Microsurgical Treatment of Unruptured Anterior Communicating Artery Aneurysms: Approaches and Outcomes in a Large Contemporary Series and Review of the Literature

2020 ◽  
Author(s):  
Eric S Nussbaum ◽  
Jillienne C Touchette ◽  
Michael T Madison ◽  
James K Goddard ◽  
Jeffrey P Lassig ◽  
...  
Keyword(s):  
Patient Outcomes ◽  
Multidisciplinary Approach ◽  
Treatment Decision ◽  
Anterior Communicating Artery ◽  
Clinical Equipoise ◽  
Neurological Outcomes ◽  
Treatment Decision Making ◽  
Anterior Communicating Artery Aneurysms ◽  
Aneurysm Morphology

Abstract BACKGROUND With advances in endovascular techniques, the relative roles of microsurgery and endovascular therapy in the management of intracranial aneurysms have become less clear, and data regarding treatment-specific outcomes are increasingly important. OBJECTIVE To describe our experience with microsurgery in a large series of unruptured anterior communicating artery aneurysms (ACOMMAAs) and detail our treatment decision-making process based on individual aneurysm morphology. METHODS We retrospectively reviewed unruptured ACOMMAAs treated microsurgically at our center between 1997 and 2018, recording aneurysm size, surgical approach, occlusion rates, neurological outcomes, and complications. RESULTS We treated 300 unruptured ACOMMAAs in 300 patients, mean age 49 yr, 180 (60.0%) female, including 245 (81.7%) small, 50 (16.7%) large, and 5 (1.7%) giant aneurysms. Most underwent a pterional approach (253, 84.3%), with orbitozygomatic or anterior interhemispheric approaches in 35 (11.7%) and 12 (4%), respectively. Greater than 95% occlusion was achieved in 284 (94.7%), 90% to 95% occlusion in 13 (4.3%), and 3 (1.0%) underwent wrapping. Serious complications occurred in 3 patients (1.0%) resulting in 2 deaths (0.7%), and minor complications in 12 (4.0%). At final follow-up, good neurological outcome was observed in 297 (99.0%) patients. CONCLUSION Given clinical equipoise regarding optimal treatment of unruptured ACOMMAAs, this work provides a benchmark for achievable microsurgical outcomes. Future surgical/endovascular studies should separate results of ruptured and unruptured lesions and describe aneurysm morphology to allow for better comparison of outcomes between treatments. We suggest that open microsurgery represents an important option for select, morphologically complex ACOMMAAs, and that a multidisciplinary approach offers optimal patient outcomes.

A Reappraisal of Anterior Communicating Artery Aneurysms

Neurosurgery ◽  
2015 ◽  
Vol 78 (2) ◽  
pp. 200-207 ◽  
Author(s):  
Leonardo B.C. Brasiliense ◽  
Jang W. Yoon ◽  
Josiah N. Orina ◽  
David A. Miller ◽  
Rabih G. Tawk ◽  
...  
Keyword(s):  
Distal Segment ◽  
Long Term Results ◽  
Anterior Communicating Artery ◽  
Post Intervention ◽  
Stent Deployment ◽  
Anterior Communicating Artery Aneurysms ◽  
Hemorrhagic Events ◽  
Retreatment Rate

ABSTRACT BACKGROUND: Wide-necked anterior communicating artery aneurysms represent a subset of lesions with challenging endovascular treatment despite new endoluminal and intrasaccular devices. OBJECTIVE: To assess the long-term clinical and angiographic outcomes of stent-assisted embolization for wide-necked anterior communicating artery aneurysms. METHODS: Between March 2008 and March 2014, 32 patients with unruptured wide-necked AComm aneurysms were treated using stent-assisted embolization. The Glasgow Outcome Scale was reviewed at the time of discharge and at latest follow-up. Ischemic and hemorrhagic events were also recorded and analyzed. Aneurysm occlusion was evaluated post-intervention and on subsequent follow-up evaluations. RESULTS: Successful stent deployment was achieved in all cases, but in 1 patient the coils could not be contained inside the aneurysm, and the procedure was aborted without complications. The distal segment of the stent was positioned in the ipsilateral A2 in 16 patients, in the contralateral A2 in 15 patients, and in the contralateral A1 in 1 patient. There were no periprocedural thromboembolic or hemorrhagic complications. The rate of major complications was 6%. One patient developed intracranial hemorrhage related to antiplatelet therapy and another had ischemic events due to in-stent stenosis. Angiographic follow-up was available for 26 aneurysms and during a mean follow-up of 22 months, 81% of the lesions were completely occluded and 8% had a small residual neck. The retreatment rate for residual aneurysms was 3%. CONCLUSION: Our long-term results suggest that stent-assisted embolization for anterior communicating artery aneurysms may be considered an excellent treatment option with an adequate combination of safety profile and effectiveness.

scholarly journals Endovascular Treatment of ACom Intracranial Aneurysms

2010 ◽  
Vol 16 (1) ◽  
pp. 7-16 ◽  
Author(s):  
S. Finitsis ◽  
R. Anxionnat ◽  
A. Lebedinsky ◽  
P.C. Albuquerque ◽  
M.F. Clayton ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Additional Treatment ◽  
Anterior Communicating Artery ◽  
Anticoagulation Management ◽  
Unruptured Aneurysms ◽  
Anterior Communicating Artery Aneurysms ◽  
Group 2 ◽  
Group 1

The immediate and long-term outcomes, complications, recurrences and the need for retreatment were analyzed in a series of 280 consecutive patients with anterior communicating artery aneurysms treated with the endovascular technique. From October 1992 to October 2001 280 patients with 282 anterior communicating artery aneurysms were addressed to our center. For the analysis, the population was divided into two major groups: group 1, comprising 239 (85%) patients with ruptured aneurysms and group 2 comprising of 42 (15%) patients with unruptured aneurysms. In group 1, 185 (77.4%) patients had a good initial pre-treatment Hunt and Hess grade of I-III. Aneurysm size was divided into three categories according to the larger diameter: less than 4 mm, between 4 and 10 mm and larger than 10 mm. The sizes of aneurysms in groups 1 and 2 were identical but a less favorable neck to depth ratio of 0.5 was more frequent in group 2. Endovascular treatment was finally performed in 234 patients in group 1 and 34 patients in group 2. Complete obliteration was more frequently obtained in group 2 unlike a residual neck or opacification of the sac that were more frequently seen in group 1. No peri-treatment complications were recorded in group 2. In group 1 the peri-treatment mortality and overall peri-treatment morbidity were 5.1% and 8.1% respectively. Eight patients (3.4%) in group 1 presented early post treatment rebleeding with a mortality of 88%. The mean time to follow-up was 3.09 years. In group 1, 51 (21.7%) recurrences occurred of which 14 were minor and 37 major. In group 2, eight (23.5%) recurrences occurred, five minor and three major. Two patients (0.8%) presented late rebleeding in group 1. Twenty-seven second endovascular retreatments were performed, 24 (10.2%) in group 1 and three (8.8%) in group 2, seven third endovascular retreatments and two surgical clippings in group 1 only. There was no additional morbidity related to retreatments. Endovascular treatment is an effective method for the treatment of anterior communicating artery aneurysms allowing late rebleeding prevention. Peri-treatment rebleeding warrants caution in anticoagulation management. This is a single center experience and the follow-up period is limited. Patients should be followed-up in the long-term as recurrences may occur and warrant additional treatment.

scholarly journals Managing Anterior Communicating Artery Aneurysms—Are We Doing It Right?

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Lauren Harris ◽  
Ciaran S Hill ◽  
Matthew Elliot ◽  
Teresa Fitzpatrick ◽  
Alejandro Feria ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Open Surgery ◽  
Group Analysis ◽  
Mass Effect ◽  
Anterior Communicating Artery ◽  
Single Centre ◽  
Increased Risk ◽  
Aneurysm Morphology ◽  
Csf Diversion

Abstract INTRODUCTION The natural history and optimal treatment—of previously ruptured anterior communicating artery (ACOM) aneurysms that recur is unclear. This study determines whether our management decisions of endovascular treatment vs open surgery is correct with respect to recurrence and rebleeding rates. METHODS A retrospective observational study. All patients presenting to a single centre with a subarachnoid haemorrhage (SAH) secondary to an ACOM aneurysm were included. Data was collected from November 2012 to September 2018. Data collected included baseline demographics, aneurysm characteristics, management, complications, follow-up imaging, and outcomes. RESULTS A total of 137 patients were included in the study. A total of 113 aneurysms were coiled and 19 were clipped. The indication for clipping was due to aneurysm morphology or the presence of a haematoma exerting mass effect. Rates of vasospasm, infarction, cerebrospinal fluid (CSF) diversion, rebleed, length of stay, and functional outcome were not significantly different in the 2 cohorts. Residual and recurrence was higher in the coiled cohort n = 46 vs clipping n = 2 (P = .0140) with over a quarter of these patients requiring further treatment at a median time of 16 mo. In a subgroup group analysis of coiled aneurysms, there was no statistical differences in rates of rebleed or functional outcome in those that recurred/had a residual and those that did not. CONCLUSION Patients treated with coiling have an increased risk of recurrence vs those treated with clipping. However, the risk of rebleed was not statistically significant. The prevention and impact of recurrence and residual aneurysms remain incompletely understood. Hence, treatment decisions should be considered carefully in a multidisciplinary setting.

Psychosocial distress and access to resources: Preliminary findings from Immunotherapy & Me.

2019 ◽  
Vol 37 (8_suppl) ◽  
pp. 91-91
Author(s):  
Maxwell Mulcahy ◽  
Linda S. House ◽  
Nicholas James Power ◽  
Julie Olson ◽  
Shauna McManus ◽  
...  
Keyword(s):  
Mental Health Professionals ◽  
Sleep Problems ◽  
Treatment Decision ◽  
Clinical History ◽  
Psychosocial Distress ◽  
Treatment Decision Making ◽  
Treatment Information ◽  
Cancer Support ◽  
Academic Center

91 Background: Immunotherapy & Me ( IO & Me) is an innovative program of supportive resources developed by Cancer Support Community to investigate and support the unique needs of immunotherapy patients. Here, we describe psychosocial distress and confidence accessing resources among a sample of program participants. Methods: IO & Me is recruiting at 4 community clinics and 1 academic center. Eligible patients must be on an anti-cancer immunotherapy. At enrollment, participants consent, provide demographic/clinical history, and report level of confidence accessing cancer treatment information and resources related to treatment decision making (TDM) and managing symptoms/side effects (SEs). Distress is reported with CancerSupportSource (CSS), a tool where patients rate level of concern on 15 items. Once enrolled, participants can access educational resources (print materials, SE tracker, eLearning courses) and a toll-free helpline staffed by licensed mental health professionals (Cancer Support Helpline). Follow-up surveys are available every 30 days for 6 months. We present data from 68 participants at enrollment and 22 at first follow-up. Results: Participants were 87% White; 69% male; mean age = 65 years (SD = 13). 43% had lung cancer; 22% melanoma; 9% kidney cancer. At baseline, the frequency who felt very or extremely confident accessing resources related to: TDM = 68%; managing SEs = 60%; treatment information = 75%. For distress, top concerns were: fatigue (35% of participants); health insurance/money worries (34%); exercise/physical activity (32%). After 30 days, the frequency who felt confident accessing resources for: TDM = 100%; managing SEs = 91%; treatment information = 100%. Top concerns were: changes/disruptions in work, school, or home life (14%); feeling irritable (9%); sleep problems (9%). Conclusions: Preliminary results show greater variability in distress and confidence accessing resources at baseline than 1-month into the program, at which time few endorse cancer-related concerns and most feel confident accessing resources. These findings highlight the utility of providing patients with educational/support resources and the value of customizable programs like IO & Me. Clinical trial information: NCT03347058.

Transorbital Keyhole Approach to Anterior Communicating Artery Aneurysms

Neurosurgery ◽  
2001 ◽  
Vol 48 (2) ◽  
pp. 347-352 ◽  
Author(s):  
Hans- J. Steiger ◽  
Robert Schmid-Elsaesser ◽  
Walter Stummer ◽  
Eberhard Uhl
Keyword(s):  
Anterior Communicating Artery ◽  
Anterior Communicating Artery Aneurysms ◽  
Invasive Method ◽  
Tailored Approach ◽  
Interhemispheric Fissure ◽  
Safe Control ◽  
Keyhole Approach ◽  
Gyrus Rectus ◽  
Better Than

Abstract OBJECTIVE The transorbital keyhole approach to anterior communicating artery aneurysms was developed as a minimally invasive method for safe control of the anterior communicating artery complex. This approach does not necessitate resection of the gyrus rectus. METHODS The technique is described in detail. The transorbital keyhole approach provides more ventral access than the supraorbital approaches, and the anterior communicating artery complex can be controlled by splitting the basal aspect of the interhemispheric fissure. RESULTS Since late 1998, the authors have used the transorbital keyhole approach routinely. During the initial experience with 33 patients, the only observed complication specific to this approach was transient diplopia in one patient. At follow-up examinations 2 to 15 months after surgery, the cosmetic results were favorable as compared with those of standard pterional craniotomy. CONCLUSION We have designed a small, custom-tailored approach to the anterior communicating artery complex for routine use. The small orbitocranial approach is a step toward the ideal of purely extra-axial safe control of anterior communicating artery aneurysms. The orbitocranial keyhole approach seems to be substantially better than the craniotomy, although it requires additional effort and time.

scholarly journals The Borderline Dysplastic Hip: Arthroscopy or PAO?

2018 ◽  
Vol 6 (7_suppl4) ◽  
pp. 2325967118S0010
Author(s):  
George Grammatopoulos ◽  
Cecilia Pascual-Garrido ◽  
Jeffrey Nepple ◽  
Christopher M. Larson ◽  
Asheesh Bedi ◽  
...  
Keyword(s):  
Outcome Measures ◽  
Hip Arthroscopy ◽  
Treatment Options ◽  
Treatment Decision ◽  
Patient Characteristics ◽  
Adjunct Treatment ◽  
Treatment Decision Making ◽  
Labral Pathology ◽  
Dysplastic Hip

Objectives: The borderline dysplastic hip (characterized by a lateral centre-edge angle (LCEA): 20 - 25° and an acetabular index (AI): 10 - 15°) can pose a significant challenge as symptoms may be due to insufficient acetabular coverage, the presence of femoro-acetabular impingement (FAI) or both. Accordingly, different treatment options have been described, including peri-acetabular osteotomy (PAO), hip arthroscopy, open arthrotomy or a combination of procedures. This study aims to determine patient and deformity-specific characteristics that direct treatment decision-making in the borderline dysplastic hip. Furthermore, we describe the early-term results of both the PAO and hip arthroscopy in treating this challenging patient population. Methods: A prospective, multicenter, longitudinal surgical cohort of young adult hips was searched. From 2060 hips, 291 hips satisfied the inclusion criteria of idiopathic borderline dysplasia, adequate follow-up (> 1-year) and functional outcome. Demographic and radiographic features are included in Table 1. Fifty-five hips (19%) had a previous hip operation (most commonly a hip arthroscopy). A number of different procedure types were performed which were broadly divided into 3 groups; PAO-only (n=42), hip arthroscopy-only (n=127) or PAO and intra-articular treatment (either arthroscopically or open, addressing the cam morphology and/or labral pathology) (n=122). Outcome measures included complications-, re-operations- rates and clinical outcomes using the Harris Hip (HHS) and HOOS scores; pre-operatively and at follow-up; the difference was defined as Δ. Patient characteristics, radiographic morphology and clinical outcome measures were compared between the 3 groups. Results: Patients that underwent a PAO were younger and more likely to be female. The PAO groups had a greater number of previous hip procedures (26%, 24%), most of which were hip arthroscopies. The patients that underwent hip arthroscopy had greater incidence of high alpha angles (66%) compared to the PAO groups (35%, 38%) (p<0.001). The PAO groups having slightly more dysplastic features (LCEA, AI, ACEA) (Table 1). At a mean follow-up of 2.5 years, there were no differences in the complication (7-10%, p=0.8) or re-operation rates (13%). Pre-operatively, the PAO groups had inferior HOOS and WOMAC scores compared to the arthroscopy group (p=0.02-7). No differences in the post-op scores were seen (Table 1). The groups that addressed the intra-articular pathology (arthroscopy and PAO-articular treatment) had significantly greater ΔHHS (23) compared to PAO-only (13) (p=0.02). Conclusion: Younger patients, those with a failed previous arthroscopy, without evidence of intra-articular wear and with worse pre-operative function were more likely to receive a PAO (with or without articular adjunct treatment). Addressing the intra-articular and impingement-related pathology (in addition to a when a PAO is considered necessary) was associated with better improvement in PROMs and should be strongly considered in the borderline hip. [Table: see text]

Treatment allocation of ruptured anterior communicating artery aneurysms: The influence of aneurysm morphology

2019 ◽  
Vol 186 ◽  
pp. 105506
Author(s):  
Marvin Darkwah Oppong ◽  
Cornelius Deuschl ◽  
Daniela Pierscianek ◽  
Laurèl Rauschenbach ◽  
Mehdi Chihi ◽  
...  
Keyword(s):  
Anterior Communicating Artery ◽  
Treatment Allocation ◽  
Anterior Communicating Artery Aneurysms ◽  
Aneurysm Morphology

Patient involvement in multidisciplinary treatment planning (MTP).

2013 ◽  
Vol 31 (31_suppl) ◽  
pp. 145-145
Author(s):  
Irene Prabhu Das ◽  
Heather Rozjabek ◽  
Mary L. Fennell ◽  
Katherine Mallin ◽  
E. Greer Gay ◽  
...  
Keyword(s):  
Decision Making ◽  
Online Survey ◽  
Patient Involvement ◽  
Treatment Plan ◽  
Multidisciplinary Treatment ◽  
Treatment Decision ◽  
Case Presentation ◽  
Patient Navigators ◽  
Treatment Decision Making

145 Background: Patient involvement in treatment decision-making has been well-studied. However, little is known about how patients are involved in the MTP process prior to their consideration of treatment options. Methods: An online survey was administered to 1,261 Commission on Cancer (CoC)-accredited programs to describe current MTP practice. Survey items addressed team structure and process, case presentation, and patient involvement. A total of 797 (63%) facilities responded. Multiple aspects of patient involvement focusing on the initial case presentation and post-meeting follow-up regarding information provision and communication are examined. Initial descriptive analyses are presented. Results: 97% of facilities reported patients are not invited to attend MTP meetings. Reasons for not inviting patients included: patients may find it overwhelming (62%), physicians not able to speak freely (58%), liability (43%) and privacy (42%) concerns. Of the facilities that do invite patients, 1/3 reported that patients often or always attend. Treatment recommendations from MTP meetings are shared with patients at 75% of facilities, 42% share treatment plans, and 28% give a meeting summary to patients. Nine percent of facilities do not give patients any information from the meeting. Prior to treatment, a written treatment plan is developed at 43% of facilities, and among these, 15% give the plan to patients. Regarding communication about MTP meetings, facilities reported pre-meeting discussions with attending physicians (95%) and patient navigators (21%). Post-meeting follow-up by 93% of facilities is usually done by physicians, 26% by patient navigators and 16% by PA/NPs, and 66% follow-up within 1 week. Conclusions: Initial findings suggest that even if facilities do not invite patients to MTP meetings, they engage patients in various ways at pre- and post-MTP meetings, providing information and having discussions. Physicians are integral in communicating with patients throughout the MTP process. Further study on the multiple facets of patient involvement in MTP is needed to better understand its influence on treatment decision-making.

Impact of a novel decision counseling program on treatment knowledge, decisional conflict, and choice in men with early-stage, low-risk prostate cancer.

2013 ◽  
Vol 31 (31_suppl) ◽  
pp. 9-9
Author(s):  
Jean H. Hoffman-Censits ◽  
Anett Petrich ◽  
Anna Quinn ◽  
Amy Leader ◽  
Leonard G. Gomella ◽  
...  
Keyword(s):  
Decision Making ◽  
Early Stage ◽  
Treatment Decision ◽  
Decisional Conflict ◽  
Counseling Program ◽  
Treatment Decision Making ◽  
Treatment Knowledge ◽  
Risk Prostate Cancer ◽  
Low Risk Prostate Cancer

9 Background: Active surveillance (AS - serial follow-up PSA, exam, and biopsy) is an option for men with early stage, low risk prostate cancer (LRPca). While data show comparable survival for AS vs active treatment (AT - surgery or radiation), currently most men with LRPca undergo AT. A pilot Decision Counseling Program (DCP) to assist men in making an informed, shared LRPca treatment decision was implemented. Methods: Men with LRPca seen at the Jefferson Genitourinary Multidisciplinary Cancer Center (JGUMDCC) were consented. A nurse educator (NE) reviewed risks/benefits of AS and AT; had the participant identify factors influencing treatment decision making and specify decision factor weights; entered data into an online DCP; and generated a report of participant treatment preference and decision factors. The report was used by the participant and clinicians in shared treatment decision making. A follow-up survey was administered 30 days after the visit, with treatment status assessed. Change in treatment-related knowledge and decisional conflict were measured using baseline and 30-day survey data. Results: Baseline decision counseling preference of 16 participants: 4 - AS, 8 equal for AS and AT, 4 - AT. At 30 days, 12 participants initiated AS, 4 chose AT; participant mean treatment knowledge scores (8-point scale) increased (+1.13 points); decisional conflict subscale scores (strongly disagree = 1, strongly agree = 5) decreased (uncertain: -1.15, uninformed: -1.36, unclear: -1.12; and unsupported: -1.15). Conclusions: Decision counseling and shared decision making helped participants become better informed about treatment choices and reduced uncertainty in treatment decision making. The combined intervention resulted in most participants choosing AS. Ongoing study recruitment, data collection, and analyses are planned.

Sign in / Sign up

Export Citation Format

Share Document