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Arnd Doerfler, Tobias Engelhorn, Sabine Heiland, Thomas Benner and Michael Forsting

Object. The aim of this study was to use two types of serial magnetic resonance (MR) imaging—perfusionweighted (PW) and diffusion-weighted (DW)—to monitor craniectomy in rats with hemispheric stroke.

Methods. Focal cerebral ischemia was induced in 36 rats by using an endovascular method of occlusion of the middle cerebral artery (MCAO). Craniectomy was performed 4 or 24 hours later in 12 animals each. Twelve control animals underwent occlusion but did not receive treatment. Perfusion-weighted, DW, and T2-weighted MR images were obtained at 4, 24, 48, 72, and 168 hours postocclusion in all animals. Relative regional cerebral blood volumes and apparent diffusion coefficients (ADCs) were calculated for the cortex and basal ganglia. Hemispheric lesion volumes (expressed as percentages of total brain volumes; %HLV) as they appeared on DW and T2-weighted MR images and on histological slices stained with 2,3,5-triphenyltetrazolium chloride were compared. Neurological performances and infarct volumes measured 7 days postocclusion were used as study end points.

Both PW and DW images demonstrated ischemic tissue 4 hours after MCAO in all animals. Early treatment by performing craniectomy significantly improved cortical perfusion (p < 0.01), whereas the same procedure conveyed no benefit to the basal ganglia. Compared with findings in control animals, the DW image—derived %HLV was significantly reduced (p < 0.01) and the cortical ADCs at 4 and 24 hours postocclusion were significantly higher in animals treated early (p < 0.05). Late treatment with craniectomy did not significantly affect cerebral perfusion. The correlation between the DW imaging—derived %HLV and the histologically derived %HLV at 4 to 72 hours postocclusion was good (r = 0.74), whereas at Day 7 postocclusion the %HLV was underestimated up to 41% on DW imaging. At 4 hours postocclusion T2-weighted imaging failed to demonstrate the ischemic lesion, whereas from 24 to 72 hours postocclusion the correlation between the T2-weighted imaging—derived %HLV and the histologically derived %HLV was good (r > 0.81). Neurological performance was significantly improved in animals treated using craniectomy.

Conclusions. Early craniectomy significantly improves cortical perfusion through leptomeningeal collateral vessels, significantly reduces infarct size, and improves neurological performance in animals with experimental acute hemispheric infarction. Both PW and DW imaging are suitable for noninvasive monitoring of the effects of decompressive craniectomy.

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Arnd Doerfler, Isabel Wanke, Thomas Egelhof, Dietmar Stolke and Michael Forsting

✓ The authors present two cases of patients with small, acutely ruptured, wide-necked aneurysms of the distal vertebral artery that were not amenable to conventional coil embolization and were instead treated by means of a double-stent method in which one stent was placed inside another. Angiography performed immediately after the procedure revealed a significant reduction in aneurysm filling; total occlusion of the lesion was observed after 7 days and confirmed 6 months later in both aneurysms. By placing one stent inside the other, stent permeability can be reduced, which may result in significant hemodynamic changes with accelerated aneurysm thrombosis. This double-stent method may represent a therapeutic alternative, especially in cases of small, wide-necked aneurysms in which conventional endovascular techniques or stent-supported coil embolization is not considered feasible or is believed to be too dangerous, and surgical treatment is contraindicated.

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Siamak Asgari, Arnd Doerfler, Isabel Wanke, Beate Schoch, Michael Forsting and Dietmar Stolke

Object. The authors present a series of patients in whom partially occluded aneurysms were retreated using complementary surgical or endovascular therapy.

Methods. During a period of 18 months, 301 patients with intracranial aneurysms were treated using either clip application (171 patients) or endovascular embolization with Guglielmi Detachable Coils ([GDCs] 130 patients). Routine posttreatment angiography studies revealed residual aneurysms in 21 of these patients, nine of whom were retreated using an endovascular or surgical method, with a mean treatment latency of 1.2 months. Four patients underwent primary surgical clip application, whereas five patients experienced GDC packing first. Among patients in the surgical group, the residual aneurysm neck was small and total elimination of the aneurysm was achieved by packing in GDCs. In patients in the endovascular group the authors incompletely packed the aneurysm because of its wide neck or fusiform component in two patients, perforation of a very small aneurysm in one patient, and coil dislocation in another patient. Typical coil compaction occurred in one case. Complete clip application was achieved in all patients. There was no complication in any patient due to the second treatment modality. Final outcome was excellent or good in six and fair in three.

Conclusions. Following clip application or endovascular embolization of intracranial aneurysms, the use of complementary surgical or endovascular management is successful and associated with low morbidity.

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Marvin Darkwah Oppong, Meltem Gümüs, Daniela Pierscianek, Annika Herten, Andreas Kneist, Karsten Wrede, Lennart Barthel, Michael Forsting, Ulrich Sure and Ramazan Jabbarli

OBJECTIVE

Current guidelines for subarachnoid hemorrhage (SAH) include early aneurysm treatment within 72 hours after ictus. However, aneurysm rebleeding remains a crucial complication of SAH. The aim of this study was to identify independent predictors allowing early stratification of SAH patients for rebleeding risk.

METHODS

All patients admitted to the authors’ institution with ruptured aneurysms during a 14-year period were eligible for this retrospective study. Demographic and radiographic parameters, aneurysm characteristics, medical history, and medications as well as baseline parameters at admission (blood pressure and laboratory parameters) were evaluated in univariate and multivariate analyses. A novel risk score was created using independent risk factors.

RESULTS

Data from 984 cases could be included into the final analysis. Aneurysm rebleeding occurred in 58 cases (5.9%), and in 48 of these cases (82.8%) rerupture occurred within 24 hours after SAH. Of over 30 tested associations, preexisting arterial hypertension (p = 0.02; adjusted odds ratio [aOR] 2.56, 1 score point), aneurysm location at the basilar artery (p = 0.001, aOR 4.5, 2 score points), sac size ≥ 9 mm (p = 0.04, aOR 1.9, 1 score point), presence of intracerebral hemorrhage (p = 0.001, aOR 4.29, 2 score points), and acute hydrocephalus (p < 0.001, aOR 6.27, 3 score points) independently predicted aneurysm rebleeding. A score built upon these parameters (0–9 points) showed a good diagnostic accuracy (p < 0.001, area under the curve 0.780) for rebleeding prediction.

CONCLUSIONS

Certain patient-, aneurysm-, and SAH-specific parameters can reliably predict aneurysm rerupture. A score developed according to these parameters might help to identify individuals that would profit from immediate aneurysm occlusion.

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Ramazan Jabbarli, Daniela Pierscianek, Karsten Wrede, Philipp Dammann, Marc Schlamann, Michael Forsting, Oliver Müller and Ulrich Sure

OBJECTIVE

The complete clipping of a cerebral aneurysm usually warrants its sustained occlusion, while clip remnants may have far-reaching consequences. The aim of this study is to identify the risk factors for clip remnants requiring retreatment and/or exhibiting growth.

METHODS

All consecutive patients with primary aneurysm clipping performed at University Hospital of Essen between January 1, 2003, and December 31, 2013, were eligible for this study. Aneurysm occlusion was judged on obligatory postoperative digital subtraction angiography and the need for repeated vascular control. The identified clip remnants were correlated with various demographic and clinical characteristics of the patients, aneurysm features, and surgery-related aspects.

RESULTS

Of 616 primarily clipped aneurysms, postoperative angiography revealed 112 aneurysms (18%) with clip remnants requiring further control (n = 91) or direct retreatment (n = 21). Seven remnants exhibited growth during follow-up, whereas 2 cases were associated with aneurysmal bleeding. Therefore, a total of 28 aneurysms (4.5%) were retreated as clip remnants (range 1 day to 67 months after clipping). In the multivariate analysis, the need for retreatment of clip remnant was correlated with the aneurysm's initial size (> 12 mm; OR 3.22; p = 0.035) and location (anterior cerebral artery > internal carotid artery > posterior circulation > middle cerebral artery; OR 1.85; p = 0.003). Younger age with a cutoff at 45 years (OR 33.31; p = 0.004) was the only independent predictor for remnant growth.

CONCLUSIONS

The size and location of the aneurysm are the main risk factors for clip remnants requiring retreatment. Because of the risk for growth, younger individuals (< 45 years old) with clip remnants require a long-term (> 5 years) vascular follow-up.

Clinical trial registration no: DRKS00008749 (Deutsches Register Klinischer Studien)

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Arnd Doerfler, Michael Forsting, Wolfgang Reith, Christian Staff, Sabine Heiland, Wolf-Rüdiger Schäbitz, Rüdiger von Kummer, Werner Hacke and Klaus Sartor

✓ Acute ischemia in the complete territory of the carotid artery may lead to massive cerebral edema with raised intracranial pressure and progression to coma and death due to uncal, cingulate, or tonsillar herniation. Although clinical data suggest that patients benefit from undergoing decompressive surgery for acute ischemia, little data about the effect of this procedure on experimental ischemia are available. In this article the authors present results of an experimental study on the effects of decompressive craniectomy performed at various time points after endovascular middle cerebral artery (MCA) occlusion in rats.

Focal cerebral ischemia was induced in 68 rats using an endovascular occlusion technique focused on the MCA. Decompressive cranioectomy was performed in 48 animals (in groups of 12 rats each) 4, 12, 24, or 36 hours after vessel occlusion. Twenty animals (control group) were not treated by decompressive craniectomy. The authors used the infarct volume and neurological performance at Day 7 as study endpoints.

Although the mortality rate in the untreated group was 35%, none of the animals treated by decompressive craniectomy died (mortality 0%). Neurological behavior was significantly better in all animals treated by decompressive craniectomy, regardless of whether they were treated early or late. Neurological behavior and infarction size were significantly better in animals treated very early by decompressive craniectomy (4 hours) after endovascular MCA occlusion (p < 0.01); surgery performed at later time points did not significantly reduce infarction size.

The results suggest that use of decompressive craniectomy in treating cerebral ischemia reduces mortality and significantly improves outcome. If performed early after vessel occlusion, it also significantly reduces infarction size. By performing decompressive craniectomy neurosurgeons will play a major role in the management of stroke patients.

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Michael Forsting, Friedrich K. Albert, Olav Jansen, Rüdiger von Kummer, Alfred Aschoff, Stefan Kunze and Klaus Sartor

In up to 4% of patients whose aneurysms are microsurgically clipped, there is an expected or unexpected aneurysm residuum. The authors describe two patients in whom surgical clipping did not result in complete obliteration of the aneurysm sac and in whom a second operation was not believed to be the solution to the problem. In both patients complete occlusion of the aneurysm residuum was achieved via an endovascular approach. Using the Guglielmi detachable coil system, it was possible to place two platinum coils selectively into the aneurysms. The endovascular approach may be a good treatment option for all patients in whom surgical clipping does not result in complete obliteration of the aneurysm sac and reoperation is contraindicated or unacceptable to the patient.

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Arnd Doerfler, Michael Forsting, Wolfgang Reith, Christian Staff, Sabine Heiland, Wolf-Rüdiger Schäbitz, Rüdiger von Kummer, Werner Hacke and Klaus Sartor

Acute ischemia in the complete territory of the carotid artery may lead to massive cerebral edema with raised intracranial pressure and progression to coma and death due to uncal, cingulate, or tonsillar herniation. Although clinical data suggest that patients benefit from undergoing decompressive surgery for acute ischemia, little data about the effect of this procedure on experimental ischemia are available. this article the authors present results of an experimental study on the effects of decompressive craniectomy performed at various time points after endovascular middle cerebral artery (MCA) occlusion in rats.

Focal cerebral ischemia was induced in 68 rats using an endovascular occlusion technique focused on the MCA. Decompressive cranioectomy was performed in 48 animals (in groups of 12 rats each) 4, 12, 24, or 36 hours after vessel occlusion. Twenty animals (control group) were not treated by decompression craniectomy. The authors used the infarct volume and neurological performance at Day 7 as study endpoints.

Although the mortality rate in the untreated group was 35%, none of the animals treated by decompressive craniectomy died (mortality 0%). Neurological behavior was significantly better in all animals treated by decompressive craniectomy, regardless of whether they were treated early or late. Neurological behavior and infarction size were significantly better in animals treated very early by decompressive craniectomy (4 hours) after endovascular MCA occlusion (p less than 0.01); surgery performed at later time points did not significantly reduce infarction size.

The results suggest that use of decompressive craniectomy in treating cerebral ischemia reduces mortality and significantly improves outcome. If performed early after vessel occlusion, it also significantly reduces infarction size. By performing decompressive craniectomy neurosurgeons will play a major role in the management of stroke patients.

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Michael Forsting, Friedrich K. Albert, Olav Jansen, Rüdiger von Kummer, Alfred Aschoff, Stefan Kunze and Klaus Sartor

✓ In up to 4% of patients whose aneurysms are microsurgically clipped, there is an expected or unexpected aneurysm residuum. The authors describe two patients in whom surgical clipping did not result in complete obliteration of the aneurysm sac and in whom a second operation was not believed to be the solution to the problem. In both patients complete occlusion of the aneurysm residuum was achieved via an endovascular approach. Using the Guglielmi detachable coil system, it was possible to place two platinum coils selectively into the aneurysms. The endovascular approach may be a good treatment option for all patients in whom surgical clipping does not result in complete obliteration of the aneurysm sac and reoperation is contraindicated or unacceptable to the patient.

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Marvin Darkwah Oppong, Kathrin Buffen, Daniela Pierscianek, Annika Herten, Yahya Ahmadipour, Philipp Dammann, Laurèl Rauschenbach, Michael Forsting, Ulrich Sure and Ramazan Jabbarli

OBJECTIVE

Clinical data on secondary hemorrhagic complications (SHCs) in patients with aneurysmal subarachnoid hemorrhage (SAH) are sparse and mostly limited to ventriculostomy-associated SHCs. This study aimed to elucidate the incidence, risk factors, and impact on outcome of SHCs in a large cohort of SAH patients.

METHODS

All consecutive patients with ruptured aneurysms treated between January 2003 and June 2016 were eligible for this study. Patients’ charts were reviewed for clinical data, and imaging studies were reviewed for radiographic data. SHCs were divided into those associated with ventriculostomy and those not associated with ventriculostomy, as well as into major and minor bleeding forms, depending on clinical impact.

RESULTS

Sixty-two (6.6%) of the 939 patients included in the final analysis developed SHCs. Ventriculostomy-associated bleedings (n = 16) were independently predicted by mono- or dual-antiplatelet therapy after aneurysm treatment (p = 0.028, adjusted odds ratio [aOR] = 10.28; and p = 0.026, aOR = 14.25, respectively) but showed no impact on functional outcome after SAH. Periinterventional use of thrombolytic agents for early effective anticoagulation was the only independent predictor (p = 0.010, aOR = 4.27) of major SHCs (n = 38, 61.3%) in endovascularly treated patients. In turn, a major SHC was independently associated with poor outcome at the 6-month follow-up (modified Rankin Scale score > 3). Blood thinning drug therapy prior to SAH was not associated with SHC risk.

CONCLUSIONS

SHCs present a rare sequela of SAH. Antiplatelet therapy during (but not before) SAH increases the risk of ventriculostomy-associated bleedings, but without further impact on the course and outcome of SAH. The use of thrombolytic agents for early effective anticoagulation carries relevant risk for major SHCs and poor outcome.