A comparative propensity-adjusted analysis of microsurgical versus endovascular treatment of unruptured ophthalmic artery aneurysms

Abstract

OBJECTIVE Ophthalmic artery (OA) aneurysms are surgically challenging lesions that are now mostly treated using endovascular procedures. However, in specialized tertiary care centers with experienced neurosurgeons, controversy remains regarding the optimal treatment of these lesions. This study used propensity adjustment to compare microsurgical and endovascular treatment of unruptured OA aneurysms in experienced tertiary and quaternary settings. METHODS The authors retrospectively reviewed the medical records of all patients who underwent microsurgical treatment of an unruptured OA aneurysm at the University of California, San Francisco, from 1997 to 2017 and either microsurgical or endovascular treatment at Barrow Neurological Institute from 2011 to 2019. Patients were categorized into two cohorts for comparison: those who underwent open microsurgical clipping, and those who underwent endovascular flow diversion or coil embolization. Outcomes included neurological or visual outcomes, residual or recurrent aneurysms, retreatment, and severe complications. RESULTS A total of 345 procedures were analyzed: 247 open microsurgical clipping procedures (72%) and 98 endovascular procedures (28%). Of the 98 endovascular procedures, 16 (16%) were treated with primary coil embolization and 82 (84%) with flow diversion. After propensity adjustment, microsurgical treatment was associated with higher odds of a visual deficit (OR 8.5, 95% CI 1.1–64.9, p = 0.04) but lower odds of residual aneurysm (OR 0.06, 95% CI 0.01–0.28, p < 0.001) or retreatment (OR 0.12, 95% CI 0.02–0.58, p = 0.008) than endovascular therapy. No difference was found between the two cohorts with regard to worse modified Rankin Scale score, modified Rankin Scale score greater than 2, or severe complications. CONCLUSIONS Compared with endovascular therapy, microsurgical clipping of unruptured OA aneurysms is associated with a higher rate of visual deficits but a lower rate of residual and recurrent aneurysms. In centers experienced with both open microsurgical and endovascular treatment of these lesions, the treatment choice should be based on patient preference and aneurysm morphology.

Flow diversion for compressive unruptured internal carotid artery aneurysms with neuro-ophthalmological symptoms: a systematic review and meta-analysis

“…Literature search was performed on March 21, 2022. After removal of duplicates and screening of titles and abstracts, we sought for the original articles of 82 publications 7 13–93. After completion of literature review and data extraction and before closing the database, the literature search was repeated on PubMed only on May 22, 2022, using the above-mentioned search string to identify additional potentially eligible articles.…”

A novel endovascular treatment for true ophthalmic aneurysms: A case report

“…This technique offers high rates of aneurysm occlusion and low rates of recurrence, though visual morbidity occurs in ~10%–30% of cases ( 20 , 22 – 26 ). A series of 345 surgically treated OphAs reiterates this, as microsurgical clipping was found to have higher odds of visual morbidity (OR 8.5, 95% CI 1.1–64.9, p = 0.04) although lower odds of residual and re-treatment (OR 0.06, 95% CI 0.01–0.28, p < 0.001; OR 0.12, 95% CI 0.02–0.58, p = 0.008, respectively) when compared to endovascular therapies ( 27 ). Importantly, the definitive nature of surgical clipping may be exaggerated in observational studies, and the non-curative treatment rate, in fact, likely approaches 12% ( 28 ).…”

“…Each of these risks is avoided in an endovascular approach, such as balloon-assisted coiling (i.e., inflating a balloon at the base of the aneurysm during coiling to secure each coil within the aneurysm’s dome), stent-assisted coiling (i.e., deploying a stent at base of the aneurysm to secure the coils within the aneurysm’s dome), flow diversion, or flow diversion with adjunctive coiling. While avoiding the challenges of an open approach is what facilitates lower visual morbidity when treating OphAs endovascularly, the recanalization and recurrence rates are higher ( 21 , 24 , 25 , 27 , 29 – 31 ). In a cohort of 138, Lu et al.…”

Endovascular treatment of aneurysms of the paraophthalmic segment of the internal carotid artery: Current status

“…Aneurysms arising from paraophthalmic segments represent ∼5-10% of intradural aneurysms (3,4). Surgical clipping of these aneurysms poses challenges given complex nearby structures and a higher rate of visual complications (5,6). Due to the advent of EVT techniques and devices, specifically flowdiverting stents (FDSs), EVT has become a good option for these aneurysms (7,8).…”