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Procedural complications in patients undergoing microsurgical treatment of unruptured intracranial aneurysms: a single-center experience with 1923 aneurysms

  • Original Article - Vascular Neurosurgery - Aneurysm
  • Published:
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Abstract

Background

With the growing use of endovascular therapy (EVT) to manage unruptured intracranial aneurysms (IAs), detailed information regarding periprocedural complication rates of microsurgical clipping and EVT becomes increasingly important in determining the optimal treatment for individual cases. We report the complication rates associated with open microsurgery in a large series of unruptured IAs and highlight the importance of maintaining surgical skill in the EVT era.

Methods

We reviewed all cases of unruptured IAs treated with open microsurgery by a single neurosurgeon between July 1997 and June 2019. We analyzed surgical complications, deaths, and patient-reported outcomes.

Results

A total of 1923 unruptured IAs in 1750 patients (mean age 44 [range: 6–84], 62.0% [1085/1750] female) were treated surgically during the study period. Of the aneurysms treated, 84.9% (1632/1923) were small, 11.1% (213/1923) were large, and 4.1% (78/1923) were giant. Aneurysm locations included the middle cerebral artery (44.2% [850/1923]), internal carotid artery (29.1% [560/1923]), anterior cerebral artery (21.0% [404/1923]), and vertebrobasilar system (5.7% [109/1923]). The overall mortality rate was 0.3% (5/1750). Surgical complications occurred in 7.4% (129/1750) of patients, but only 0.4% (7/1750) experienced permanent disability. The majority of patients were able to return to their preoperative lifestyles with no modifications (95.9% [1678/1750]).

Conclusions

At a high-volume, multidisciplinary center, open microsurgery in carefully selected patients with unruptured IAs yields favorable clinical outcomes with low complication rates. The improvement of EVT techniques and the ability to refer cases for EVT when a high complication rate with open microsurgery was expected have contributed to an overall decrease in surgical complication rates. These results may serve as a useful point of reference for physicians involved in treatment decision-making for patients with unruptured IAs.

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Acknowledgements

The authors acknowledge Superior Medical Experts for research and drafting assistance.

Funding

This manuscript was supported by a grant from the United Hospital Foundation, awarded to ESN.

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Authors and Affiliations

  1. Department of Neurosurgery, National Brain Aneurysm and Tumor Center, United Hospital, 3033 Excelsior Boulevard, Suite 495, Minneapolis, MN, USA

    Eric S. Nussbaum, Jodi Lowary, Tariq Janjua & Leslie A. Nussbaum

  2. Superior Medical Experts, St. Paul, MN, USA

    Jillienne C. Touchette

  3. Midwest Radiology, St. Paul, MN, USA

    Michael T. Madison, James K. Goddard, Jeffrey P. Lassig, Mark E. Meyers, Collin M. Torok & Jason J. Carroll

  4. Department of Interventional Neuroradiology, John Nasseff Neuroscience Institute, United Hospital, St. Paul, MN, USA

    Jeffrey P. Lassig

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Correspondence to Eric S. Nussbaum.

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Comments:

First, we would like to congratulate the authors on their effort across almost a quarter of century to establish a new standard for morbidity and mortality of unruptured intracranial aneurysm surgery. Notwithstanding, the paper and the data deserve some comments.

First, microsurgery for unruptured intracranial aneurysms is a well established, effective and durable treatment. Neurosurgeons should not apologize when they decide to treat aneurysms microsurgically, especially those on MCA tree and anterior circulation. No study to the present date showed unequivocally the superiority of other treatments over microsurgery.

Having said that, unruptured aneurysms have a rupture rate on the long-term, recurrence after treatment,and a biology that is different from ruptured ones. It’s a common mistake to look to this group retrospectively with data gathered from the analysis of ruptured aneurysms. This means that we should be very careful with the selection of those unruptured aneurysms that deserve treatment as well as our M&M should be kept at a very low level. That level remains to be determined.

In the years to come, hopefully, new modalities to help us determine which aneurysms deserve treatment will come to our armamentarium. Then, we’ll rely less on morphological criteria and more on biological characteristics of the aneurysm’ wall. Considering the complexity of the disease this won’t be an easy task. Until then and also from then on the focus should be on prevention, especially on restricted smoking public policies as well as hypertension awareness and effective treatment.

Another point of interest is the reporting of occlusion rates as a measure of success in aneurysm surgery. Complete occlusion is unquestionably important or mandatory in ruptured aneurysms since the inflammation process proved to come to a ‘no-return’ point and the re-rupture is a big concern. Contrariwise, in unruptured aneurysms the focus should be on the side of avoiding complications, since rupture of a neck remnant is an extremely uncommon event. The authors should be congratulated for this.

Finally, the authors tried to evaluate cognitive and quality-of-life issues in this paper. They claim, correctly, that this is a commonly overlooked problem in neurosurgery. However, in our opinion, worst than non-assessment is a bad or confusing one. Without a proper pre-operative neuropsychological evaluation, a post-operative MRI searching for new lesions (especially minor asymptomatic strokes or contusions) followed by new neuropsychological assessment it’s not possible to judge on this issue properly. New studies with new designs should be undertaken with this purpose.

Joao Silva and Mika Niemelä

Helsinki, Finland

In this manuscript the authors describe a large number of unruptured aneurysms which have undergone clipping by a single neurosurgeon.  The study is generally descriptive in that they are selected from a larger cohort, about half of which underwent endovascular treatment and half of which underwent open surgical treatment. The overall mortality rate was low at 0.3% (5/1750). Permanent disability occurred in 0.4% (7/1750).  A return to preoperative lifestyles with no modifications occurred in 95.9% (1678/1750).  While more granular data regarding specific quality of life measures and neurocognitive outcomes is lacking, this constitutes an endorsement of the safety of microsurgery in experienced hands.  This study does not provide data regarding different epochs in the surgeon's experience, but the event numbers are so low that it is unlikely that there would be any significant difference between the early and later parts of the surgeon's career.  The retrospective and selected nature of the study means that the low complication rates cannot be attributed to any specific factors, but one can speculate that clipping aneurysms under the favorable conditions present in the unruptured state makes very good outcomes possible.  Endovascular techniques and technology continue to evolve and produce better and better outcomes.  However, arguably a major role still exists for clipping as is employed in this practice, provided the practitioner is careful, skilled, and experienced.  Preservation and perfection of the skill of open clipping should still be emphasized strongly so that whatever the choice of modality, the best outcome for that modality is being offered to the patient.  Loss of clipping skills may lead to a bias in favor of endovascular treatment outcomes, with a commensurate bias in modality selection generating a self-fulfilling prophecy in favor of more endovascular treatment.  It has been our observation that the clipping learning curve is longer and more difficult to navigate; this is not a reason not to attain such expertise.

Roland Jabre,

Brittany Madison Gerald,

Peter Nakaji,

Phoenix, Arizona, USA

This article is part of Topical Collection on Vascular Neurosurgery – Aneurysm

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Nussbaum, E., Touchette, J., Madison, M. et al. Procedural complications in patients undergoing microsurgical treatment of unruptured intracranial aneurysms: a single-center experience with 1923 aneurysms. Acta Neurochir 164, 525–535 (2022). https://doi.org/10.1007/s00701-021-04996-9

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