R are diseases are defined in the United States as any disorder or condition affecting < 200,000 people. 1 While the prevalence of cerebrovascular diseases such as stroke and aneurysms makes these conditions far from rare, the prevalence of brain vascular malformations, including dural arteriovenous fistulas (dAVFs), easily reaches this criterion. The crude prevalence of the most common brain vascular malformation, arteriovenous malformation (AVM), has been calculated at approximately 30,000. 2 Unfortunately, prevalence estimates for dAVFs are
Chad W. Washington, L. Ian Taylor, Robert J. Dambrino, Paul R. Clark, and Gregory J. Zipfel
certification was partially based on treatment volume thresholds. 3 , 12 , 41 The current CSC annual volume requirements are treatment of 20 or more SAH patients, performance of 15 or more endovascular coiling or surgical clipping procedures for aneurysms, and administration of intravenous tissue plasminogen activator in 25 or more eligible patients. 23 Evidence that increasing treatment volume improves outcomes has been shown across a number of neurological diagnoses and procedures, including cerebral aneurysms, 3 , 6 , 8 , 9 , 11 , 12 , 20 , 27 , 30 , 36–38 , 41 carotid
Gregory J. Zipfel and Ralph G. Dacey
Over the past decade, several factors have led to a dramatic change in the manner in which patients with unruptured intracranial aneurysms are diagnosed and treated. These factors include the increased use of noninvasive imaging modalities for the diagnosis of intracranial aneurysms, publication of new natural history data detailing the hemorrhage risks associated with unruptured intracranial aneurysms, and the broad application of endovascular therapy for their treatment. With these new technologies and new natural history data has come considerable uncertainty about the optimal treatment strategy for patients with unruptured intracranial aneurysms. In this light, it seems prudent to review periodically and examine critically all recent data pertaining to the natural history and treatment of unruptured intracranial aneurysms, in an effort to provide a scientific update on which management recommendations can be based. This review article represents the authors' attempt at such an update, and it is their hope that members of the community of neurovascular surgeons might find this information helpful during their continuing efforts to provide optimal care for their patients with unruptured intracranial aneurysms.
Eric J. Arias, Bhuvic Patel, DeWitte T. Cross III, Christopher J. Moran, Ralph G. Dacey Jr., Gregory J. Zipfel, and Colin P. Derdeyn
U nruptured intracranial aneurysms are common: the prevalence of unruptured cerebral aneurysms in the general population is approximately 2.0%. 16 Over the last decade, an increasing number of unruptured cerebral aneurysms have been treated using endovascular techniques. Analysis of the Nationwide Inpatient Sample demonstrates that from 1998 to 2007 there were 14,765 discharges for patients with an unruptured cerebral aneurysm. 6 From 2002 to 2007, 61.7% of all treated unruptured aneurysms were managed with endovascular coil embolization, making it the
Chad W. Washington, Gregory J. Zipfel, Michael R. Chicoine, Colin P. Derdeyn, Keith M. Rich, Christopher J. Moran, DeWitte T. Cross, and Ralph G. Dacey Jr.
S ince McKissock et al. 28 first demonstrated the benefits of surgical intervention for ruptured intracranial aneurysms, significant efforts have been devoted toward optimizing the safety and efficacy of surgical aneurysm obliteration. From these efforts we have learned that total obliteration of the aneurysm while maintaining blood flow through parent and branch vessels is the hallmark of successful surgical therapy. However, even in the most modern series where state-of-the-art equipment and techniques were used, this task has not always proven to be
Eric J. Arias and Gregory J. Zipfel
Giant cerebral aneurysms may be treated through a variety of options, including aneurysm trapping with concurrent bypass. This video describes the case of a large, recurrent, left middle cerebral artery aneurysm that was treated using a high flow, radial artery bypass graft, from the external carotid artery to the left temporal M2 branch. A step-by-step operative description, with emphasis on proper microsurgical technique, is included.
The video can be found here: http://youtu.be/9xTMC6InivQ.
Gregory J. Zipfel
I n this issue, Park and colleagues analyzed patient outcome before and after implementation of a protocol of “emergency treatment” for patients with aneurysmal subarachnoid hemorrhage (SAH) admitted to their highvolume tertiary care hospital. 3 Prior to implementing this protocol, the authors admitted patients with SAH on hospital Day 0, performed diagnostic catheter angiography on hospital Day 1, and treated the offending aneurysm on hospital Day 2. After implementing this protocol, the authors admitted patients with SAH, performed diagnostic catheter
Gregory J. Zipfel
In this issue Aaron Cohen-Gadol and colleagues report on a prospective study examining the utility of microscope-integrated intravenous fluorescein videoangiography (FL-VA) versus microscope-integrated intravenous indocyanine green videoangiography (ICG-VA) as intraoperative assessment tools to determine the safety and efficacy of surgical aneurysm obliteration. 1 As the authors state, ICG-VA has become an invaluable tool in assessing the completeness of aneurysm obliteration and the patency of neighboring parent and branch arteries during aneurysm surgery
Matthew R. Reynolds, Jon T. Willie, Gregory J. Zipfel, and Ralph G. Dacey Jr.
R uptured intracranial aneurysms constitute a significant cause of morbidity and mortality in young and middle-aged patients. The annual incidence of SAH ranges from 7 to 28 cases per 100,000, 40 , 77 and the vast majority of these cases (75%) are attributable to ruptured cerebral aneurysms. 78 There is evidence that some cases of aneurysmal SAH are precipitated by sexual intercourse 1 , 22 , 87 and other episodes of intense physical exertion. 2 , 64 , 80 It is estimated that these activities increase the risk of aneurysm rupture by as much as 15-fold
Chad W. Washington, Colin P. Derdeyn, Ralph G. Dacey Jr., Rajat Dhar, and Gregory J. Zipfel
selected based on the admitting diagnosis of aneurysmal SAH (ICD-9-CM 430). The charts of these patients were reviewed to verify that the reason for admission was a ruptured cerebral aneurysm. Those patients without an aneurysm or with other etiologies (for example, trauma, arteriovenous malformation, hemorrhagic stroke) were excluded. The final population was then cross-matched to their admission HH grade and hospital discharge mRS score, which were obtained from the prospectively collected database maintained as part of our institutional Stroke and Cerebrovascular