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Neurosurgical Forum: Letters to the Editor To The Editor Daryl R. Gress , M.D. University of California San Francisco, California 159 160 Abstract Object. Repair of unruptured aneurysms is a reasonable course of action if their expected natural history is worse than the predicted risks of treatment. The purpose of this study was to examine the presenting symptoms of unruptured aneurysms and to test the hypothesis that unruptured intracranial aneurysms can be repaired without significant functional worsening. A

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Bryce Weir, Christina Amidei, Gail Kongable, J. Max Findlay, Neal F. Kassell, John Kelly, Lanting Dai and Theodore G. Karrison

Patients were retrospectively selected for this study based on the availability of angiograms and a clear diagnosis of an unruptured or ruptured aneurysm. Patient age and sex, and the location of the aneurysm were also recorded, but were missing in 99, two, and six cases, respectively. Five hundred thirty-two patients with 774 aneurysms were included from three centers. The sex distribution in these patients was 29% male and 71% female, a distribution that did not differ significantly among centers. One hundred twenty-seven patients harbored unruptured aneurysms alone

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H. Richard Winn

I n this issue of the Journal of Neurosurgery , there are several valuable contributions to the literature concerning unruptured intracranial aneurysms. The first article is an encyclopedic overview of the literature, written by Bryce Weir, M.D. There is virtually no fact or nuance related to unruptured aneurysms that is not covered by Dr. Weir in a highly thoughtful manner. Also included in this issue are a series of editorials and comments addressing controversies related to unruptured aneurysms. Dumont and colleagues 1 summarize three recent studies of

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Edward M. Marchan, Raymond F. Sekula Jr., Andrew Ku, Robert Williams, Brent R. O'Neill, Jack E. Wilberger and Matthew R. Quigley

I n intracranial aneurysms endovascular treatment involving detachable coils has become an accepted alternative or adjunct to surgery. Until recently, endovascular surgeons have used bare platinum coils to treat unruptured aneurysms, but these coils have been associated with a low to moderate risk of coil compaction and subsequent aneurysm recurrence. 13 , 15 Moreover, they are not useful for treating wide-necked or giant aneurysms, as the coils tend to dislodge into the parent vessel. In an effort to reduce the recurrence rate associated with bare

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Beverly J. Rice, Sydney J. Peerless and Charles G. Drake

cerebellar artery 43  basilar trunk 7  vertebrobasilar junction 1 vertebral artery 11 posterior cerebral artery 18 Fifty-three patients (32%) had solitary unruptured aneurysms and the remaining 114 patients (68%) had multiple intracranial aneurysms or AVM's. This latter group harbored an additional 209 aneurysms (97% in the anterior circulation) and 15 AVM's (11 supratentorial and four infratentorial). Eleven of the AVM's were supplied by parent arteries of posterior circulation aneurysms. Seventy patients (61% of the group

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. A review of 3684 arteriograms demonstrated 24 cases of asymptomatic aneurysms, yielding a prevalence rate of 0.65%. The majority (67%) of the 24 patients harboring unruptured aneurysms were women. More than 90% of the unruptured aneurysms were located in the anterior circulation and in locations similar to those found in patients with ruptured aneurysms. Nearly 80% of the aneurysms were smaller than 1 cm in their greatest diameter. The frequency of asymmetrical unruptured aneurysms (0.6–1.5%) was constant throughout all relevant age ranges (35–84 years

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Dale M. Swift and Robert A. Solomon

aneurysms are found to have multiple aneurysms. 6 Often, the additional (unruptured) aneurysm is on the opposite side or is otherwise inaccessible during craniotomy and clipping of the ruptured aneurysm. This leaves the unruptured aneurysm unprotected during the postoperative period and subject to increased hemodynamic stress imparted by volume expansion, often with induced hypertension. There is understandable concern regarding possible rupture of such aneurysms and one wonders if hypervolemic management should be modified in these patients. To date there have been no

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Bryce Weir

following statements. The larger an aneurysm is, the more likely it is to rupture until, perhaps, a giant size is reached. The median size of all ruptured aneurysms is greater than the median size of all unruptured aneurysms discovered incidentally or at autopsy. The median size of ruptured aneurysms is less than 10 mm and the majority of ruptured aneurysms are smaller than 10 mm. The average size of ruptured aneurysms in cases of multiple aneurysms is not significantly different from the average size of single aneurysms that rupture. The rate of growth of aneurysms is

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H. Richard Winn and Gavin W. Britz

case fatality in New Zealand between 1981–1983 and 1991–1993 . Stroke 29 : 2298 – 2303 , 1998 23 Ujiie H , Sato K , Onda H , Oikawa A , Kagawa M , Takakura K , : Clinical analysis of incidentally discovered unruptured aneurysms . Stroke 24 : 1850 – 1856 , 1993 24 Weir B : Unruptured aneurysms . J Neurosurg 97 : 1011 – 1013 , 2002 25 Weir B : Unruptured intracranial aneurysms: a review . J Neurosurg 96 : 3 – 42 , 2002 26 Winn HR , Jane JA Sr , Taylor J , Kaiser D , Britz GW : Prevalence of asymptomatic

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/second, however, they should compare the diagnostic accuracy of their 3D CT angiography with catheter angiography or surgical findings, and they should indicate the tube voltage/current they applied. In previous studies, including ours, more than 120 kV/200 mA was used. 3, 5, 8, 10, 11 As aneurysm or bleb enlargement and de novo bleb formation are risk factors for rupture, unruptured aneurysms must be monitored closely by 3D CT angiography to detect any subtle morphological changes. The authors reported that 10 aneurysms in nine patients exhibited changes indicative of