScienceDirect www.sciencedirect.com
Original article
Multidisciplinary management of intracranial aneurysms: The experience of Lille university hospital center Prise en charge multidisciplinaire des anévrismes intracrâniens : l’expérience du CHU de Lille R. Aboukais a,∗ , F. Zairi a , L. Thines a , P. Aguettaz b , X. Leclerc b , J.-P. Lejeune a a b
Department of neurosurgery, Lille university hospital, rue E.-Laine, 59037 Lille cedex, France Department of neuroradiology, Lille university hospital, rue E.-Laine, 59037 Lille cedex, France
a r t i c l e
i n f o
Article history: Received 15 October 2013 Received in revised form 22 March 2014 Accepted 29 June 2014 Available online xxx Keywords: Aneurysm Microsurgery Clipping Endovascular
a b s t r a c t Background. – In recent years, the multidisciplinary approach has become an important concern for the management of intracranial aneurysms. Objective. – This study aims to evaluate the functional outcomes of patients treated for an intracranial aneurysm (ruptured or unruptured), when the treatment modality was defined in a multidisciplinary fashion. Materials and methods. – In this retrospective study, we included all patients (n = 209) treated for an intracranial saccular aneurysm at Lille university hospital between January 2009 and December 2009. There were 70 men and 139 women with a mean age of 50.5 years (range 24 to 73 years). The clinical data were recorded before treatment including the American Society of Anesthesiology (ASA) and the World Federation of Neurosurgical Societies (WFNS) scores. Microsurgical approach was performed in 110 patients whereas 99 patients underwent an endovascular procedure. A modified Rankin Scale (mRS) was reported at 3 months after treatment. Intracranial vascular imaging was performed before and immediately after the treatment and then renewed at 3 years in all patients to detect any recurrence. Results. – Among the 121 patients with ruptured aneurysm, the functional outcomes were similar between patients who underwent microsurgery and patients who had an endovascular treatment. In the 88 patients with an unruptured aneurysm, functional outcomes were also similar between the two treatment modalities. Among the 99 patients treated by the endovascular approach, 4 had a significant aneurysm reopening on follow-up imaging leading to additional treatment (3 clipping, 1 coiling). No aneurysm recurrence was reported among the 110 patients who underwent microsurgical treatment. Conclusion. – In a trained team, the multidisciplinary approach appears to be a valuable strategy in the management of intracranial aneurysms, to achieve good functional outcomes. © 2014 Elsevier Masson SAS. All rights reserved.
r é s u m é Mots clés : Anévrisme Microchirurgie Clippage Endovasculaire
Contexte. – Au cours des dernières années, l’approche multidisciplinaire est devenue une préoccupation importante pour la gestion des anévrismes intracrâniens. Objectif. – Cette étude vise à évaluer les résultats fonctionnels des patients traités pour un anévrisme intracrânien (rompu ou non rompu), lorsque la modalité de traitement a été définie de fac¸on multidisciplinaire. Patients et méthodes. – Dans cette étude rétrospective, nous avons inclus tous les patients (n = 209) traités pour un anévrisme sacculaire intracrânien au CHU de Lille de janvier 2009 à décembre 2009. Il y avait 70 hommes et 139 femmes avec un âge moyen de 50,5 ans (extrêmes : 24–73 ans). Les données cliniques ont été recueillies avant le traitement, dont les scores ASA (American Society of Anesthesiology) et de
∗ Corresponding author. E-mail address: [email protected] (R. Aboukais). http://dx.doi.org/10.1016/j.neuchi.2014.06.010 0028-3770/© 2014 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Aboukais R, et al. Multidisciplinary management of intracranial aneurysms: The experience of Lille university hospital center. Neurochirurgie (2014), http://dx.doi.org/10.1016/j.neuchi.2014.06.010
G Model NEUCHI-659; No. of Pages 5
ARTICLE IN PRESS R. Aboukais et al. / Neurochirurgie xxx (2014) xxx–xxx
2
la WFNS (World Federation of Neurosurgical Societies). Une exclusion microchirurgicale a été réalisée chez 110 patients alors que 99 patients ont bénéficié d’une procédure endovasculaire. L’échelle de Rankin modifiée (mRS) a été utilisée pour évaluer le statut fonctionnel à 3 mois après le traitement. Une imagerie vasculaire intracrânienne a été réalisée avant et immédiatement après le traitement, puis renouvelée à 3 ans chez tous les patients pour détecter toute récurrence. Résultats. – Parmi les 121 patients avec un anévrisme rompu, les résultats fonctionnels étaient similaires entre les patients qui ont eu un traitement microchirurgical et ceux qui ont eu un traitement endovasculaire. Parmi les 88 patients présentant un anévrisme non rompu, les résultats fonctionnels étaient également similaires pour les deux modalités de traitement. Au total, parmi les 99 patients traités par voie endovasculaire, 4 patients ont présenté une recanalisation sur l’imagerie de suivi conduisant à un traitement complémentaire (3 par microchirurgie, 1 par embolisation). Il n’a pas été noté de recanalisation parmi les 110 patients qui ont bénéficié d’un traitement par microchirurgie. Conclusion. – Dans une équipe entraînée, l’approche multidisciplinaire semble être une stratégie utile dans la gestion des anévrismes intracrâniens, pour optimiser le résultat fonctionnel. © 2014 Elsevier Masson SAS. Tous droits réservés.
1. Introduction In France, the incidence of aneurysmal subarachnoid hemorrhage (aSAH) is estimated to be 7/100,000 a year [1]. Many studies have shown that endovascular coiling and microsurgical clipping are 2 valuable treatment options [2–4]. The ISAT study, which was a prospective randomized trial, demonstrated that endovascular treatment should be preferred when the 2 options were feasible [5–7]. However, each treatment option has its own limitations [5–7]. Therefore, many clinical and anatomical criteria must be considered in order to define the optimal treatment for each patient. This multimodal evaluation requires a truly multidisciplinary approach, for best patient care. For this reason, many teams have defended the importance of the multidisciplinary management of intracranial aneurysms [8–14]. This multidisciplinary management is also valuable for unruptured intracranial aneurysms [15–17], with a prevalence estimated at 3.2% [18]. The aim of this study was to evaluate the functional outcomes of patients treated for an intracranial aneurysm (ruptured or unruptured), whatever the treatment modality when defined in a multidisciplinary fashion..
treatment and at 3 years. A conventional cerebral angiography after treatment was preferred in cases of complex aneurysm requiring multiple clips. The operated patients with a ruptured aneurysm underwent a CT angiography before treatment and a conventional angiography immediately after treatment to detect other aneurysms not observed on the CT angiography. A CT angiography was performed at 3 years. Radiological data were collected by studying the medical records. Radiological records were reviewed by the neuroradiologist for all patients who presented a recanalization. They were classified using the classification of Raymond et al. [22]. 2.3. Data analysis For statistical data analysis, the “paired samples t-test” was used for normally distributed data. For non-numerical data, the Chi2 test was used to compare the group of the operated patients to the group of the patients who had endovascular treatment. A P value < 0.05 was considered statistically significant. The analyses were performed using the SPSS statistical software, version 17 (SPSS Inc.).
2. Materials and methods 3. Results 2.1. Data collection/inclusion criteria 3.1. Population Using the hospital database, we studied the medical records of all patients admitted to our institution for the management of ruptured or unruptured intracranial aneurysm between January 2009 and December 2009 (n = 219). We excluded all patients who died before the treatment of their aneurysm (n = 5). All patients who harbored a fusiform, large (> 20 mm) or giant aneurysm (n = 5) were also excluded. 2.2. Clinical and radiological follow-up Among clinical data, the American Society of Anesthesiologists score [19] (ASA) and the World Federation of Neurosurgical Societies score [20] (WFNS) were recorded before treatment and all patients were re-evaluated 3 months after treatment using a modified Rankin Scale [21] (mRS). All patients who underwent endovascular treatment had a conventional cerebral angiography before treatment, and at the end of the procedure. Then, magnetic resonance angiography (MRA) was performed at 6 months, 18 months and 3 years after treatment. In surgically treated patients with an unruptured aneurysm, a conventional cerebral angiography was performed before treatment. In case of simple exclusion of the aneurysm using a single clip, cerebral computed tomography angiography (CT angiography) was performed immediately after
A total of 209 patients were included in this study and no patient was lost to follow-up. There were 70 men and 139 women with a mean age of 50.5 years (range 24 to 73 years; SD = 7.7). The treatment was an endovascular procedure for 99 patients and microsurgical approach for 110 patients. Fifty-six patients (27%) had multiple intracranial aneurysms. The patients with middle cerebral artery (MCA) aneurysms underwent, in most cases, microsurgery, whereas the patients with vertebro-basilar aneurysms had endovascular treatment (Tables 1A and 1B). 3.2. Patients with unruptured aneurysms There were 62 women and 26 men (sex ratio = 2.4). The mean age at diagnosis was 51 years for both the operated patients (n = 52) and patients who underwent endovascular treatment (n = 36). The ASA score was statistically comparable between the two groups. The mRS score, 3 months after the treatment, was also comparable between both groups. There were no deaths or no neurological impairments at 3 months. All patients were mRS 0–2. Only 13% of patients reported minor disorders such as memory loss and concentration problems, which have not required further investigations and treatments. After 3 years, 9 reopened aneurysms (25%) after
Please cite this article in press as: Aboukais R, et al. Multidisciplinary management of intracranial aneurysms: The experience of Lille university hospital center. Neurochirurgie (2014), http://dx.doi.org/10.1016/j.neuchi.2014.06.010
G Model
ARTICLE IN PRESS
NEUCHI-659; No. of Pages 5
R. Aboukais et al. / Neurochirurgie xxx (2014) xxx–xxx
Fig. 1. Initial neurological status of patients with treated ruptured aneurysms. État neurologique initial des patients traités d’un anévrisme rompu.
embolization were identified (4 Raymond 1; 4 Raymond 2a and 1 Raymond 3), only one patient required a further treatment by microsurgery procedure. No recanalization was recorded on the angiographic CT scan performed at 3 years after the microsurgical treatment. 3.3. Patients with ruptured aneurysms There were 76 women and 45 men (sex ratio = 1.7). The mean age at the time of diagnosis was 50 years for both patients surgically treated (n = 58) and patients who underwent endovascular treatment (n = 63). The pre-therapeutic clinical status including ASA and WFNS scores, was statistically similar between the two groups (Fig. 1). The mRS score at 3 months (Fig. 2) showed no significant difference between the two groups. Ninety-five patients (78.5%) were mRS 0–2, and only 3 of them were shunt dependant.
Fig. 2. Functional outcome (RMS) at 3 months of patients with treated ruptured aneurysms. Devenir fonctionnel (mRS) à 3 mois des patients traités d’un anévrisme rompu.
Twenty-six patients (21.5%) were mRS 3–6 and 9 of them were shunt dependant. Ischemia was considered to be the main cause of unfavourable outcomes in 22 patients. Among them, nine patients died (mRS 6). The cause of death was directly related to SAH in 6 patients (5 with severe cerebral vasospasm and 1 with rebleeding) and to multi-organ failure in 3 patients. Over 3 years, 13 aneurysmal recurrences were observed after endovascular treatment (8 Raymond 1; 1 Raymond 2a; 2 Raymond 2b and 2 Raymond 3) including 3 that required treatment by microsurgery and 1 an additional endovascular procedure. No recanalization was recorded on the angiographic CT scan performed at 3 years after the microsurgical treatment. Regarding shunt dependence, no difference (P = 0.17) was observed between endovascular treatment (n = 8) and microsurgery (n = 4). 3.4. Complementarity between microsurgery and endovascular treatment
Table 1A Location of treated ruptured aneurysms. Localisation des anévrismes rompus traités.
Paraclinoid Posterior wall ICA ICA bifurcation ACoA Pericallosa aneurysm MCA PICA Basilar artery
3
Microsurgery
Endovascular
0 6 1 17 1 32 1 0
1 13 2 35 2 1 2 7
Among the 209 treated patients, endovascular treatment was unsuccessful in 4 cases and patients were operated on. One patient had a residual aneurysm after surgery that required endovascular occlusion by coils. Three patients treated by endovascular coiling harboured a reopened aneurysm that required microsurgery. At the long-term follow-up, aneurysm recurrence was observed in 3 patients after endovascular treatment that required further microsurgical treatment. 4. Discussion
Table 1B Location of treated unruptured aneurysms. Localisation des anévrismes non rompus traités.
Paraclinoid Posterior wall ICA ICA bifurcation ACoA Pericallosa aneurysm MCA PICA Basilar artery
Microsurgery
Endovascular
2 8 3 10 1 24 1 0
12 5 2 5 1 2 0 7
In our study, the functional outcome was comparable between the operated patients and the patients who underwent endovascular treatment when a collegial decision was taken. 4.1. Population As reported in other series, women were the predominant gender with a mean age of 50 years [19,20]. Aneurysms located in the anterior circulation were more frequent, especially in the anterior communicating complex [21]. The rate of patients with multiple aneurysms was comparable to recent studies in the literature [23],
Please cite this article in press as: Aboukais R, et al. Multidisciplinary management of intracranial aneurysms: The experience of Lille university hospital center. Neurochirurgie (2014), http://dx.doi.org/10.1016/j.neuchi.2014.06.010
G Model NEUCHI-659; No. of Pages 5
ARTICLE IN PRESS R. Aboukais et al. / Neurochirurgie xxx (2014) xxx–xxx
4
but higher than previous studies, probably because of a greater sensitivity of angiography using three-dimensional reconstruction of the vascular architecture. 4.2. Choice of treatment The choice of treatment was discussed for each patient during a multidisciplinary meeting according to their clinical status and the angio-architecture of the aneurysm. Each therapeutic procedure has its limitations. Since ISAT [1], it is recognized that endovascular treatment is less invasive than microsurgery and it is the reason why we first chose endovascular treatment, if it was feasible [24]. Endovascular treatment is also more effective than microsurgery for elderly patients with basilar artery aneurysms. Microsurgery is known to be more effective than endovascular treatment for aneurysms with a high “neck diameter” to “sac diameter” ratio. Microsurgery is also more effective if the aneurysmal sac is oriented in the axis of the arterial blood flow or if the aneurysm is located on a cerebral dysplastic bifurcation [25], because it may allow, during the same procedure, a vascular reconstruction. Patients were assigned to surgery according to their medical history, clinical status, aneurysm characteristics (wide neck, arteries branched to the neck, “small” size, associated aneurysm accessible throw the same surgical approach) or unsuccessful for endovascular treatment. The main objective is of course to protect the patient from any bleeding. Using a multidisciplinary approach, half of the patients underwent microsurgical treatment and the other half endovascular procedure at our institution. By consulting the ratio “microsurgery/endovascular treatment” of the major European and American hospital centres specialized in the treatment of intracranial aneurysms, we found a similar ratio between these two treatments [1,26]. Whatever the treatment was, the follow-up is obligatory using MRA after endovascular treatment and angiography CT after microsurgery. 4.3. Functional outcome of the patients after multidisciplinary discussion After discussion, the functional outcome was similar between patients who underwent microsurgery and those who had endovascular treatment. This result was found in the group of patients with ruptured aneurysms as well as in the group of patients with unruptured aneurysms. In patient group with unruptured aneurysms, all patients had a mRS score at 3 months under 2. There were no deaths and only 13% of patients had minor cognitive disorders like moderate anterograde memory impairment which did not prevent the resumption of work and activities. These results are consistent with several studies on series of patients with unruptured aneurysms [27,28]. Concerning the patient group with SAH, the medical treatment was similar in all patients. They were hospitalized in the same neurosurgical ICU [29] and managed by the same team of intensivists, neurosurgeons and neuroradiologists. These data explain, in part, the similarity of the clinical outcome of patients operated or embolized. The medical management of their disease was also comparable [30]. Nine patients died due the SAH. Among them, 5 died from severe vasospasm after endovascular treatment in 4 and after microsurgery in 1. Nevertheless, the incidence of vasospasm has been reported to be similar between both treatments [31,32]. We also noted that the mRS score was close to the initial clinical condition, i.e. the WFNS score of the patient. The more severe the initial neurological status, the worse is the functional outcome. According to our study, with a multidisciplinary decision, the type of therapeutic procedure does not seem to interfere with the functional outcome of patients. Despite the various locations of intracranial aneurysms in the present study that differed
between clipped and coiled aneurysms, we showed that the clinical condition of patients was similar. Aneurysm location data were taken into account in the choice of treatment. The aim was to evaluate the relevance of the collegial decision on the outcome of patients with intracranial aneurysm. The goal of the treatment is to prevent bleeding or rebleeding, involving in a major way the vital and functional prognosis of the patient and also reduce the possible risk of remote recanalization as much as possible. 4.4. Angiographic outcome Of the 99 embolized patients, we noted 18 minor recanalizations requiring no further treatment and 4 significant recanalizations leading to additional treatment in 2010 and 2011 (3 by surgery and 1 by new embolization). As in several series, the occurrence of post-embolization recanalization was more frequent in the group of patients with ruptured aneurysms [33,34]. The rate of late recanalization after embolization seems to be comparable to other large series reported in the literature [35,36]. Of the 110 operated patients, we recorded no recanalization on the angiographic CT scan performed at 3 years after the microsurgical treatment. Microsurgery is known to have less recanalization after treatment [37]. Endovascular procedure can complete the procedure of a residual aneurysm after clipping and microsurgery can be used for recanalization after embolization [38]. Complementarity between neuroradiologists and neurosurgeons do not lie only on the initial decision of treatment but also in the late follow-up of patients with intracranial arterial aneurysm [39,40]. 4.5. Limitations Although, a number of radiological criteria regarding bleeding severity and aneurysm morphology are important concerns for treatment decision, they have not been all recorded. The retrospective nature of the study was also an important limitation. 5. Conclusion Multidisciplinary discussion is essential in the management of patients with intracranial ruptured or unruptured aneurysm. The goal is to obtain optimal occlusion of the aneurysmal sac, the most sustainable, with less risk of morbidity/mortality for the patient. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet 2005;366:809–17. [2] Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, et al. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 2002;360:1267–74. [3] Molyneux AJ, Kerr RS, Birks J, Ramzi N, Yarnold J, Sneade M, et al. Risk of recurrent subarachnoid haemorrhage, death, or dependence and standardised mortality ratios after clipping or coiling of an intracranial aneurysm in the International Subarachnoid Aneurysm Trial (ISAT): long-term follow-up. Lancet Neurol 2009;8:427–33. [4] Wiebers D. Unruptured intracranial aneurysms: risk of rupture and risks of surgical intervention. International Study of Unruptured Intracranial Aneurysms Investigators. N Engl J Med 1998;339:1725–33. [5] Wiebers DO, Whisnant JP, Huston 3rd J, Meissner I, Brown Jr RD, Piepgras DG, et al. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 2003;362:103–10.
Please cite this article in press as: Aboukais R, et al. Multidisciplinary management of intracranial aneurysms: The experience of Lille university hospital center. Neurochirurgie (2014), http://dx.doi.org/10.1016/j.neuchi.2014.06.010
G Model NEUCHI-659; No. of Pages 5
ARTICLE IN PRESS R. Aboukais et al. / Neurochirurgie xxx (2014) xxx–xxx
[6] Linn FH, Rinkel GJ, Algra A, van Gijn J. Incidence of subarachnoid hemorrhage: role of region, year, and rate of computed tomography: a meta-analysis. Stroke 1996;27:625–9. [7] Vlak MH, Algra A, Brandenburg R, Rinkel GJ. Prevalence of unruptured intracranial aneurysms, with emphasis on sex, age, comorbidity, country, and time period: a systematic review and meta-analysis. Lancet Neurol 2011;10:626–36. [8] Lanterna LA, Tredici G, Dimitrov BD, Biroli F. Treatment of unruptured cerebral aneurysms by embolization with guglielmi detachable coils: case-fatality, morbidity, and effectiveness in preventing bleeding: a systematic review of the literature. Neurosurgery 2004;55:767–75 [discussion 75–8]. [9] Andaluz N, Zuccarello M. Treatment strategies for complex intracranial aneurysms: review of a 12-year experience at the university of cincinnati. Skull Base 2011;21:233–42. [10] Ingelmo Ingelmo I, Fabregas Julia N, Rama-Maceiras P, Hernandez-Palazon J, Rubio Romero R, Carmona Aurioles J. [Subarachnoid hemorrhage: epidemiology, social impact and a multidisciplinary approach]. Rev Esp Anestesiol Reanim 2010;57(Suppl. 2):S4–15. [11] Kim YB, Lee JW, Huh SK, Kim BM, Kim DJ. Outcomes of multidisciplinary treatment for posterior cerebral artery aneurysms. Clin Neurol Neurosurg 2013;115:2062–8. [12] Mpotsaris A, Loehr C, Harati A, Lohmann F, Puchner M, Weber W. Interdisciplinary clinical management of high grade arteriovenous malformations and ruptured flow-related aneurysms in the posterior fossa. Interv Neuroradiol 2010;16:400–8. [13] Proust F, Gerardin E, Derrey S, Lesveque S, Ramos S, Langlois O, et al. Interdisciplinary treatment of ruptured cerebral aneurysms in elderly patients. J Neurosurg 2010;112:1200–7. [14] Sherif C, Gruber A, Dorfer C, Bavinzski G, Standhardt H, Knosp E. Ruptured carotid artery aneurysms of the ophthalmic (C6) segment: clinical and angiographic long-term follow-up of a multidisciplinary management strategy. J Neurol Neurosurg Psychiatry 2009;80:1261–7. [15] Uhl E, Zausinger S, Morhard D, Heigl T, Scheder B, Rachinger W, et al. Intraoperative computed tomography with integrated navigation system in a multidisciplinary operating suite. Neurosurgery 2009;64:231–9 [discussion 9–40]. [16] Sidi A, Lobato EB, Cohen JA. The American Society of Anesthesiologists’ Physical Status: category V revisited. J Clin Anesth 2000;12:328–34. [17] Lagares A, Alen JF, Gomez PA, Lobato RD. Re: Grading of subarachnoid hemorrhage: modification of the World Federation of Neurosurgical Societies scale on the basis of data for a large series of patients. Neurosurgery 2005;56:E629 [author reply E]. [18] Rankin J. Cerebral vascular accidents in patients over the age of 60. II. Prognosis. Scott Med J 1957;2:200–15. [19] Ghods AJ, Lopes D, Chen M. Gender differences in cerebral aneurysm location. Front Neurol 2012;3:78. [20] Clarke G, Mendelow AD, Mitchell P. Predicting the risk of rupture of intracranial aneurysms based on anatomical location. Acta Neurochir Suppl 2005;147:259–63 [discussion 63]. [21] Mira JM, Costa FA, Horta BL, Fabiao OM. Risk of rupture in unruptured anterior communicating artery aneurysms: meta-analysis of natural history studies. Surg Neurol 2006;66(Suppl. 3):S12–9 [discussion S9]. [22] Raymond J, Guilbert F, Weill A, Georganos SA, Juravsky L, Lambert A, et al. Long-term angiographic recurrences after selective endovascular treatment of aneurysms with detachable coils. Stroke 2003;34:1398–403. [23] Inagawa T. Incidence and risk factors for multiple intracranial saccular aneurysms in patients with subarachnoid hemorrhage in Izumo City, Japan. Acta Neurochir Suppl 2009;151:1623–30.
5
[24] van der Schaaf I, Algra A, Wermer M, Molyneux A, Clarke M, van Gijn J, et al. Endovascular coiling versus neurosurgical clipping for patients with aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev 2005;(4):CD003085. [25] Regli L, Dehdashti AR, Uske A, de Tribolet N. Endovascular coiling compared with surgical clipping for the treatment of unruptured middle cerebral artery aneurysms: an update. Acta Neurochir Suppl 2002;82:41–6. [26] Dorhout Mees SM, Molyneux AJ, Kerr RS, Algra A, Rinkel GJ. Timing of aneurysm treatment after subarachnoid hemorrhage: relationship with delayed cerebral ischemia and poor outcome. Stroke 2012;43:2126–9. [27] Seifert V, Gerlach R, Raabe A, Guresir E, Beck J, Szelenyi A, et al. The interdisciplinary treatment of unruptured intracranial aneurysms. Deutsches Arzteblatt Int 2008;105:449–56. [28] Gerlach R, Beck J, Setzer M, Vatter H, Berkefeld J, Du Mesnil de Rochemont R, et al. Treatment related morbidity of unruptured intracranial aneurysms: results of a prospective single centre series with an interdisciplinary approach over a 6-year period (1999–2005). J Neurol Neurosurg Psychiatry 2007;78:864–71. [29] Wijdicks EF, Kallmes DF, Manno EM, Fulgham JR, Piepgras DG. Subarachnoid hemorrhage: neurointensive care and aneurysm repair. Mayo Clin Proc 2005;80:550–9. [30] Sztark F, Petitjean ME, Thicoipe M, Dabadie P. [Subarachnoid hemorrhage caused by aneurysm rupture. Initial management of patients]. Ann Fr Anesth Reanim 1996;15:322–7. [31] Hoh BL, Topcuoglu MA, Singhal AB, Pryor JC, Rabinov JD, Rordorf GA, et al. Effect of clipping, craniotomy, or intravascular coiling on cerebral vasospasm and patient outcome after aneurysmal subarachnoid hemorrhage. Neurosurgery 2004;55:779–86 [discussion 86–9]. [32] Rabinstein AA, Friedman JA, Nichols DA, Pichelmann MA, McClelland RL, Manno EM, et al. Predictors of outcome after endovascular treatment of cerebral vasospasm. AJNR Am J Neuroradiol 2004;25:1778–82. [33] Tan IY, Agid RF, Willinsky RA. Recanalization rates after endovascular coil embolization in a cohort of matched ruptured and unruptured cerebral aneurysms. Interv Neuroradiol 2011;17:27–35. [34] Nguyen TN, Hoh BL, Amin-Hanjani S, Pryor JC, Ogilvy CS. Comparison of ruptured vs. unruptured aneurysms in recanalization after coil embolization. Surg Neurol 2007;68:19–23. [35] Starke RM, Chalouhi N, Ali MS, Penn DL, Tjoumakaris SI, Jabbour PM, et al. Endovascular treatment of very small ruptured intracranial aneurysms: complications, occlusion rates and prediction of outcome. J Neurointerv Surg 2012;4(3):196–8, http://dx.doi.org/10.1136/neurintsurg-2011-010047 [Epub 2011 Jul 7]. [36] Lum C, Narayanam SB, Silva L, Shankar J, Bussiere M, Dos Santos MP, et al. Outcome in small aneurysms (< 4 mm) treated by endovascular coiling. J Neurointerventional Surg 2012;4:196–8. [37] Kaku Y, Watarai H, Kokuzawa J, Tanaka T, Andoh T. Cerebral aneurysms: conventional microsurgical technique and endovascular method. Surg Technol Int 2007;16:228–35. [38] Waldron JS, Halbach VV, Lawton MT. Microsurgical management of incompletely coiled and recurrent aneurysms: trends, techniques, and observations on coil extrusion. Neurosurgery 2009;64:301–15 [discussion 15–7]. [39] Lawton MT, Quinones-Hinojosa A, Sanai N, Malek JY, Dowd CF. Combined microsurgical and endovascular management of complex intracranial aneurysms. Neurosurgery 2008;62:1503–15. [40] Hacein-Bey L, Connolly Jr ES, Mayer SA, Young WL, Pile-Spellman J, Solomon RA. Complex intracranial aneurysms: combined operative and endovascular approaches. Neurosurgery 1998;43:1304–12 [discussion 12–3].
Please cite this article in press as: Aboukais R, et al. Multidisciplinary management of intracranial aneurysms: The experience of Lille university hospital center. Neurochirurgie (2014), http://dx.doi.org/10.1016/j.neuchi.2014.06.010
