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 5-year period were analyzed in endovascular (n = 16) and microsurgical (n = 87) cohorts. Overall morbidity (Glasgow Outcome Score <5) after 12-month follow-up was 9 %. There was no significant difference between the two cohorts. Complete or “near complete” aneurysm occlusion was achieved in 97 and 75 % in the microsurgical, respective endovascular cohort. A “complex” aneurysm configuration had a significant impact on complete aneurysm occlusion in both cohorts, however, not on clinical outcome. Treatment of unruptured MCA aneurysms can be performed with a low risk of repair using both approaches. However, the risk for incomplete occlusion was higher for the endovascular approach in this series.
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Jeremy J. Lewis, Samuel L. Barnett, Dallas, USA
Dammann et al. present their series of 103 patients with unruptured middle cerebral artery aneurysms undergoing elective endovascular or microsurgical treatment from 2006 to 2010. Their institution utilizes a “coil first” philosophy likely supported by the results of the International Subarachnoid Aneurysm Trial (ISAT) published in 2005 [1]. Despite their “coil first” philosophy, 87 patients underwent microsurgical treatment and only 16 patients underwent endovascular treatment with a clear bias to treat larger and more complex aneurysms via clip ligation. Their microsurgical outcomes compare closely to the results of Lawton’s large experience treating unruptured middle cerebral artery aneurysms [2]. The microsurgical treatment cohort’s morbidity and mortality rates were 9 and 0 %, respectively, with 99 % of patients having a good (GOS 4 or 5) outcome at 12 months. The results of their endovascular cohort were similar with morbidity and mortality rates of 12 and 0 %, respectively. Ninety-four percent of endovascular patients had a good outcome (GOS 4 or 5) 12 months out from treatment with one (6 %) having a GOS of 3 at 12 months. Complete or near complete occlusion was seen in 97 % of patients undergoing microsurgical treatment, significantly better (p = 0.0016) than the 75 % of endovascular patients that achieved complete or near complete aneurysm occlusion. Their endovascular experience is slightly less encouraging than that reported by Johnson et al. [3] who found a 90.4 % complete occlusion rate at 6 months after stent-assisted embolization with a morbidity and mortality rate of 5.1 % for unruptured aneurysms. Brinjikji et al. [4] published a meta-analysis of 1,030 coiled MCA aneurysms revealing an overall morbidity and mortality rate of 5.5 %.
Despite their “coil first” philosophy, Dammann et al. acknowledge their selection bias by utilizing endovascular treatment primarily for smaller, narrow-necked and “simple” aneurysms. The lower occlusion rates and higher morbidity in their selective endovascular cohort suggest their results would be even less favorable if they had randomized their treatment groups. As suggested from ISAT, their 1-year follow-up period is within the time frame when endovascular safety advantages are evident. A longer follow-up period would be necessary to document the recurrence, rehemorrhage, and re-treatment rates.
Clip ligation of middle cerebral artery aneurysms has long been considered the gold standard treatment. We have an institutional preference for microsurgical treatment of middle cerebral artery aneurysms because of their accessibility after splitting the fissure and the potential for clip reconstruction or trapping of large or giant aneurysms that require bypass. Stent-assisted coiling is often necessary for middle cerebral artery aneurysms. Antiplatelet therapy is contraindicated in the setting of acute subarachnoid hemorrhage, furthering our own bias of treating ruptured lesions with clipping.
Overall, this is a well-written report on a large series with thoughtful conclusions. The authors are to be commended on their contribution.
References
1. Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, et al (2005) International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2,143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet 366:809–817
2. Rodriguez-Hernandez A, Sughrue ME, Akhavan S, Habdank- Kolaczkowski J, Lawton MT (2013) Current management of middle cerebral artery aneurysms: surgical results with a “clip first” policy. Neurosurgery 72(3): 415–27
3. Johnson AK, Heiferman DM, Lopes DK (2013) Stent-assisted embolization of 100 middle cerebral artery aneurysms. J Neurosurgy 118(5):950–955
4. Brinjikji W, Lanzino G, Cloft HJ, Rabinstein A, Kallmes DF (2011) Endovascular treatment of middle cerebral artery aneurysms: a systematic review and single-center series. Neurosurgery 68:397–402
Kaoru Kurisu, Hiroshima, Japan
The authors showed reasonable results to treat patients with unruptured middle cerebral artery (MCA) aneurysms by microsurgery or endovascular coil embolization (ECE). Before era of ECE all intracranial aneurysms were treated by transcranial microsurgical approaches. Even at the beginning of ECE era, transcranial microsurgical approaches have been a mainstream for treatment of them. But, according to the development of endovascular treatment devices and development of diagnostic machines such as rotational DSA, three 3D CT angiography, and three tesla MRA, we can get more accurate information about aneurysmal configurations, neck-dome ratio, transluminal observation of the aneurysm and surrounding arteries, small branching from aneurysm itself and close the neck, and so on; it makes us treat patients with aneurysms by multimodality options. Additionally, the important thing is to share the information and to do coordinal work between neuroradiologists and neurosurgeons. Even in transcranial microsurgical approach, less invasive techniques were widely distributed in the field not only clipping, but also combination of vascular reconstruction and clipping, especially to the complicated large-sized aneurysms. In Japan, generally speaking, almost all ECE and microsurgical clipping are achieved in the same department of neurosurgery. So, we are always discussing in one place what the best treatment for the patients is. In future, additional development of ECE treatments with intracranial artery stent, we will have more suitable options and higher surgical results with less invasiveness to the patients.
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Dammann, P., Schoemberg, T., Müller, O. et al. Outcome for unruptured middle cerebral artery aneurysm treatment: surgical and endovascular approach in a single center. Neurosurg Rev 37, 643–651 (2014). https://doi.org/10.1007/s10143-014-0563-5
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DOI: https://doi.org/10.1007/s10143-014-0563-5