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  • Author or Editor: David F. Kallmes x
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Ioannis Loumiotis, Robert D. Brown Jr., Roanna Vine, Harry J. Cloft, David F. Kallmes and Giuseppe Lanzino

Object

The management of incidental small unruptured intracranial aneurysms (UIAs) is controversial and many factors need to be considered in the decision-making process. The authors describe a large consecutive series of patients harboring small incidental intracranial aneurysms. Treatment strategy, natural history, complications, and short-term outcomes are presented.

Methods

Between January 2008 and May 2011, the authors prospectively evaluated 212 patients with 272 small (< 10-mm) incidental aneurysms. Treatment recommendations (observation, endovascular treatment, or surgery), complications of treatment, and short-term outcomes were assessed.

Results

Recommended treatment consisted of observation in 125 patients, endovascular embolization in 64, and surgery in 18. Six patients were excluded from further analysis because they underwent treatment elsewhere. In the observation group, at a mean follow-up of 16.7 months, only 1 patient was moved to the embolization group. Seven (6%) of the 125 patients in the observation group died of causes unrelated to aneurysm. Sixty-five patients underwent 69 embolization procedures. The periprocedural permanent morbidity and mortality rates in patients undergoing endovascular treatment were 1.5% and 1.5%, respectively (overall morbidity and mortality rate 3.0%). In the surgery group no periprocedural complications were observed, although 1 patient did not return to her previous occupation. No aneurysmal rupture was documented in any of the 3 treatment groups during the follow-up period.

Conclusions

A cautious and individualized approach to incidental UIAs is of utmost importance for formulation of a safe and effective treatment algorithm. Invasive treatment (either endovascular or surgery) can be considered in selected younger patients, certain “higher-risk” locations, expanding aneurysms, patients with a family history of aneurysmal hemorrhage, and in those who cannot live their lives knowing that they harbor the UIA. Although the complication rate of invasive treatment is very low, it is not negligible. The study confirms that small incidental UIAs deemed to be not in need of treatment have a very benign short-term natural history, which makes observation a reasonable approach in selected patients.

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Robert D. Ecker, Robert D. Brown Jr, Douglas A. Nichols, Robyn L. McClelland, Megan S. Reinalda, David G. Piepgras, Harry J. Cloft and David F. Kallmes

Object. Definitive data characterizing the safety and efficacy of carotid angioplasty with stent placement (CAS) for symptomatic, occlusive carotid artery (CA) disease require further refinements and standardization of techniques as well as large prospective studies on a par with the North American Symptomatic Carotid Endarterectomy Trial (NASCET). Despite the absence of such data, many surgeons have performed angioplasty and stent placement in patients with clinical or anatomical features known to add significant perioperative risk and capable of disqualifying the patients from participation in NASCET. There exists no cost analysis comparing high-risk endarterectomy with percutaneous angioplasty and stent insertion.

Methods. Forty-five patients (29 men and 16 women) with high-risk, symptomatic CA stenosis have been treated with CAS at the authors' institution since 1996. Indications for this procedure included symptomatic recurrent stenosis following CA endarterectomy (CEA), active coronary disease, high CA bifurcation, and severe medical comorbidities. A long-standing CEA computer database was screened for control patients with similar risk factors; 391 patients (276 men and 115 women) were identified. Actual cost data, duration of hospital stay, and relevant clinical data from the time of treatment until hospital discharge were collected in each patient. The median total cost of CAS was $10,628, whereas that for CEA was $10,148 (p = 0.495).

Conclusions. In patients with high-risk, NASCET-ineligible CA stenosis there was no overall statistically significant cost difference between CEA and CAS. Given that there may not be a cost advantage for either procedure, procedural risk, efficacy, and durability should be key factors in determining the optimal treatment strategy.

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Lisa Anne Cannon-Albright

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Robert D. Brown JR., John Huston III, Richard Hornung, DR.P.H., Tatiana Foroud, David F. Kallmes, Dawn Kleindorfer, Irene Meissner, Daniel Woo, Laura Sauerbeck, Joseph Broderick and for the Familial Intracranial Aneurysm (FIA) Investigators

Object

Approximately 20% of patients with an intracranial saccular aneurysm report a family history of intracranial aneurysm (IA) or subarachnoid hemorrhage. A better understanding of predictors of aneurysm detection in familial IA may allow more targeted aneurysm screening strategies.

Methods

The Familial Intracranial Aneurysm (FIA) study is a multicenter study, in which the primary objective is to define the susceptibility genes related to the formation of IA. First-degree relatives (FDRs) of those affected with IA are offered screening with magnetic resonance (MR) angiography if they were previously unaffected, are ≥ 30 years of age, and have a history of smoking and/or hypertension. Independent predictors of aneurysm detection on MR angiography were determined using the generalized estimating equation version of logistic regression.

Results

Among the first 303 patients screened with MR angiography, 58 (19.1%) had at least 1 IA, including 24% of women and 11.7% of men. Ten (17.2%) of 58 affected patients had multiple aneurysms. Independent predictors of aneurysm detection included female sex (odds ratio [OR] 2.46, p = 0.001), pack-years of cigarette smoking (OR 3.24 for 20 pack-years of cigarette smoking compared with never having smoked, p < 0.001), and duration of hypertension (OR 1.26 comparing those with 10 years of hypertension to those with no hypertension, p = 0.006).

Conclusions

In the FIA study, among the affected patients' FDRs who are > 30 years of age, those who are women or who have a history of smoking or hypertension are at increased risk of suffering an IA and should be strongly considered for screening.

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Jason Mackey, Robert D. Brown Jr., Charles J. Moomaw, Laura Sauerbeck, Richard Hornung, Dheeraj Gandhi, Daniel Woo, Dawn Kleindorfer, Matthew L. Flaherty, Irene Meissner, Craig Anderson, E. Sander Connolly, Guy Rouleau, David F. Kallmes, James Torner, John Huston III and Joseph P. Broderick

Object

Familial predisposition is a recognized nonmodifiable risk factor for the formation and rupture of intracranial aneurysms (IAs). However, data regarding the characteristics of familial IAs are limited. The authors sought to describe familial IAs more fully, and to compare their characteristics with a large cohort of nonfamilial IAs.

Methods

The Familial Intracranial Aneurysm (FIA) study is a multicenter international study with the goal of identifying genetic and other risk factors for formation and rupture of IAs in a highly enriched population. The authors compared the FIA study cohort with the International Study of Unruptured Intracranial Aneurysms (ISUIA) cohort with regard to patient demographic data, IA location, and IA multiplicity. To improve comparability, all patients in the ISUIA who had a family history of IAs or subarachnoid hemorrhage were excluded, as well as all patients in both cohorts who had a ruptured IA prior to study entry.

Results

Of 983 patients enrolled in the FIA study with definite or probable IAs, 511 met the inclusion criteria for this analysis. Of the 4059 patients in the ISUIA study, 983 had a previous IA rupture and 657 of the remainder had a positive family history, leaving 2419 individuals in the analysis. Multiplicity was more common in the FIA patients (35.6% vs 27.9%, p < 0.001). The FIA patients had a higher proportion of IAs located in the middle cerebral artery (28.6% vs 24.9%), whereas ISUIA patients had a higher proportion of posterior communicating artery IAs (13.7% vs 8.2%, p = 0.016).

Conclusions

Heritable structural vulnerability may account for differences in IA multiplicity and location. Important investigations into the underlying genetic mechanisms of IA formation are ongoing.