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Cognitive Changes After Treatment: Clipping Versus Coiling
Perspectives Commentary on: Cognitive Changes in Patients with Aneurysmal Subarachnoid Hemorrhage Before and Early Posttreatment: Differences Between Surgical and Endovascular by Vieira et al. pp. 95-100.
Atos Alves de Sousa, M.D., Ph.D. Honorary President of the WFNS Professor and Chairman of Neurosurgery Faculdade de Ciências Médicas de Minas Gerais Santa Casa Hospital and Lifecenter Hospital
Cognitive Changes After Treatment: Clipping Versus Coiling Atos Alves de Sousa
I
t is difficult to differentiate the role of subarachnoid hemorrhage (SAH) from its treatment (endovascular or surgery) in cognitive impairment as most of the patients around the world are treated very early after the SAH. Besides being well written, the paper from Vieira et al. in this issue of WORLD NEUROSURGERY is very interesting because all the patients, as the result of local conditions (i.e., the institution in which the authors work), were treated very late after SAH. The authors were able to prospectively study the cognitive changes before and after surgical or endovascular treatment and compare the results obtained with both techniques. They concluded that “[P]atients submitted to endovascular treatment did not show additional cognitive impairment and had a better performance in language and verbal memory, when compared to patients submitted to surgical treatment in an early post-operative period.” The problem of this paper is the selection of patients to be treated by surgery or coil embolization. To be able to really compare the two methods of treatment, the size and location of the aneurysms in the two groups should be very similar. It is clear that giant, partially thrombosed and complex aneurysms present a worse prognosis and are preferentially treated by microsurgery. Therefore, we should compare the results of both methods for aneurysms of similar sizes, which means excluding the complex and giant aneurysms that are treated nearly always by clipping.
Key words 䡲 Coil embolization 䡲 Intracranial aneurysm 䡲 Neuropsychological assessment 䡲 Neurosurgery 䡲 Subarachnoid hemorrhage
Abbreviations and Acronyms SAH: Subarachnoid hemorrhage
The location is also a very important prognostic factor because aneurysms located in the anterior communicating artery and in the left middle cerebral artery have a greater tendency to create language and other cognitive disturbances in the patient after treatment. In the presented series, only one patient having a left middle cerebral artery aneurysm was treated by endovascular embolization, which is certainly an important factor to determine the worse result of open surgery and was confirmed by the authors when this patient was excluded from the series. It is also well known that the patient’s cognition just after surgery is usually worse but that the patients have a great tendency to ameliorate progressively and, if the cognitive evaluation is repeated 6 or 12 months later, the result is much better. So, as stated by the authors, the definitive result will only be obtained from six months to one year after surgery and endovascular treatment. My personal opinion, which is also the same of the majority of vascular neurosurgeons and endovascular neurosurgeons, is that all patients with aneurismal SAH should be treated in the acute phase, that is, in the first 24 hours. It is also clear that, if the aneurysm is appropriate for endovascular treatment, it is the best option in the acute period.
Faculdade de Ciencias Medicas de Minas Gerais. Santa Casa Hospital Belo Horizonte, Minas Gerais, Brazil To whom correspondence should addressed: Atos Alves de Sousa, M.D., Ph.D. [E-mail: [email protected]; [email protected]] Citation: World Neurosurg. (2012) 78, 1/2:47. DOI: 10.1016/j.wneu.2011.11.016 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2012 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY 78 [1/2]: 47, JULY/AUGUST 2012
www.WORLDNEUROSURGERY.org
47
Atos Alves de Sousa, M.D., Ph.D. Honorary President of the WFNS Professor and Chairman of Neurosurgery Faculdade de Ciências Médicas de Minas Gerais Santa Casa Hospital and Lifecenter Hospital
Cognitive Changes After Treatment: Clipping Versus Coiling Atos Alves de Sousa
I
t is difficult to differentiate the role of subarachnoid hemorrhage (SAH) from its treatment (endovascular or surgery) in cognitive impairment as most of the patients around the world are treated very early after the SAH. Besides being well written, the paper from Vieira et al. in this issue of WORLD NEUROSURGERY is very interesting because all the patients, as the result of local conditions (i.e., the institution in which the authors work), were treated very late after SAH. The authors were able to prospectively study the cognitive changes before and after surgical or endovascular treatment and compare the results obtained with both techniques. They concluded that “[P]atients submitted to endovascular treatment did not show additional cognitive impairment and had a better performance in language and verbal memory, when compared to patients submitted to surgical treatment in an early post-operative period.” The problem of this paper is the selection of patients to be treated by surgery or coil embolization. To be able to really compare the two methods of treatment, the size and location of the aneurysms in the two groups should be very similar. It is clear that giant, partially thrombosed and complex aneurysms present a worse prognosis and are preferentially treated by microsurgery. Therefore, we should compare the results of both methods for aneurysms of similar sizes, which means excluding the complex and giant aneurysms that are treated nearly always by clipping.
Key words 䡲 Coil embolization 䡲 Intracranial aneurysm 䡲 Neuropsychological assessment 䡲 Neurosurgery 䡲 Subarachnoid hemorrhage
Abbreviations and Acronyms SAH: Subarachnoid hemorrhage
The location is also a very important prognostic factor because aneurysms located in the anterior communicating artery and in the left middle cerebral artery have a greater tendency to create language and other cognitive disturbances in the patient after treatment. In the presented series, only one patient having a left middle cerebral artery aneurysm was treated by endovascular embolization, which is certainly an important factor to determine the worse result of open surgery and was confirmed by the authors when this patient was excluded from the series. It is also well known that the patient’s cognition just after surgery is usually worse but that the patients have a great tendency to ameliorate progressively and, if the cognitive evaluation is repeated 6 or 12 months later, the result is much better. So, as stated by the authors, the definitive result will only be obtained from six months to one year after surgery and endovascular treatment. My personal opinion, which is also the same of the majority of vascular neurosurgeons and endovascular neurosurgeons, is that all patients with aneurismal SAH should be treated in the acute phase, that is, in the first 24 hours. It is also clear that, if the aneurysm is appropriate for endovascular treatment, it is the best option in the acute period.
Faculdade de Ciencias Medicas de Minas Gerais. Santa Casa Hospital Belo Horizonte, Minas Gerais, Brazil To whom correspondence should addressed: Atos Alves de Sousa, M.D., Ph.D. [E-mail: [email protected]; [email protected]] Citation: World Neurosurg. (2012) 78, 1/2:47. DOI: 10.1016/j.wneu.2011.11.016 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2012 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY 78 [1/2]: 47, JULY/AUGUST 2012
www.WORLDNEUROSURGERY.org
47