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Clinical implications and radiographic characteristics of the relation between giant intracranial aneurysms of the posterior circulation and the brainstem

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

Background

Giant intracranial aneurysms of the posterior circulation (GPCirA) are rare entities compressing the brainstem and adjacent structures. Previous evidence has shown that the amount of brainstem shift away from the cranial base is not associated with neurological deficits. This raises the question whether other factors may be associated with neurological deficits.

Methods

All data were extracted from the Giant Intracranial Aneurysm Registry, an international multicenter prospective study on giant intracranial aneurysms. We grouped GPCirA according to the mass effect on the brainstem (lateral versus medial). Brainstem compression was evaluated with two indices: (a) brainstem compression ratio (BCR) or diameter of the compressed brainstem to the assumed normal diameter of the brainstem and (b) aneurysm to brainstem ratio (ABR) or diameter of the aneurysm to the diameter of the compressed brainstem. We examined associations between neurological deficits and GPCirA characteristics using binary regression analysis.

Results

Twenty-eight GPCirA were included. Twenty GPCirA showed medial (71.4%) and 8 lateral compression of the brainstem (28.6%). Baseline characteristics did not differ between the groups for patient age, aneurysm diameter, aneurysm volume, modified Rankin Scale (mRS), motor deficit (MD), or cranial nerve deficits (CND). Mean BCR was 53.0 in the medial and 54.0 in the lateral group (p = 0.92). The mean ABR was 2.9 in the medial and 2.3 in the lateral group (p = 0.96).

In the entire cohort, neither BCR nor ABR nor GPCirA volumes were associated with the occurrence of CND or MD. In contrast, disability (mRS) was significantly associated with ABR (OR 1.94 (95% CI 1.01–3.70; p = 0.045) and GPCirA volumes (OR 1.21 (95% CI 1.01–1.44); p = 0.035), but not with BCR.

Conclusion

In this cohort of patients with GPCirA, neither the degree of lateral projection nor the amount of brainstem compression predicted neurological deficits. Disability was associated only with aneurysm volume. When designing treatment strategies for GPCirA, aneurysm laterality or the amount of brainstem compression should be viewed as less relevant while the high risk of rupture of such giant lesions should be emphasized.

Trial registration

The registry is listed at clinicaltrials.gov under the registration no. NCT02066493.

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Funding

The Center for Stroke Research Berlin (no. CS-2009-12) provided financial support to the senior author (J.D.). This grant is exclusively dedicated to the maintenance of the Internet-based database.

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Authors and Affiliations

  1. Department of Neurosurgery, Charité-Universitaetsmedizin Berlin, Berlin, Germany

    Julien Haemmerli, Pavlina Lenga, Peter Vajkoczy & Julius Dengler

  2. Department of Neurosurgery, University Hospital Geneva, Geneva, Switzerland

    Julien Haemmerli & Philippe Bijlenga

  3. Department of Neurosurgery, Hannover Medical School, Hanover, Germany

    Bujung Hong

  4. Department of Neurosurgery and Interventional Neuroradiology, Donauisar Klinikum Deggendorf, Deggendorf, Germany

    Adisa Kursumovic

  5. Department of Neurosurgery, University Hospital of Zurich, Zurich, Switzerland

    Nicolai Maldaner & Jan-Karl Burkhardt

  6. Department of Neuroradiology, Hirslanden Clinic, Zurich, Switzerland

    Daniel A. Rüfenacht

  7. Department of Neurosurgery, University Medical Center, Eppendorf, Hamburg, Germany

    Nils-Ole Schmidt

  8. Brandenburg Medical School Theodor Fontane, Campus Bad Saarow, Bad Saarow, Germany

    Julius Dengler

  9. Department of Neurosurgery, Helios Clinic, Bad Saarow, Germany

    Julius Dengler

Authors
  1. Julien Haemmerli
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  2. Pavlina Lenga
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  9. Nils-Ole Schmidt
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  10. Peter Vajkoczy
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  11. Julius Dengler
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Corresponding author

Correspondence to Julien Haemmerli.

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The authors declare that they have no conflict of interest.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee (Charité-Universitaetsmedizin Berlin) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Comments

The major risk of giant aneurysms in the posterior circulation is the risk of rupture (50% in 5 years, cumulative). Unless the patient is in a medical condition which makes a treatment contraindicated, I believe all basilar tip giant aneurysms should be given the same level of attention and be treated if a reasonable clinical setting is present. The fact that a laterally projecting aneurysm or a degree of compression is not impacting C/N or motor function is not a legit criteria to delay or not to treat an unruptured giant aneurysm. This is a well-designed study on a small population and lacks treatment data. I encourage the authors to provide us with their updated information on what treatment modality is used in this population and whether the projection and compressive factors of the aneurysm could/should impact the treatment modality.

Amir Dehdashti

NY, USA

This research was carried out at the Department of Neurosurgery, Charité-Universitaetsmedizin Berlin, Germany.

This article is part of the Topical Collection on Vascular Neurosurgery - Aneurysm

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Haemmerli, J., Lenga, P., Hong, B. et al. Clinical implications and radiographic characteristics of the relation between giant intracranial aneurysms of the posterior circulation and the brainstem. Acta Neurochir 161, 1747–1753 (2019). https://doi.org/10.1007/s00701-019-04016-x

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  • DOI: https://doi.org/10.1007/s00701-019-04016-x

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