"Clip first" policy in management of intracranial MCA aneurysms: Single-centre experience with a systematic review of literature

Štekláčová, Anna; Bradáč, Ondřej; Charvát, František; Lacy, Patricia de; Beneš, Vladimı́r

doi:10.1007/s00701-015-2687-y

Cited by 35 publications

(20 citation statements)

References 73 publications

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“…Aneurysm size and location also dictate intervention, with middle cerebral artery aneurysms treated with clipping based on better patient outcomes than with coiling. 11,18,27,29,30 Our study demonstrated no significant adjusted odds of ARF in the CACo cohort, although this could be due to pertinent complications of iodine contrast-induced nephropathy in high-risk patients with renal disease. 5,26 Thus, is it possible that patients with renal disease were preferably treated with CAC.…”

Section: Discussionmentioning

confidence: 52%

Unruptured aneurysms in the elderly: perioperative outcomes and cost analysis of endovascular coiling and surgical clipping

Silva¹,

Shao²,

Sylvester

et al. 2018

Neurosurgical Focus

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OBJECTIVEObservation and neurosurgical intervention for unruptured intracranial aneurysms (UIAs) in the elderly population is rapidly increasing. Cerebral aneurysm coiling (CACo) is favored over cerebral aneurysm clipping (CAC) in elderly patients, yet some elderly individuals still undergo CAC. The cost-effectiveness of treating UIAs requires further exploration. Understanding the effect of intervention on hospital charges and length of stay (LOS) as well as perioperative mortality and complications can further shed light on its economic impact. The purpose of this study was to analyze the cost and perioperative outcomes of UIAs in elderly patients (≥ 65 years of age) after CACo or CAC intervention.METHODSRetrospective cohorts of CACo and CAC admissions were extracted from National (Nationwide) Inpatient Sample data obtained between 2002 and 2013, forming parallel intervention groups to compare the following outcomes between elderly and nonelderly patients: average LOS and mean hospital admission costs, in-hospital mortality, and complications. Covariates included sex, race or ethnicity, and comorbidities.RESULTSElderly patients undergoing CAC experienced an average LOS of 8.0 days, whereas elderly patients undergoing CACo stayed an average of 3.2 days. The mean hospital charges incurred during admission totaled $95,960 in the elderly patients who underwent CAC versus $87,960 in the ones who underwent CACo. Elderly patients in whom CAC was performed had a 2.2% rate of in-hospital mortality, with a 2.6 greater adjusted odds of in-hospital mortality than nonelderly patients treated with CAC. In contrast, elderly patients who underwent CACo had a 1.36 greater adjusted odds of in-hospital mortality than their nonelderly counterparts. Compared to nonelderly patients receiving both interventions, elderly individuals had a significantly higher prevalence of various comorbidities and incidence of complications. Elderly patients who received CAC experienced a 10.3% incidence rate of perioperative stroke, whereas their CACo counterparts experienced this complication at a rate of 3.5%. Elderly patients treated with CAC had greater odds of perioperative acute renal failure, whereas their CACo counterparts had greater odds of perioperative deep venous thrombosis and pulmonary embolism.CONCLUSIONSIntervention with CAC and CACo in the elderly is resource intensive and is associated with higher risk than in the nonelderly. Those deciding between intervention and conservative management should consider these risks and costs, especially the 2.2% postoperative mortality rate associated with CAC in the elderly population. Further comparative cost-effectiveness research is needed to weigh these costs and outcomes against those of conservative management.

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Section: Discussionmentioning

confidence: 52%

Unruptured aneurysms in the elderly: perioperative outcomes and cost analysis of endovascular coiling and surgical clipping

Silva¹,

Shao²,

Sylvester

et al. 2018

Neurosurgical Focus

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“…In response to recent series of endovascular treatment of ruptured MCA aneurysms, several authors have reported their institution's results of a "clip-first" policy for MCA lesions. 19,24 In a series of 282 ruptured MCA aneurysms treated with microsurgical clipping, Rodríguez-Hernández et al 19 reported good outcomes (mRS scores 0-2) in 70.2% of these patients. This finding is comparable to the results in our series.…”

Section: Discussionmentioning

confidence: 99%

Long-term results of middle cerebral artery aneurysm clipping in the Barrow Ruptured Aneurysm Trial

Mooney¹,

Simon²,

Brigeman³

et al. 2019

Journal of Neurosurgery

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OBJECTIVE A direct comparison of endovascular versus microsurgical treatment of ruptured middle cerebral artery (MCA) aneurysms in randomized trials is lacking. As endovascular treatment strategies continue to evolve, the number of reports of endovascular treatment of these lesions is increasing. Herein, the authors report a detailed post hoc analysis of ruptured MCA aneurysms treated by microsurgical clipping from the Barrow Ruptured Aneurysm Trial (BRAT). METHODS The cases of patients enrolled in the BRAT who underwent microsurgical clipping for a ruptured MCA aneurysm were reviewed. Characteristics of patients and their clinical outcomes and long-term angiographic results were analyzed. RESULTS Fifty patients underwent microsurgical clipping of a ruptured MCA aneurysm in the BRAT, including 21 who crossed over from the endovascular treatment arm. Four patients with nonsaccular (e.g., dissecting, fusiform, or blister) aneurysms were excluded, leaving 46 patients for analysis. Most (n = 32; 70%) patients presented with a Hunt and Hess grade II or III subarachnoid hemorrhage, with a high prevalence of intraparenchymal blood (n = 23; 50%), intraventricular blood (n = 21; 46%), or both. At the last follow-up (up to 6 years after treatment), clinical outcomes were good (modified Rankin Scale score 0-2) in 70% (n = 19) of 27 Hunt and Hess grades I-III patients and in 36% (n = 4) of 11 Hunt and Hess grade IV or V patients. There were no instances of rebleeding after the surgical clipping of aneurysms in this series at the time of last clinical follow-up. CONCLUSIONS Microsurgical clipping of ruptured MCA aneurysms has several advantages over endovascular treatment, including durability over time. The authors report detailed outcome data of patients with ruptured MCA aneurysms who underwent microsurgical clipping as part of a prospective, randomized trial. These results should be used for comparison with future endovascular and surgical series to ensure that the best results are being achieved for patients with ruptured MCA aneurysms.

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“…Recently, rates of procedure-related mortality and morbidity were reported as 0.6%-5% for surgical clipping by the standard pterional approach for unruptured MCA aneurysm. 7,15,19,23,29 For unruptured MCA aneurysms less than 12 mm in diameter, the surgical morbidity of the standard pterional approach was 0%-0.6%. 19,23 These findings show that the neurological outcomes of our pteri- onal keyhole technique for unruptured MCA aneurysms are not inferior to those of the standard pterional approach.…”

Section: Discussionmentioning

confidence: 99%

Keyhole strategy aiming at minimizing hospital stay for surgical clipping of unruptured middle cerebral artery aneurysms

Mori

Wada

Otani

et al. 2019

Journal of Neurosurgery

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OBJECTIVE Aneurysms of the middle cerebral artery (MCA) are still most often treated by clipping through standard craniotomy, but a longer hospital stay is one of the main drawbacks of this treatment. The authors developed a pterional keyhole clipping strategy for unruptured MCA aneurysms with the intention of minimizing hospital stay. In this paper, they report on their experience with this approach and analyze the long-term neurological and radiological outcomes. METHODS A total of 160 relatively small unruptured MCA aneurysms (mean 6.4 mm) were clipped through the pterional keyhole approach (19-30 mm, mean 24.6 mm) in 149 patients (aged 34-79 years, mean 62 years). Neurological and cognitive function were examined by several scales, including the modified Rankin Scale (mRS) and Mini-Mental State Examination (MMSE). Patients' level of depression was assessed using the Beck Depression Inventory and Hamilton Depression Scale. The state of clipping was assessed at 1 year and then every few years after the operation. RESULTS The mean duration of postoperative hospitalization was 2.3 ± 3.4 days; in 31.3% of the cases, the patients were discharged on the day after the operation (overnight hospital stay) and in 93.2% within 3 days. Of the patients younger than 60 years, 40.4% required only an overnight stay. Complete aneurysm neck clipping was confirmed in 157 cases (98.1%). None of the completely clipped aneurysms showed any recurrence during the mean follow-up period of 5.0 years. The mean length of clinical follow-up was 5.4 years. After 2 (1.3%) of the surgical procedures, the patients showed persistent neurological deficits, defined as mRS score 1, but the overall operative morbidity based on the International Study of Unruptured Intracranial Aneurysms (ISUIA) definition (mRS score ≥ 2 or MMSE score < 24) was 0% at the last examination. Depression scores were significantly improved after surgery, and in 85.6% of the cases the patients were satisfied with their cosmetic results. CONCLUSIONS Pterional keyhole clipping is less invasive than clipping via standard craniotomy, minimizes hospital stay, and achieves durable treatment for relatively small unruptured MCA aneurysms.

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"Clip first" policy in management of intracranial MCA aneurysms: Single-centre experience with a systematic review of literature

Cited by 35 publications

References 73 publications

Unruptured aneurysms in the elderly: perioperative outcomes and cost analysis of endovascular coiling and surgical clipping

Unruptured aneurysms in the elderly: perioperative outcomes and cost analysis of endovascular coiling and surgical clipping

Long-term results of middle cerebral artery aneurysm clipping in the Barrow Ruptured Aneurysm Trial

Keyhole strategy aiming at minimizing hospital stay for surgical clipping of unruptured middle cerebral artery aneurysms

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