Miikka Korja, Riku Kivisaari, Behnam Rezai Jahromi and Hanna Lehto
Large consecutive series on the size and location of ruptured intracranial aneurysms (RIAs) are limited, and therefore it has been difficult to estimate population-wide effects of size-based treatment strategies of unruptured intracranial aneurysms. The authors' aim was to define the size and location of RIAs in patients diagnosed with subarachnoid hemorrhage due to aneurysm rupture in a high-volume academic center.
Consecutive patients admitted to a large nonprofit academic hospital with saccular RIAs between 1995 and 2009 were identified, and the size, location, and multiplicity of RIAs were defined and reported by patient sex.
In the study cohort of 1993 patients (61% women) with saccular RIAs, the 4 most common locations of RIAs were the middle cerebral (32%), anterior communicating (32%), posterior communicating (14%), and pericallosal arteries (5%). However, proportional distribution of RIAs varied considerably by sex; for example, RIAs of the anterior communicating artery were more frequently found in men than in women. Anterior circulation RIAs accounted for 90% of all RIAs, and 30% of the patients had multiple intracranial aneurysms. The median size (measured as maximum diameter) of all RIAs was 7 mm (range 1–43 mm), but the size varied considerably by location. For example, RIAs of the ophthalmic artery had a median size of 11 mm, whereas the median size of RIAs of the pericallosal artery was 6 mm. Of all RIAs, 68% were smaller than 10 mm in maximum diameter.
In this large consecutive series of RIAs, 83% of all RIAs were found in 4 anterior circulation locations. The majority of RIAs were small, but the size and location varied considerably by sex. The presented data may be of help in defining effective prevention strategies.
Justiina Huhtakangas, Martin Lehecka, Hanna Lehto, Behnam Rezai Jahromi, Mika Niemelä and Riku Kivisaari
Occlusive treatment of posterior communicating artery (PCoA) aneurysms has been seen as a fairly uncomplicated procedure. The objective here was to determine the radiological and clinical outcome of patients after PCoA aneurysm rupture and treatment and to evaluate the risk factors for impaired outcome.
In a retrospective clinical follow-up study, data were collected from 620 consecutive patients who had been treated for ruptured PCoA aneurysms at a single center between 1980 and 2014. The follow-up was a minimum of 1 year after treatment or until death.
Of the 620 patients, 83% were treated with microsurgical clipping, 8% with endovascular coiling, 2% with the two procedures combined, 1% with indirect surgical methods, and 6% with conservative methods. The most common procedural complications were treatment-related brain infarctions (15%). The occurrence of artery occlusions (10% microsurgical, 8% endovascular) was higher than expected. Most patients made a good recovery at 1 year after aneurysmal subarachnoid hemorrhage (modified Rankin Scale [mRS] score 0–2: 386 patients [62%]). A fairly small proportion of patients were left severely disabled (mRS score 4–5: 27 patients [4%]). Among all patients, 20% died during the 1st year. Independent risk factors for an unfavorable outcome, according to the multivariable analysis, were poor preoperative clinical condition, intracerebral or subdural hematoma due to aneurysm rupture, age over 65 years, artery occlusion on postoperative angiography, occlusive treatment–related ischemia, delayed cerebral vasospasm, and hydrocephalus requiring a shunt.
Even though most patients made a good recovery after PCoA aneurysm rupture and treatment during the 1st year, the occlusive treatment–related complications were higher than expected and caused morbidity even among initially good-grade patients. Occlusive treatment of ruptured PCoA aneurysms seems to be a high-risk procedure, even in a high-volume neurovascular center.
Patcharin Intarakhao, Peeraphong Thiarawat, Behnam Rezai Jahromi, Danil A. Kozyrev, Mario K. Teo, Joham Choque-Velasquez, Teemu Luostarinen and Juha Hernesniemi
The purpose of this study was to analyze the impact of adenosine-induced cardiac arrest (AiCA) on temporary clipping (TC) and the postoperative cerebral infarction rate among patients undergoing intracranial aneurysm surgery.
In this retrospective matched-cohort study, 65 patients who received adenosine for decompression of aneurysms during microsurgical clipping were identified (Group A) and randomly matched with 65 selected patients who underwent clipping but did not receive adenosine during surgery (Group B). The matching criteria included age, Fisher grade, aneurysm size, rupture status, and location of aneurysms. The primary outcomes were TC time and the postoperative infarction rate. The secondary outcome was the incidence of intraoperative aneurysm rupture (IAR).
In Group A, 40 patients underwent clipping with AiCA alone and 25 patients (38%) received AiCA combined with TC, and in Group B, 60 patients (92%) underwent aneurysm clipping under the protection of TC (OR 0.052; 95% CI 0.018–0.147; p < 0.001). Group A required less TC time (2.04 minutes vs 4.46 minutes; p < 0.001). The incidence of postoperative lacunar infarction was equal in both groups (6.2%). There was an insignificant between-group difference in the incidence of IAR (1.5% in Group A vs 6.1% in Group B; OR 0.238; 95% CI 0.026–2.192; p = 0.171).
AiCA is a useful technique for microneurosurgical treatment of cerebral aneurysms. AiCA can minimize the use of TC and does not increase the risk of IAR and postoperative infarction.