Neurosurg Rev (2014) 37:643–651 DOI 10.1007/s10143-014-0563-5
ORIGINAL ARTICLE
Outcome for unruptured middle cerebral artery aneurysm treatment: surgical and endovascular approach in a single center Philipp Dammann & Tobias Schoemberg & Oliver Müller & Neriman Özkan & Marc Schlamann & Isabel Wanke & I. Erol Sandalcioglu & Michael Forsting & Ulrich Sure
Received: 22 September 2013 / Revised: 20 March 2014 / Accepted: 18 May 2014 / Published online: 9 July 2014 # Springer-Verlag Berlin Heidelberg 2014
Abstract The rupture of an intracranial aneurysm leads to subarachnoid hemorrhage (SAH). To prevent SAH, unruptured lesions can be treated by either endovascular or microsurgical approach. Due to their complex anatomy, middle cerebral artery (MCA) aneurysms represent a unique subgroup of intracranial aneurysms. Primary objective was to determine radiological and clinical outcomes in patients with middle cerebral artery aneurysms who were interdisciplinary treated by either endovascular or microsurgical approach in a single center. Secondary objective was to determine the impact of the lesions’ angiographic characteristics on treatment outcome. Clinical and radiological data of 103 patients interdisciplinary treated for unruptured MCA aneurysms over a 5year period were analyzed in endovascular (n=16) and microsurgical (n=87) cohorts. Overall morbidity (Glasgow Outcome Score 50 cases/year) vascular centers [3] which is due to their unique and complex anatomical features [18], presumably leaving rather “easily assessable” lesions for endovascular treatment.
644
Neurosurg Rev (2014) 37:643–651
Nowadays, the underlying evidence for this treatment preselection may be regarded as outdated, especially since endovascular technology has improved over the last decade, introducing new coil material and treatment devices [28, 27, 4]. The disproportional subjection of most MCA aneurysms to microsurgical treatment, including rather complex lesions, may bias outcome in this group on the other hand. In addition, most large clinical series building the current body of literature are summarizing cases over one or two decades [18, 25]; thus, they do not reflect the emerging technical standards and experience in both microsurgical and endovascular treatments over the last years. In previous work, we demonstrated our interdisciplinary single-center (>150 cases/year) treatment algorithm for intracranial aneurysm, reflecting a large volume of unruptured aneurysms subjected to both microsurgical and endovascular treatments [19]. As treatment of unruptured intracranial aneurysm is predominately performed in vascular centers like ours [15], our interdisciplinary experience gives a sharp image of the recent unruptured MCA aneurysm management and treatment risk. We therefore collected the data of 103 patients undergoing microsurgical clipping or endovascular treatment for unruptured MCA aneurysms in our department in the recent period between 2006 and 2010. We analyzed aneurysm morphology and consecutive indications for treatment. We evaluated completeness of occlusion and clinical outcome at 12month or later follow-up as well as subjection to re-treatment in both treatment cohorts.
upon aneurysms. Patients were divided into two cohorts: treatment by microsurgical clipping or endovascular treatment. The specific indications for microsurgical treatment were analyzed. Completeness of aneurysm occlusion was controlled by DSA after the procedure in both groups (complete occlusion, 91–99 % occlusion (near complete occlusion), 70–90 % occlusion, 25 mm), and 50 (49 %) were classified “simple” (see Fig. 1). In the microsurgical cohort, 54 MCA aneurysms (62 %) were located on the right side and 33 (38 %) on the left side. We found 70 bifurcation aneurysms (80 %), 12 M1 (14 %), four M2 (5 %), and one M3 (1 %) aneurysm. Mean aneurysm size was 9.2±7.2 mm (range 2–50 mm). Neck size was confirmed narrow in 13 patients (15 %), midsized in eight patients (9 %), and wide in 66 patients (76 %). Forty-seven
In the microsurgical cohort, outcome at discharge was GOS 5 in 75 patients (86 %), GOS 4 in nine patients (10 %), and GOS 3 in three patients (4 %). Overall morbidity was 14 %. At the 12-month follow-up, GOS 5 was confirmed in 80 patients (91 %), GOS 4 in six patients (8 %), and GOS three in 1 patient (1 %). No surgery-related death was found. Overall morbidity was 9 %. In the endovascular cohort, outcome at discharge was GOS 5 in 13 patients (81 %), GOS 4 in one patient (6 %), and GOS 3 in two patients (13 %). Overall morbidity (GOS
ORIGINAL ARTICLE
Outcome for unruptured middle cerebral artery aneurysm treatment: surgical and endovascular approach in a single center Philipp Dammann & Tobias Schoemberg & Oliver Müller & Neriman Özkan & Marc Schlamann & Isabel Wanke & I. Erol Sandalcioglu & Michael Forsting & Ulrich Sure
Received: 22 September 2013 / Revised: 20 March 2014 / Accepted: 18 May 2014 / Published online: 9 July 2014 # Springer-Verlag Berlin Heidelberg 2014
Abstract The rupture of an intracranial aneurysm leads to subarachnoid hemorrhage (SAH). To prevent SAH, unruptured lesions can be treated by either endovascular or microsurgical approach. Due to their complex anatomy, middle cerebral artery (MCA) aneurysms represent a unique subgroup of intracranial aneurysms. Primary objective was to determine radiological and clinical outcomes in patients with middle cerebral artery aneurysms who were interdisciplinary treated by either endovascular or microsurgical approach in a single center. Secondary objective was to determine the impact of the lesions’ angiographic characteristics on treatment outcome. Clinical and radiological data of 103 patients interdisciplinary treated for unruptured MCA aneurysms over a 5year period were analyzed in endovascular (n=16) and microsurgical (n=87) cohorts. Overall morbidity (Glasgow Outcome Score 50 cases/year) vascular centers [3] which is due to their unique and complex anatomical features [18], presumably leaving rather “easily assessable” lesions for endovascular treatment.
644
Neurosurg Rev (2014) 37:643–651
Nowadays, the underlying evidence for this treatment preselection may be regarded as outdated, especially since endovascular technology has improved over the last decade, introducing new coil material and treatment devices [28, 27, 4]. The disproportional subjection of most MCA aneurysms to microsurgical treatment, including rather complex lesions, may bias outcome in this group on the other hand. In addition, most large clinical series building the current body of literature are summarizing cases over one or two decades [18, 25]; thus, they do not reflect the emerging technical standards and experience in both microsurgical and endovascular treatments over the last years. In previous work, we demonstrated our interdisciplinary single-center (>150 cases/year) treatment algorithm for intracranial aneurysm, reflecting a large volume of unruptured aneurysms subjected to both microsurgical and endovascular treatments [19]. As treatment of unruptured intracranial aneurysm is predominately performed in vascular centers like ours [15], our interdisciplinary experience gives a sharp image of the recent unruptured MCA aneurysm management and treatment risk. We therefore collected the data of 103 patients undergoing microsurgical clipping or endovascular treatment for unruptured MCA aneurysms in our department in the recent period between 2006 and 2010. We analyzed aneurysm morphology and consecutive indications for treatment. We evaluated completeness of occlusion and clinical outcome at 12month or later follow-up as well as subjection to re-treatment in both treatment cohorts.
upon aneurysms. Patients were divided into two cohorts: treatment by microsurgical clipping or endovascular treatment. The specific indications for microsurgical treatment were analyzed. Completeness of aneurysm occlusion was controlled by DSA after the procedure in both groups (complete occlusion, 91–99 % occlusion (near complete occlusion), 70–90 % occlusion, 25 mm), and 50 (49 %) were classified “simple” (see Fig. 1). In the microsurgical cohort, 54 MCA aneurysms (62 %) were located on the right side and 33 (38 %) on the left side. We found 70 bifurcation aneurysms (80 %), 12 M1 (14 %), four M2 (5 %), and one M3 (1 %) aneurysm. Mean aneurysm size was 9.2±7.2 mm (range 2–50 mm). Neck size was confirmed narrow in 13 patients (15 %), midsized in eight patients (9 %), and wide in 66 patients (76 %). Forty-seven
In the microsurgical cohort, outcome at discharge was GOS 5 in 75 patients (86 %), GOS 4 in nine patients (10 %), and GOS 3 in three patients (4 %). Overall morbidity was 14 %. At the 12-month follow-up, GOS 5 was confirmed in 80 patients (91 %), GOS 4 in six patients (8 %), and GOS three in 1 patient (1 %). No surgery-related death was found. Overall morbidity was 9 %. In the endovascular cohort, outcome at discharge was GOS 5 in 13 patients (81 %), GOS 4 in one patient (6 %), and GOS 3 in two patients (13 %). Overall morbidity (GOS
