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  • Author or Editor: Emmanuel Gérardin x
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François Proust, Bertrand Debono, Didier Hannequin, Emmanuel Gerardin, Erick Clavier, Olivier Langlois and Pierre Fréger

Object. Endovascular and surgical treatment must be clearly defined in the management of anterior communicating artery (ACoA) aneurysms. In this study the authors report their recent experience in using a combined surgical and endovascular team approach for ACoA aneurysms, and compare these results with those obtained during an earlier period in which surgical treatment was used alone. Morbidity and mortality rates, causes of unfavorable outcomes, and morphological results were also assessed.

Methods. The prospective study included 223 patients who were divided into three groups: Group A (83 microsurgically treated patients, 1990–1995); Group B (103 microsurgically treated patients, 1996–2000); and Group C (37 patients treated with Guglielmi Detachable Coil [GDC] embolization, 1996–2000). Depending on the direction in which the aneurysm fundus projected, the authors attempted to apply microsurgical treatment to Type 1 aneurysms (located in front of the axis formed by the pericallosal arteries). They proposed the most adapted procedure for Type 2 aneurysms (located behind the axis of the pericallosal arteries) after discussion with the neurovascular team, depending on the physiological status of the patient, the treatment risk, and the size of the aneurysm neck. In accordance with the classification of Hunt and Hess, the authors designated those patients with unruptured aneurysms (Grade 0) and some patients with ruptured aneurysms (Grades I–III) as having good preoperative grades. Patients with Grade IV or V hemorrhages were designated as having poor preoperative grades. By performing routine angiography and computerized tomography scanning, the causes of unfavorable outcome (Glasgow Outcome Scale [GOS] score < 5) and the morphological results (complete or incomplete occlusion) were analyzed.

Overall, the clinical outcome was excellent (GOS Score 5) in 65% of patients, good (GOS Score 4) in 9.4%, fair (GOS Score 3) in 11.6%, poor (GOS Score 2) in 3.6%, and fatal in 10.3% (GOS Score 1). Among 166 patients in good preoperative grades, an excellent outcome was observed in 134 patients (80.7%). The combined permanent morbidity and mortality rate accounted for up to 19.3% of patients. The rates of permanent morbidity and death that were related to the initial subarachnoid hemorrhage were 6.2 and 1.5% for Group A, 6.6 and 1.3% for Group B, and 4 and 4% for Group C, respectively. The rates of permanent morbidity and death that were related to the procedure were 15.4 and 1.5% for Group A, 3.9 and 0% for Group B, and 8 and 8% for Group C, respectively. When microsurgical periods were compared, the rate of permanent morbidity or death related to microsurgical complications decreased significantly (Group A, 11 patients [16.9%] and Group B, three patients [3.9%]); Fisher exact test, p = 0.011) from the period of 1990 to 1995 to the period of 1996 to 2000. The combined rate of morbidity and mortality that was related to the endovascular procedure (16%) explained the nonsignificance of the different rates of procedural complications for the two periods, despite the significant decrease in the number of microsurgical complications. Among 57 patients in poor preoperative grade, an excellent outcome was observed in 11 patients (19.3%); however, permanent morbidity (GOS Scores 2–4) or death (GOS Score 1) occurred in 46 patients (80.7%). With regard to the correlation between vessel occlusion (the primary microsurgical complication) and the morphological characteristics of aneurysms, only the direction in which the fundus projected appeared significant as a risk factor for the microsurgically treated groups (Fisher exact test: Group A, p = 0.03; Group B, p = 0.002). The difference between endovascular and microsurgical procedures in the achievement of complete occlusion was considered significant (χ2 = 6.13, p = 0.01).

Conclusions. The direction in which the fundus projects was chosen as the morphological criterion between endovascular and surgical methods. The authors propose that microsurgical clip application should be the preferred option in the treatment of ACoA aneurysms with anteriorly directed fundi and that endovascular packing be selected for those lesions with posteriorly directed fundi, depending on morphological criteria.

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Stéphane Derrey, Romain Lefaucheur, Nathalie Chastan, Emmanuel Gérardin, Didier Hannequin, Marie Desbordes and David Maltête

Object

A collision/implantation or microlesion effect is commonly described after subthalamic nucleus (STN) implantation for high-frequency stimulation, and this is presumed to reflect disruption of cells and/or fibers. Off-period dystonia, a frequent cause of disability in patients with advanced Parkinson disease, can lead to the need for surgical treatment. The authors assessed the early effect of this microlesion on off-period dystonia.

Methods

The authors assessed 30 consecutive patients with the advanced levodopa-responsive form of Parkinson disease. The patients' symptoms were Hoehn and Yahr Scale score ≥ 3, the mean duration of their disease was 11.4 ± 3.5 years, and they had undergone bilateral implantation of electrodes within the STN for high-frequency stimulation between February 2004 and December 2006. The microlesion effect was defined by the clinical improvement (Unified Parkinson's Disease Rating Scale [UPDRS] Part III score, UPDRS Part IV, item 35) assessed the morning of the 3rd day following STN implantation, after at least a 12-hour withdrawal of dopaminergic treatment and before the programmable pulse generator was switched on (off-drug/off-stimulation mode).

Results

Compared with baseline (off state), the microlesion effect improved the motor score (UPDRS Part III) by 27%. Subscores for tremor, rigidity, and bradykinesia respectively improved by 42, 37, and 25%. Nineteen patients (63%) suffered from off-period dystonia before surgery. Twelve (41%) reported complete relief of their symptoms in the immediate postoperative period and remained free of painful off-period dystonia throughout the 6-month follow-up period.

Conclusions

The author postulated that off-period dystonia alleviation may reflect both a microsubthalamotomy and micropallidotomy effect. They hypothesize, moreover, that the microlesion could play a role in the 6-month postoperative outcome.

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François Proust, Olivier Martinaud, Emmanuel Gérardin, Stéphane Derrey, Sophie Levèque, Sandrine Bioux, Eléonore Tollard, Erick Clavier, Olivier Langlois, Olivier Godefroy, Didier Hannequin and Pierre Fréger

Object

For anterior communicating artery (ACoA) aneurysms, endovascular coil embolization constitutes a safe alternative therapeutic procedure to microsurgical clip occlusion. The authors' aim in this study was to evaluate the quality of life (QOL), cognitive function, and brain structure damage after the treatment of ruptured ACoA aneurysms in a group of patients who underwent microsurgical clipping (36 patients) compared with a reference group who underwent endovascular coiling (14 patients).

Methods

At 14 months posttreatment all patients underwent evaluations by independent observers. These observers evaluated global efficacy, executive functions using a frontal assessment battery of tests (Trail making test, Stroop tasks, dual task of Baddeley, verbal fluency, and Wisconsin Card Sorting test), behavior dysexecutive syndrome (the Inventaire du Syndrome Dysexécutif Comportemental questionnaire [ISDC]), and QOL by using the Reintegration To Normal Living Index. Brain damage was analyzed using MR imaging.

Results

In the microsurgical clipping and endovascular coiling groups, the distribution on the modified Rankin Scale (p = 0.19) and mean QOL score (85.4 vs 83.4, respectively) were similar. Moreover, the proportion of executive dysfunctions (19.4 vs 28.6%, respectively) and the mean score on the ISDC questionnaire (8.9 vs 8.5, respectively) were not significant, but verbal memory was more altered in the microsurgical clipping group (p = 0.055). Magnetic resonance imaging revealed that the incidence of local encephalomalacia and the median number of lesions per patient increased significantly in the microsurgical clipping group (p = 0.003).

Conclusions

In the 2 groups, no significant difference was observed regarding QOL, executive functions, and behavior. Despite the significant decrease in verbal memory after microsurgical clipping, the interdisciplinary approach remains a safe and useful strategy.