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Long-term follow-up survey reveals a high yield, up to 30% of patients presenting newly detected aneurysms more than 10 years after ruptured intracranial aneurysms clipping

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Abstract

The need to pursue long-term follow-up in patients treated for a ruptured aneurysm remains debated. New aneurysms development is a crucial element to consider but remains scarcely analyzed especially after a mean follow-up longer than 10 years. Our study was designed to provide rates of newly developed aneurysms in patients who have undergone prior clipping who were not followed with serial imaging. Patients were included if they were (1) treated more than 10 years ago by clipping of a ruptured aneurysm, (2) independent at time of discharge, (3) presently younger than 65 years, and if (4) they agreed to undergo a late digital subtraction angiography (DSA) control or to transmit results of a recent one performed elsewhere. Twenty patients were included with a mean delay between aneurysm treatment and late DSA of 18.0 years (10–26.5 years). Out of these patients, six (30%) harbored new aneuryms. Of these six individuals, four (66.6%) presented multiple aneurysms with a total of 15 newly discovered aneurysms. Aneurysm sizes ranged from 1 to 10 mm. One patient suffered from a de novo aneurysm rupture. Multiple aneurysms at the time of the first hemorrhage were a risk factor in developing de novo aneurysm (p = 0.0175). In conclusion, based on a 30% rate of new aneurysm formation in patients clipped more than a decade ago, close screening on a very long-term perspective is encouraged. This study suggests aneurysm formation to be a continuous process.

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Acknowledgments

We are grateful to Patrick Fransen, MD, for providing information regarding digital subtraction angiographies performed in his institution (Clinique du Parc Léopold, Brussels, Belgium); Christian Melot, MD, PhD, MSciBiostat (Department of Emergency Medicine, Erasme Hospital, Brussels, Belgium) for his assistance in statistical analysis; and Jeroen Coppens, MD (Department of Neurosurgery, Saint Louis, MO) for his help in grammatical corrections.

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Authors and Affiliations

  1. Department of Neurosurgery, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium

    Michaël Bruneau, Michal Rynkowski, Jacques Brotchi & Olivier De Witte

  2. Department of Neurology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium

    Karina Smida-Rynkowska

  3. Department of Neuroradiology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium

    Boris Lubicz

  4. Department of Neurosurgery, Hôpital Erasme, Route de Lennik, 808, 1070, Brussels, Belgium

    Michaël Bruneau

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  1. Michaël Bruneau
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  5. Olivier De Witte
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Correspondence to Michaël Bruneau.

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Comments

Elke R. Gizewski, Giessen, Germany

For a long time, patients with cerebral artery aneurysms have been treated using surgical clipping. The method is reported to be the most definite treatment of aneurysms; therefore, the debate of long-term follow-up in this group was and is controversial. There is a high clinical impact in patients suffering from a cerebral artery aneurysm in which way the neurosurgeons interpret this pathology: a focal vessel wall defect or more general vessel wall instability.

As clearly summarized in this article, many patients treated by clipping after an SAH were considered cured with no reason for follow-up. However, there are studies reporting a higher risk of recurrent SAH in those patients even if all aneurysms at the time of the first event were successfully treated. This article also presents the two many possible findings in a rebleeding: regrowth of the initial aneurysm (e.g., at the neck) or de novo aneurysms; both pathologies indicating that the aneurysm is not a focal defect and a finding that is also reported for endovascular-treated aneurysms (1). As the risk of de novo aneurysms increases over the time, the authors present an interesting and very important evaluation of the value of long-term follow-up diagnostics in patients after aneurysm clipping.

The here presented study and the review of the literature have an important impact on the clinical management of patients after clip therapy of a cerebral artery aneurysm. The authors present an evaluation of the DSA in 20 patients after clipping. The strength of this study is the follow-up time more than 10 years after the first surgery (10–26 years). The authors could find one recurrent aneurysm at the neck of a clipped aneurysm and de novo aneurysms in six patients of whom four had multiple de novo aneurysms. Within this study, there is a relatively high rate of new aneurysms (de novo aneurysm/patient-year, 4.15%). However, one shortcoming is that the statistical interpretations are partly preliminary as the included patient number was low. As the authors very clearly summarize in Table 2, there are further studies with much lower de novo rates. One argument is the follow-up of less than 10 years in most studies, however, two studies also had a follow-up comparable to the here presented one and a 1% de novo aneurysm/patient-year with groups of 40 and 89 patients, respectively. Besides the total number of patients included, the authors discuss correctly the possible overestimation in their study due to one patient with seven de novo aneurysms. Apart from this main topic, the authors present an interesting discussion concerning the point of “true de novo” aneurysms and possible overseen aneurysms in the first examination. Furthermore, CTA and DSA are compared in respect of sensitivity especially for small aneurysms. This point is very important for the method of follow-up; on one hand, the CTA has the advantage of a non-invasive technique, on the other hand, it is known that even small aneurysms (maybe not detectable in CTA) can cause a bleeding in patients with SAH in history.

In total, due to the small group, the authors cannot identify any risk factors for de novo aneurysms apart from SAH in history. However, they come to the conclusion that a long-term follow-up is important for such patients which is a message with high clinical impact. Further studies with larger patient groups or even multi-center registers are necessary to evaluate further risk factors but also the best choice of the method. The higher sensitivity of DSA might be useless if many patients are “lost” because they would not agree to this invasive procedure or clinics could have logistic problems (in recent times also cost restrictions). As newer CT developments (dual source technique) could be even used to analyze the clipped aneurysm, this non-invasive method could be an acceptable alternative (2).

References

1. Plowman RS, Clarke A, Clarke M, Byrne JV (2011) Sixteen-year single-surgeon experience with coil embolization for ruptured intracranial aneurysms: recurrence rates and incidence of late rebleeding. Clinical Article. J Neurosurg 114(3):863–874

2. Fahrendorf DM, Goericke SL, Oezkan N, Breyer T, Hussain S, Sandalcioglu EI, Sure U, Forsting M, Gizewski ER (2011) The value of dual-energy CTA for control of surgically clipped aneurysms. Eur Radiol. doi:10.1007/s00330-011-2147-x

Kiyohiro Houkin, Sapporo, Japan

We empirically know that de novo cerebral aneurysms are occasionally seen in the long-term follow-up after the surgical treatment of aneurysms. However, there are quite few systemic studies on this clinical question since these studies require well-designed long-term observation.

This study revealed the high incidence of the de novo aneurysms seen in patients with multiple aneurysms that is quite intuitively acceptable for neurosurgeons. The conclusion that 30% rate of new aneurysm formation in patients clipped more than a decade ago invokes us that the careful follow-up is indispensable even in 10 years after the surgery.

However, this study includes some drawbacks. Firstly, the possibility of missing of the detection of the aneurysm in the first event is not always ruled out. Secondly, we neurosurgeons, often detect very small aneurysms during surgery that are not correctly diagnosed in the angiography. Indeed, true “de novo” aneurysm is not always clearly discriminated from the missing small aneurysm in the first procedures. However, in any case, the high rate of the new formation of the cerebral aneurysm detected in the long-term follow-up is quite an important suggestion for us. We have to carefully watch the treated patients with cerebral aneurysm considering high incidence of new formation of the cerebral aneurysm in particular when the patient is young and has multiple aneurysms. In addition, we might have to consider some new guidelines for the follow-up of the patients with previously clipped aneurysms based on the similar studies. I sincerely expect that more studies with more number of patients on this issue will be launched in many major institutions.

Marc Sindou, Lyon, France

This study pleads for following the patients with previously ruptured intracranial aneurysms (and also those with asymptomatic aneurysms), especially when they are multiple or developed in dysplastic arteries. For practical reasons, perhaps imaging monitoring should only be CT angiography or MR angiography. Secondary DSA through direct femoral route should be limited to the exploration of patients’ candidates to endovascular or surgical treatment, or when images are difficult to interpret.

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Bruneau, M., Rynkowski, M., Smida-Rynkowska, K. et al. Long-term follow-up survey reveals a high yield, up to 30% of patients presenting newly detected aneurysms more than 10 years after ruptured intracranial aneurysms clipping. Neurosurg Rev 34, 485–496 (2011). https://doi.org/10.1007/s10143-011-0332-7

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