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Surgical treatment of unruptured middle cerebral artery aneurysms: Complication avoidance
G Model
ARTICLE IN PRESS
CLINEU-4555; No. of Pages 2
Clinical Neurology and Neurosurgery xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Surgical treatment of unruptured middle cerebral artery aneurysms: Complication avoidance
Keywords: Complication Endovascular procedures Intracranial aneurysm Microsurgery Middle cerebral artery Stroke
Intracranial aneurysms arising from the middle cerebral artery (MCA) are anatomically favorable lesions for surgical clipping. Ischemic complications (IC) secondary to compromise of an M2 trunk or perforator branch during surgical treatment of MCA aneurysms can cause substantial neurological morbidity and longterm functional impairment. The sequelae of these postoperative complications can be particularly devastating for patients harboring unruptured aneurysms, who are frequently minimally symptomatic or entirely asymptomatic. Over the years, cerebrovascular surgeons have devised a number of strategies to abrogate the risk of ICs after aneurysm clipping. Byoun et al. sought to assess the effectiveness of intraoperative electrophysiologic monitoring with somatosensory evoked potentials (SSEP) in reducing ICs after clipping of unruptured MCA aneurysms [1]. The authors analyzed a cohort of 411 patients who were surgically treated for unruptured MCA aneurysms, of which 216 had SSEP monitoring (52.6%). The overall rate of ICs was 3.1%, which was lower in the SSEP subgroup (0.9%) compared to the non-SSEP subgroup (5.6%). In the multivariate logistic regression analysis, a prior history of stroke (P = 0.007), patient age ≥62.5 years (P = 0.011), and the lack of SSEP monitoring (P = 0.019) were found to be independent predictors of ICs. Notably, while aneurysm size ≥4.15 mm and the use of temporary clipping were predictive of ICs in the univariate analysis, these factors were not significantly associated with ICs in the multivariate model. The findings from this study suggest that the routine use of intraoperative electrophysiologic monitoring may diminish the rate of ICs after clipping of unruptured MCA aneurysms. Over the past decade, there has been an overall trend toward increasing utilization of endovascular therapies for the treatment of both ruptured and unruptured aneurysms. However, the angioarchitectural features of MCA aneurysms theoretically favor clipping over coiling. Specifically, MCA aneurysms are located in relatively close proximity to the brain surface and are readily accessible
from a trans-Sylvian corridor. The absence of cerebral edema and subarachnoid hemorrhage in patients with unruptured MCA aneurysms facilitates Sylvian fissure dissection. In contrast, MCA aneurysms require more extensive endovascular navigation compared to other common aneurysms. Additionally, the neck of an MCA aneurysm commonly incorporates one or both M2 trunks, and preservation of these branch vessels during coiling may be challenging without stent assistance [2]. Smith et al. performed a systematic review and meta-analysis comparing clipping to coiling for unruptured MCA aneurysms, and found that clipping yielded higher rates of aneurysm occlusion (97% vs. 52%) and lower rates of unfavorable outcome (2% vs. 5%) [3]. However, as endovascular techniques and devices for aneurysm treatment continue to evolve, the outcomes for coiling, particularly with regard to aneurysm obliteration, may approach those of clipping [4–17]. Advances in microsurgery must keep abreast with endovascular technologies in order to minimize the risk of complications during the treatment of unruptured MCA aneurysms. Specific measures for complication avoidance, such as refraining from the use of fixed retractors, venous and pial preservation during Sylvian fissure dissection, judicious use of temporary clipping during the final stages of aneurysm dissection, employment of lesion-specific clipping strategies, and careful post-clipping assessment of branch artery patency with Doppler ultrasonography, indocyanine green video angiography, and/or intraoperative catheter angiography, are paramount to keeping neurosurgeons at the forefront of the management of MCA aneurysms [18–22]. Currently, surgical clipping remains the treatment of choice at many high-volume cerebrovascular centers for unruptured MCA aneurysms deemed appropriate for intervention. Endovascular therapy is a reasonable alternative to surgery for unruptured MCA aneurysms in older patients, those with significant medical comorbidities, and those who refuse a craniotomy. References [1] H.S. Byoun, J.S. Bang, C.W. Oh, O.K. Kwon, G.G. Hwang, J.H. Han, et al., The incidence of and risk factors for ischemic complications after microsurgical clipping of unruptured middle cerebral artery aneurysms and the efficacy of intraoperative monitoring of somatosensory evoked potentials: a retrospective study, Clin. Neurol. Neurosurg. (2016) (in press). [2] A.K. Johnson, D.M. Heiferman, D.K. Lopes, Stent-assisted embolization of 100 middle cerebral artery aneurysms, J. Neurosurg. 118 (5) (2013) 950–955. [3] T.R. Smith, D.J. Cote, H.H. Dasenbrock, Y.J. Hamade, S.G. Zammar, N.E. El Tecle, et al., Comparison of the efficacy and safety of endovascular coiling versus
http://dx.doi.org/10.1016/j.clineuro.2016.11.002 0303-8467/© 2016 Elsevier B.V. All rights reserved.
Please cite this article in press as: D. Ding, Surgical treatment of unruptured middle cerebral artery aneurysms: Complication avoidance, Clin Neurol Neurosurg (2016), http://dx.doi.org/10.1016/j.clineuro.2016.11.002
G Model CLINEU-4555; No. of Pages 2
ARTICLE IN PRESS
Surgical treatment of unruptured middle cerebral artery aneurysms: Complication avoidance / Clinical Neurology and Neurosurgery xxx (2016) xxx–xxx
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[5]
[6]
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[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
microsurgical clipping for unruptured middle cerebral artery aneurysms: a systematic review and meta-analysis, World Neurosurg 84 (4) (2015) 942–953. R.M. Starke, C.R. Durst, A. Evans, D. Ding, D.M. Raper, M.E. Jensen, et al., Endovascular treatment of unruptured wide-necked intracranial aneurysms: comparison of dual microcatheter technique and stent-assisted coil embolization, J. Neurointerv. Surg. 7 (4) (2015) 256–261. D. Raper, D. Ding, E.C. Peterson, R.W. Crowley, K.C. Liu, N. Chalouhi, et al., Cavernous carotid aneurysms: a new treatment paradigm in the era of flow diversion, Expert Rev. Neurother. (July (22)) (2016) (Epub ahead of print). T. Becske, D.F. Kallmes, I. Saatci, C.G. McDougall, I. Szikora, G. Lanzino, et al., Pipeline for uncoilable or failed aneurysms: results from a multicenter clinical trial, Radiology 267 (3) (2013) 858–868. D. Ding, R.M. Starke, C.R. Durst, J.R. Gaughen Jr., A.J. Evans, M.E. Jensen, et al., DynaCT imaging for intraprocedural evaluation of flow-diverting stent apposition during endovascular treatment of intracranial aneurysms, J. Clin. Neurosci. 21 (11) (2014) 1981–1983. D. Ding, R.M. Starke, A.J. Evans, M.E. Jensen, K.C. Liu, Endovascular treatment of recurrent intracranial aneurysms following previous microsurgical clipping with the Pipeline Embolization Device, J. Clin. Neurosci. 21 (7) (2014) 1241–1244. D. Ding, R.M. Starke, A.J. Evans, M.E. Jensen, K.C. Liu, Balloon anchor technique for pipeline embolization device deployment across the neck of a giant intracranial aneurysm, J. Cerebrovasc. Endovasc. Neurosurg. 16 (2) (2014) 125–130. P.K. Nelson, P. Lylyk, I. Szikora, S.G. Wetzel, I. Wanke, D. Fiorella, The pipeline embolization device for the intracranial treatment of aneurysms trial, AJNR Am. J. Neuroradiol. 32 (1) (2011) 34–40. C.R. Durst, R.M. Starke, D. Clopton, H.R. Hixson, P.J. Schmitt, J.M. Gingras, et al., Endovascular treatment of ophthalmic artery aneurysms: ophthalmic artery patency following flow diversion versus coil embolization, J. Neurointerv. Surg. 8 (9) (2016) 919–922. R.M. Starke, A. Turk, D. Ding, R.W. Crowley, K.C. Liu, N. Chalouhi, et al., Technology developments in endovascular treatment of intracranial aneurysms, J. Neurointerv. Surg. 8 (2) (2016) 135–144. J. Caroff, C. Mihalea, F. Dargento, H. Neki, L. Ikka, N. Benachour, et al., Woven Endobridge (WEB) Device for endovascular treatment of ruptured intracranial wide-neck aneurysms: a single-center experience, Neuroradiology 56 (9) (2014) 755–761. D. Ding, K.C. Liu, Microsurgical extraction of a malfunctioned pipeline embolization device following complete deployment, J. Cerebrovasc. Endovasc. Neurosurg. 15 (3) (2013) 241–245. D. Ding, K.C. Liu, Management strategies for intraprocedural coil migration during endovascular treatment of intracranial aneurysms, J. Neurointerv. Surg. 6 (6) (2014) 428–431.
[16] D. Ding, R.M. Starke, K.C. Liu, Microsurgical strategies following failed endovascular treatment with the pipeline embolization device: case of a giant posterior cerebral artery aneurysm, J. Cerebrovasc. Endovasc. Neurosurg. 16 (1) (2014) 26–31. [17] K.C. Liu, D. Ding, R.M. Starke, S.R. Geraghty, M.E. Jensen, Intraprocedural retrieval of migrated coils during endovascular aneurysm treatment with the Trevo Stentriever device, J. Clin. Neurosci. 21 (3) (2014) 503–506. [18] M.K. Morgan, W. Mahattanakul, A. Davidson, J. Reid, Outcome for middle cerebral artery aneurysm surgery, Neurosurgery 67 (3) (2010) 755–761 (discussion 761.). [19] A. Rodriguez-Hernandez, M.E. Sughrue, S. Akhavan, J. Habdank-Kolaczkowski, M.T. Lawton, Current management of middle cerebral artery aneurysms: surgical results with a clip first policy, Neurosurgery 72 (3) (2013) 415–427. [20] C.W. Washington, T. Ju, G.J. Zipfel, R.G. Dacey Jr., Middle cerebral artery bifurcation aneurysms: an anatomic classification scheme for planning optimal surgical strategies, Neurosurgery 10 (Suppl (1)) (2014) (p. 145-53; discussion 153-5). [21] D.A. Hardesty, H. Thind, J.M. Zabramski, R.F. Spetzler, P. Nakaji, Safety, efficacy, and cost of intraoperative indocyanine green angiography compared to intraoperative catheter angiography in cerebral aneurysm surgery, J. Clin. Neurosci. (2014). [22] C.W. Washington, G.J. Zipfel, M.R. Chicoine, C.P. Derdeyn, K.M. Rich, C.J. Moran, et al., Comparing indocyanine green videoangiography to the gold standard of intraoperative digital subtraction angiography used in aneurysm surgery, J. Neurosurg. 118 (2) (2013) 420–427.
Dale Ding University of Virginia, Department of Neurosurgery, P.O. Box 800212, Charlottesville, VA 22908, United States E-mail address: [email protected] 17 October 2016 2 November 2016 3 November 2016 Available online xxx
Please cite this article in press as: D. Ding, Surgical treatment of unruptured middle cerebral artery aneurysms: Complication avoidance, Clin Neurol Neurosurg (2016), http://dx.doi.org/10.1016/j.clineuro.2016.11.002
ARTICLE IN PRESS
CLINEU-4555; No. of Pages 2
Clinical Neurology and Neurosurgery xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Surgical treatment of unruptured middle cerebral artery aneurysms: Complication avoidance
Keywords: Complication Endovascular procedures Intracranial aneurysm Microsurgery Middle cerebral artery Stroke
Intracranial aneurysms arising from the middle cerebral artery (MCA) are anatomically favorable lesions for surgical clipping. Ischemic complications (IC) secondary to compromise of an M2 trunk or perforator branch during surgical treatment of MCA aneurysms can cause substantial neurological morbidity and longterm functional impairment. The sequelae of these postoperative complications can be particularly devastating for patients harboring unruptured aneurysms, who are frequently minimally symptomatic or entirely asymptomatic. Over the years, cerebrovascular surgeons have devised a number of strategies to abrogate the risk of ICs after aneurysm clipping. Byoun et al. sought to assess the effectiveness of intraoperative electrophysiologic monitoring with somatosensory evoked potentials (SSEP) in reducing ICs after clipping of unruptured MCA aneurysms [1]. The authors analyzed a cohort of 411 patients who were surgically treated for unruptured MCA aneurysms, of which 216 had SSEP monitoring (52.6%). The overall rate of ICs was 3.1%, which was lower in the SSEP subgroup (0.9%) compared to the non-SSEP subgroup (5.6%). In the multivariate logistic regression analysis, a prior history of stroke (P = 0.007), patient age ≥62.5 years (P = 0.011), and the lack of SSEP monitoring (P = 0.019) were found to be independent predictors of ICs. Notably, while aneurysm size ≥4.15 mm and the use of temporary clipping were predictive of ICs in the univariate analysis, these factors were not significantly associated with ICs in the multivariate model. The findings from this study suggest that the routine use of intraoperative electrophysiologic monitoring may diminish the rate of ICs after clipping of unruptured MCA aneurysms. Over the past decade, there has been an overall trend toward increasing utilization of endovascular therapies for the treatment of both ruptured and unruptured aneurysms. However, the angioarchitectural features of MCA aneurysms theoretically favor clipping over coiling. Specifically, MCA aneurysms are located in relatively close proximity to the brain surface and are readily accessible
from a trans-Sylvian corridor. The absence of cerebral edema and subarachnoid hemorrhage in patients with unruptured MCA aneurysms facilitates Sylvian fissure dissection. In contrast, MCA aneurysms require more extensive endovascular navigation compared to other common aneurysms. Additionally, the neck of an MCA aneurysm commonly incorporates one or both M2 trunks, and preservation of these branch vessels during coiling may be challenging without stent assistance [2]. Smith et al. performed a systematic review and meta-analysis comparing clipping to coiling for unruptured MCA aneurysms, and found that clipping yielded higher rates of aneurysm occlusion (97% vs. 52%) and lower rates of unfavorable outcome (2% vs. 5%) [3]. However, as endovascular techniques and devices for aneurysm treatment continue to evolve, the outcomes for coiling, particularly with regard to aneurysm obliteration, may approach those of clipping [4–17]. Advances in microsurgery must keep abreast with endovascular technologies in order to minimize the risk of complications during the treatment of unruptured MCA aneurysms. Specific measures for complication avoidance, such as refraining from the use of fixed retractors, venous and pial preservation during Sylvian fissure dissection, judicious use of temporary clipping during the final stages of aneurysm dissection, employment of lesion-specific clipping strategies, and careful post-clipping assessment of branch artery patency with Doppler ultrasonography, indocyanine green video angiography, and/or intraoperative catheter angiography, are paramount to keeping neurosurgeons at the forefront of the management of MCA aneurysms [18–22]. Currently, surgical clipping remains the treatment of choice at many high-volume cerebrovascular centers for unruptured MCA aneurysms deemed appropriate for intervention. Endovascular therapy is a reasonable alternative to surgery for unruptured MCA aneurysms in older patients, those with significant medical comorbidities, and those who refuse a craniotomy. References [1] H.S. Byoun, J.S. Bang, C.W. Oh, O.K. Kwon, G.G. Hwang, J.H. Han, et al., The incidence of and risk factors for ischemic complications after microsurgical clipping of unruptured middle cerebral artery aneurysms and the efficacy of intraoperative monitoring of somatosensory evoked potentials: a retrospective study, Clin. Neurol. Neurosurg. (2016) (in press). [2] A.K. Johnson, D.M. Heiferman, D.K. Lopes, Stent-assisted embolization of 100 middle cerebral artery aneurysms, J. Neurosurg. 118 (5) (2013) 950–955. [3] T.R. Smith, D.J. Cote, H.H. Dasenbrock, Y.J. Hamade, S.G. Zammar, N.E. El Tecle, et al., Comparison of the efficacy and safety of endovascular coiling versus
http://dx.doi.org/10.1016/j.clineuro.2016.11.002 0303-8467/© 2016 Elsevier B.V. All rights reserved.
Please cite this article in press as: D. Ding, Surgical treatment of unruptured middle cerebral artery aneurysms: Complication avoidance, Clin Neurol Neurosurg (2016), http://dx.doi.org/10.1016/j.clineuro.2016.11.002
G Model CLINEU-4555; No. of Pages 2
ARTICLE IN PRESS
Surgical treatment of unruptured middle cerebral artery aneurysms: Complication avoidance / Clinical Neurology and Neurosurgery xxx (2016) xxx–xxx
2
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
microsurgical clipping for unruptured middle cerebral artery aneurysms: a systematic review and meta-analysis, World Neurosurg 84 (4) (2015) 942–953. R.M. Starke, C.R. Durst, A. Evans, D. Ding, D.M. Raper, M.E. Jensen, et al., Endovascular treatment of unruptured wide-necked intracranial aneurysms: comparison of dual microcatheter technique and stent-assisted coil embolization, J. Neurointerv. Surg. 7 (4) (2015) 256–261. D. Raper, D. Ding, E.C. Peterson, R.W. Crowley, K.C. Liu, N. Chalouhi, et al., Cavernous carotid aneurysms: a new treatment paradigm in the era of flow diversion, Expert Rev. Neurother. (July (22)) (2016) (Epub ahead of print). T. Becske, D.F. Kallmes, I. Saatci, C.G. McDougall, I. Szikora, G. Lanzino, et al., Pipeline for uncoilable or failed aneurysms: results from a multicenter clinical trial, Radiology 267 (3) (2013) 858–868. D. Ding, R.M. Starke, C.R. Durst, J.R. Gaughen Jr., A.J. Evans, M.E. Jensen, et al., DynaCT imaging for intraprocedural evaluation of flow-diverting stent apposition during endovascular treatment of intracranial aneurysms, J. Clin. Neurosci. 21 (11) (2014) 1981–1983. D. Ding, R.M. Starke, A.J. Evans, M.E. Jensen, K.C. Liu, Endovascular treatment of recurrent intracranial aneurysms following previous microsurgical clipping with the Pipeline Embolization Device, J. Clin. Neurosci. 21 (7) (2014) 1241–1244. D. Ding, R.M. Starke, A.J. Evans, M.E. Jensen, K.C. Liu, Balloon anchor technique for pipeline embolization device deployment across the neck of a giant intracranial aneurysm, J. Cerebrovasc. Endovasc. Neurosurg. 16 (2) (2014) 125–130. P.K. Nelson, P. Lylyk, I. Szikora, S.G. Wetzel, I. Wanke, D. Fiorella, The pipeline embolization device for the intracranial treatment of aneurysms trial, AJNR Am. J. Neuroradiol. 32 (1) (2011) 34–40. C.R. Durst, R.M. Starke, D. Clopton, H.R. Hixson, P.J. Schmitt, J.M. Gingras, et al., Endovascular treatment of ophthalmic artery aneurysms: ophthalmic artery patency following flow diversion versus coil embolization, J. Neurointerv. Surg. 8 (9) (2016) 919–922. R.M. Starke, A. Turk, D. Ding, R.W. Crowley, K.C. Liu, N. Chalouhi, et al., Technology developments in endovascular treatment of intracranial aneurysms, J. Neurointerv. Surg. 8 (2) (2016) 135–144. J. Caroff, C. Mihalea, F. Dargento, H. Neki, L. Ikka, N. Benachour, et al., Woven Endobridge (WEB) Device for endovascular treatment of ruptured intracranial wide-neck aneurysms: a single-center experience, Neuroradiology 56 (9) (2014) 755–761. D. Ding, K.C. Liu, Microsurgical extraction of a malfunctioned pipeline embolization device following complete deployment, J. Cerebrovasc. Endovasc. Neurosurg. 15 (3) (2013) 241–245. D. Ding, K.C. Liu, Management strategies for intraprocedural coil migration during endovascular treatment of intracranial aneurysms, J. Neurointerv. Surg. 6 (6) (2014) 428–431.
[16] D. Ding, R.M. Starke, K.C. Liu, Microsurgical strategies following failed endovascular treatment with the pipeline embolization device: case of a giant posterior cerebral artery aneurysm, J. Cerebrovasc. Endovasc. Neurosurg. 16 (1) (2014) 26–31. [17] K.C. Liu, D. Ding, R.M. Starke, S.R. Geraghty, M.E. Jensen, Intraprocedural retrieval of migrated coils during endovascular aneurysm treatment with the Trevo Stentriever device, J. Clin. Neurosci. 21 (3) (2014) 503–506. [18] M.K. Morgan, W. Mahattanakul, A. Davidson, J. Reid, Outcome for middle cerebral artery aneurysm surgery, Neurosurgery 67 (3) (2010) 755–761 (discussion 761.). [19] A. Rodriguez-Hernandez, M.E. Sughrue, S. Akhavan, J. Habdank-Kolaczkowski, M.T. Lawton, Current management of middle cerebral artery aneurysms: surgical results with a clip first policy, Neurosurgery 72 (3) (2013) 415–427. [20] C.W. Washington, T. Ju, G.J. Zipfel, R.G. Dacey Jr., Middle cerebral artery bifurcation aneurysms: an anatomic classification scheme for planning optimal surgical strategies, Neurosurgery 10 (Suppl (1)) (2014) (p. 145-53; discussion 153-5). [21] D.A. Hardesty, H. Thind, J.M. Zabramski, R.F. Spetzler, P. Nakaji, Safety, efficacy, and cost of intraoperative indocyanine green angiography compared to intraoperative catheter angiography in cerebral aneurysm surgery, J. Clin. Neurosci. (2014). [22] C.W. Washington, G.J. Zipfel, M.R. Chicoine, C.P. Derdeyn, K.M. Rich, C.J. Moran, et al., Comparing indocyanine green videoangiography to the gold standard of intraoperative digital subtraction angiography used in aneurysm surgery, J. Neurosurg. 118 (2) (2013) 420–427.
Dale Ding University of Virginia, Department of Neurosurgery, P.O. Box 800212, Charlottesville, VA 22908, United States E-mail address: [email protected] 17 October 2016 2 November 2016 3 November 2016 Available online xxx
Please cite this article in press as: D. Ding, Surgical treatment of unruptured middle cerebral artery aneurysms: Complication avoidance, Clin Neurol Neurosurg (2016), http://dx.doi.org/10.1016/j.clineuro.2016.11.002