The quiet revolution: retractorless surgery for complex vascular and skull base lesions

Spetzler, Robert F.; Sanai, Nader

doi:10.3171/2011.8.jns101896

Cited by 97 publications

(77 citation statements)

References 20 publications

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“…In the group with repeat imaging, 145 patients (24.3%) had mi- nor postcoiling residuals and 127 (22.1%) had significant aneurysm residual or growth. In the latter group, initial treatment with coiling resulted in complete occlusion in 68.5% (87), subtotal occlusion in 22.0% (28), and incomplete occlusion in 9.4% (12). The fact that the 68.5% of the patients with significant aneurysm residual or growth on follow-up were documented to have had complete aneurysm obliteration after initial treatment is troublesome and emphasizes the risk of recurrence of coil-treated aneurysms and the need for continued follow-up.…”

Section: Obliteration and Rebleeding Of Aneurysmsmentioning

confidence: 99%

“…Finally, avoiding the use of rigid retraction even for the most complex aneurysms, as was done routinely during BRAT, minimizes surgical trauma to adjacent brain tissue. 28 Although there is continued and dramatic progress in endovascular technology, there is also a price associated with the use of complex aneurysmal constructs. Early promising results with stents provide tantalizing promise of the ability to treat more complex aneurysms.…”

Section: Evolution Of Treatmentmentioning

confidence: 99%

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The Barrow Ruptured Aneurysm Trial: 3-year results

Spetzler

McDougall

Albuquerque

et al. 2013

JNS

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280

176

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Object The authors report the 3-year results of the Barrow Ruptured Aneurysm Trial (BRAT). The objective of this ongoing randomized trial is to compare the safety and efficacy of microsurgical clip occlusion and endovascular coil embolization for the treatment of acutely ruptured cerebral aneurysms and to compare functional outcomes based on clinical and angiographic data. The 1-year results have been previously reported. Methods Two-hundred thirty-eight patients were assigned to clip occlusion and 233 to coil embolization. There were no anatomical exclusions. Crossovers were allowed based on the treating physician's determination, but primary outcome analysis was based on the initial assignment to treatment modality. Patient outcomes were assessed independently using the modified Rankin Scale (mRS). A poor outcome was defined as an mRS score > 2. At 3 years' follow-up 349 patients who had actually undergone treatment were available for evaluation. Of the 170 patients who had been originally assigned to coiling, 64 (38%) crossed over to clipping, whereas 4 (2%) of 179 patients assigned to surgery crossed over to coiling. Results The risk of a poor outcome in patients assigned to clipping compared with those assigned to coiling (35.8% vs 30%) had decreased from that observed at 1 year and was no longer significant (OR 1.30, 95% CI 0.83–2.04, p = 0.25). In addition, the degree of aneurysm obliteration (p = 0.0001), rate of aneurysm recurrence (p = 0.01), and rate of retreatment (p = 0.01) were significantly better in the group treated with clipping compared with the group treated with coiling. When outcomes were analyzed based on aneurysm location (anterior circulation, n = 339; posterior circulation, n = 69), there was no significant difference in the outcomes of anterior circulation aneurysms between the 2 assigned groups across time points (at discharge, 6 months, 1 year, or 3 years after treatment). The outcomes of posterior circulation aneurysms were significantly better in the coil group than in the clip group after the 1st year of follow-up, and this difference persisted after 3 years of follow-up. However, while aneurysms in the anterior circulation were well matched in their anatomical location between the 2 treatment arms, this was not the case in the posterior circulation where, for example, 18 of 21 posterior inferior cerebellar artery aneurysms were in the clip group. Conclusions Based on mRS scores at 3 years, the outcomes of all patients assigned to coil embolization showed a favorable 5.8% absolute difference compared with outcomes of those assigned to clip occlusion, although this difference did not reach statistical significance (p = 0.25). Patients in the clip group had a significantly higher degree of aneurysm obliteration and a significantly lower rate of recurrence and retreatment. In post hoc analysis examining only anterior circulation aneurysms, no outcome difference between the 2 treatment cohorts was observed at any recorded time point. Clinical trial registration no.: NCT01593267 (ClinicalTrials.gov).

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Section: Obliteration and Rebleeding Of Aneurysmsmentioning

confidence: 99%

Section: Evolution Of Treatmentmentioning

confidence: 99%

The Barrow Ruptured Aneurysm Trial: 3-year results

Spetzler

McDougall

Albuquerque

et al. 2013

JNS

Self Cite

280

176

View full text Add to dashboard Cite

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“…Additionally, recent advances in surgical techniques including minimal retraction and retractorless aneurysm clipping are evolving to improve the long-term outcome in these patients. 16) Old age and female sex are strong predictors of poor outcome in the general population. 9) Studies discussing outcomes of aneurysmal SAH in young adults have demonstrated favorable outcomes in this subgroup of patients.…”

Section: Discussionmentioning

confidence: 99%

Prediction of Outcomes in Young Adults With Aneurysmal Subarachnoid Hemorrhage

Chotai

Moon

et al. 2013

Neurol. Med. Chir.(Tokyo)

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Subarachnoid hemorrhage (SAH) is rare in young adults and little is known about aneurysms in this subgroup. The effect of clinical and prognostic factors on the outcome based on the Glasgow Outcome Scale (GOS) scores and the predictors of unfavorable outcomes were analyzed in young adults with aneurysmal SAH. A retrospective review of the clinical parameters, including age, sex, hypertension, smoking status, hyperlipidemia, location of the cerebral aneurysm, size of the aneurysm, multiplicity, perioperative complication such as hydrocephalus, vasospasm, and hematoma, and Hunt and Hess and Fisher grading on presentation, was conducted in 108 young adults (mean age 34.8 years) managed at our institute. The outcome was classified based on GOS grading into unfavorable (GOS scores 1-3) or favorable (GOS scores 4 or 5). The overall mortality rate was 3.7% (4/108 patients). Univariate regression analysis for the outcomes at discharge found that age at the time of presentation, male sex, size of aneurysm, multiple aneurysms, hyperlipidemia, and poor Hunt and Hess and Fischer grades were associated with unfavorable outcome. Multivariate regression analysis found independent effects of sex, multiple aneurysms, size of aneurysm, and Hunt and Hess grade on the outcome at discharge. Size of aneurysm, presence of multiple aneurysms, Hunt and Hess grade, and hypertension were the predictors of outcome at mean 2-year follow up based on multivariate exact regression analysis. The multimodal approach with aggressive medical management, early intervention, and surgical treatment might contribute to favorable long-term outcomes in patients with poor expected outcomes.

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“…3). 1,18,19 The diagnosis is generally made radiographically and the preoperative work-up includes MRI and computed tomography. Magnetic resonance venograms can be useful to evaluate venous anatomy, dominance of transverse/sigmoid sinuses, temporal lobe draining patterns, and jugular bulb size.…”

Section: Posterior Skull Base Meningiomasmentioning

confidence: 99%

“…The introduction of microsurgical techniques, advances in neuroanesthesiology, magnetic resonance imaging (MRI), neuronavigation, injury to underlying brain. 1 Patient positioning that enhances gravity retraction, extensive dissection of arachnoid planes, the refinement of microsurgical instrumentation, appropriate selection of operative corridors, and neuronavigation have all been used to improve patient outcomes and reduce morbidities. [1][2][3][4] The key principle of skull base surgery is to deconstruct the bony skull base around the brain to create safe apertures to resect deep-seated pathologies.…”

Section: Introductionmentioning

confidence: 99%