Neurosurgical clipping versus endovascular coiling for patients with ruptured anterior circulation aneurysms: A systematic review and meta-analysis.

To compare the safety and efficacy of clipping and coiling in patients with ruptured anterior circulation aneurysms. A systematic search of four databases (PubMed, Web of Science, Cochrane Library, and Embase) was conducted to identify comparative articles on endovascular coiling and surgical clipping in patients with ruptured anterior circulation aneurysms. Meta-analyses were conducted using random-effects models. Nineteen studies, including 1983 patients, were included. The meta-analysis showed that neurosurgical clipping was associated with a lower incidence of retreatment (OR:0.28, 95% CI (0.11, 0.70), P = 0.006) than endovascular coiling, which seemed to be a result of incomplete occlusion (OR:0.22, 95% CI (0.11, 0.45), P < 0.001). Neurosurgical clipping was associated with lower mortality (OR:0.45, 95% CI (0.25, 0.82), P = 0.009) at short-term follow-up than endovascular coiling. However, neurosurgical clipping showed a higher incidence of ischemic infarction (OR:2.28, 95% CI (1.44, 3.63), P < 0.001) and a longer length of stay (LOS) (WMD:6.12, 95% CI (4.19, 8.04), P < 0.001) after surgery than endovascular coiling. Furthermore, the pooled results showed no statistically significant differences between the two groups regarding poor outcome, long-term mortality, rebleeding, vasospasm, and hydrocephalus. Evidence from this systematic review illustrates that neurosurgical clipping may be superior to endovascular coiling for ruptured anterior circulation aneurysms. Large-scale RCTs should be conducted to verify these outcomes and provide results according to patient status.

Carotid-cavernous fistula: A potential treatable cause of bilateral abducens palsy and conjunctival hyperemia.

OBJECTIVE: Carotid cavernous fistulas (CCFs) represent uncommon and anomalous communications between the carotid artery and the cavernous sinus. MATERIALS AND METHODS: Case report RESULTS: We present the clinical details and successful management of a previously healthy 44-year-old patient who presented with one-month worsening headache, bilateral abducens palsy and conjunctival injection. Imaging modalities including magnetic resonance imaging (MRI) with contrast and digital subtraction angiography (DSA) facilitated the diagnosis of CCF. The patient underwent endovascular coiling of the CCF, leading to neurological recovery and symptom remission. CONCLUSION: This case highlights the importance of promptly CCF diagnosis in patients with multiple cranial nerve palsies and conjunctival hyperemia. Moreover, it emphasizes the efficacy of endovascular coiling in achieving symptom remission.

A Rare Neurological Presentation of Noonan Syndrome and Its Management-A Case Report.

Although Noonan syndrome is a relatively common congenital disorder with autosomal dominant inheritance, its association with cerebrovascular anomalies is rare. We report a case of a 20-year-old with Noonan syndrome with cerebrovascular aneurysm, who underwent successful endovascular coiling. Only four cases of cerebrovascular aneurysms in Noonan syndrome have been reported in the literature so far. To the best of our knowledge, this is only the fifth reported case and the first one that has been treated successfully with endovascular coiling. We hereby discuss the management of this case, which had several comorbidities like congenital heart disease and craniovertebral junction anomaly.

Microneurosurgery for Ruptured Aneurysm of Distal Intracranial Vertebral Artery: A Case Report.

The International Subarachnoid Aneurysm Trial led to a shift from clipping to endovascular coiling as the primary therapy for cerebral aneurysm particularly in the management of posterior circulation aneurysm. However, endovascular therapy is often unavailable in low-resource settings, emphasizing the importance of maintaining surgical skill sets in resource-poor countries. This article presents a detailed case report on the successful microneurosurgical management of a 65-year-old female with a history of headache and weakness with past history of hypertension and a right posterior cerebral artery territory infarct who was diagnosed with a ruptured aneurysm situated within the intracranial vertebral artery. Patient was operated with the far lateral approach and clipping of the aneurysm. This case report elucidates the intricate surgical techniques employed, and the challenges neurosurgeons encountered in treating posterior circulation intracranial aneurysms, particularly those with ruptured complications. The aneurysms' intricate anatomy and increased rupture risk necessitate a meticulous microneurosurgical approach. The severity of subarachnoid hemorrhage from ruptured aneurysms increases morbidity and mortality rates.

Recovery of Oculomotor Nerve Palsy After Surgical and Endovascular Repair of Unruptured Internal Carotid-Posterior Communicating Artery Aneurysms.

OBJECTIVE: Unruptured posterior communicating artery (Pcom) aneurysms cause oculomotor nerve palsy (ONP). However, the time course of recovery after aneurysm repair remains unclear. We aimed to evaluate the ONP course after clipping and coiling for unruptured Pcom aneurysms. METHODS: We retrospectively reviewed the medical records of 25 consecutive patients with ONP due to unruptured Pcom aneurysms, undergoing aneurysm repair at our institution during 2010-2022. We analyzed the clinical data, angiographic results, and surgical complications. The time to ONP recovery was evaluated using the Kaplan-Meier method. RESULTS: This study included 14 patients undergoing surgical clipping and 11 undergoing endovascular coiling. The two groups exhibited no significant differences in complete or partial ONP percentage or in symptom presentation (ptosis, diplopia, ocular paralysis, pupillary light reflex disorder, or mydriasis). All patients achieved complete or partial recovery during the follow-up period. The median time to partial or complete improvement in ONP was significantly shorter for clipping compared to coiling (2 days vs. 33 days; P = 0.009). Preoperative partial and complete ONP were stratified; clipping improved significantly earlier than coiling in the complete ONP group (P = 0.010). In the early treatment group (based on the median duration of treatment), clipping resulted in earlier improvement than coiling (P = 0.014). In the small aneurysm group (based on the median of the aneurysm maximum diameter), clipping resulted in earlier improvement than coiling (P = 0.005). CONCLUSION: In ONP caused by an unruptured Pcom aneurysm, clipping may provide faster recovery than coiling, particularly in cases of early onset, complete palsy, and small aneurysms.

Efficacy of endovascular embolization versus microsurgical clamping in the treatment of intracranial aneurysms: a meta-analysis.

Intracranial aneurysms (IA) can induce increased intracranial pressure, headache, and the development of nausea and vomiting if not treated in time, and failure to receive timely diagnosis and treatment can lead to disability or death. However, the efficacy and prognostic value of craniotomy and endovascular embolization in patients with IA remains a controversial topic. This meta-analysis systematically evaluated the efficacy of endovascular coiling versus cranial aneurysm clamping on the immediate postoperative outcome and prognosis of patients with IA. PubMed, EMBASE, and the Cochrane Library databases were searched for retrieval of relevant references. Literature was screened according to pre-defined inclusion and exclusion criteria, and data were extracted and assessed for quality. A total of 10 studies, including 2,654 cases, were included in the analysis. Among them, 1,313 cases underwent craniotomy clipping surgery (clip group), and 1,341 cases underwent endovascular coiling (coil group). The quality of the studies in 8 articles evaluated using the Newcastle-Ottawa Scale (NOS) was ≥6. Meta-analysis was conducted using Rev Man 5.3 and Stata 17 software. The results of meta-analysis showed that no significant difference in complete occlusion rate [OR=1.76, 95% CI (0.78, 3.96), P=0.17] when comparing the clip and coil group. Compared to the clip group, the coil group had a better clinical short-term outcome [OR=1.55, 95% CI (1.05, 2.27), P=0.03], but an increased rate of postoperative residual or recurrence [OR=0.40, 95% CI (0.17, 0.91), P=0.03]. In addition, there were no significance differences identified in terms of complications, including the rates of postoperative rebleeding [OR=1.60, 95% CI (0.97, 2.63), P=0.07], ischemic stroke [OR=1.12, 95% CI (0.45, 2.79), P=0.81], and cerebral vasospasm [OR=0.90, 95% CI (0.13, 6.03), P=0.91]. Subsequently, we conducted experimental sequence analysis for each indicator, and the results were consistent with the results of meta-analysis. According to the recent clinical prognosis, a funnel plot was constructed, showing significant asymmetry on both sides, indicating some publication bias. However, the results of Begg's test with P=0.734 and Egger's test with P=0.633 suggest no significant publication bias. In general, endovascular coiling and microsurgical clipping appear to be equally effective in achieving vascular occlusion. Endovascular coiling may be more effective in improving the short-term clinical outcomes for patients. However, this approach may increase the rate of postoperative residual issue or recurrence.

The Management of Intracranial Aneurysms: Current Trends and Future Directions.

Intracranial aneurysms represent a major global health burden. Rupture of an intracranial aneurysm is a catastrophic event. Without access to treatment, the fatality rate is 50% in the first 30 days. Over the last three decades, treatment approaches for intracranial aneurysms have changed dramatically. There have been improvements in the medical management of aneurysmal subarachnoid haemorrhage, and there has been an evolution of treatment strategies. Endovascular therapy is now the mainstay of the treatment of ruptured intracranial aneurysms based on robust randomised controlled trial data. There is now an expansion of treatment indications for unruptured intracranial aneurysms to prevent rupture with both microsurgical clipping and endovascular treatment. Both microsurgical and endovascular treatment modalities have evolved, in particular with the introduction of innovative endovascular treatment options including flow diversion and intra-saccular flow disruption. These novel therapies allow clinicians to treat more complex and previously untreatable aneurysms. We aim to review the evolution of treatment strategies for intracranial aneurysms over time, and discuss emerging technologies that could further improve treatment safety and functional outcomes for patients with an intracranial aneurysm.

Posterior Inferior Cerebellar Artery Aneurysm Presenting With Severe Vertigo and Altered Sensorium.

Posterior inferior cerebellar artery (PICA) aneurysms are relatively uncommon among intracranial aneurysms and present unique challenges due to their complex anatomical origins. PICA aneurysms arise from the vertebral artery (VA), basilar artery, or anterior inferior cerebellar artery and can have complex anatomical sites and structures. A 31-year-old female known case of trigeminal neuralgia, currently asymptomatic for the same, experienced acute vertigo, headache, and altered sensorium. On the basis of the magnetic resonance imaging of the brain with angiography, she was diagnosed with a PICA aneurysm, necessitating immediate intervention. The patient subsequently underwent endovascular coiling of the aneurysm. The successful management of this unusual case emphasizes the significance of prompt diagnosis and early intervention in managing posterior inferior cerebellar artery aneurysms, leading to a favourable outcome. The patient is on regular follow-ups and has satisfactory progress.

Management of Previously Failed Coiling and Clipping of a Middle Cerebral Artery Aneurysm.

Endovascular coiling techniques have emerged as an alternative and effective approach for treating intracranial aneurysms. However, in some cases, previously coiled aneurysms may require secondary treatment with surgical clipping, presenting a more complex challenge compared with the initial intervention.1,2 We present the case of a 39-year-old man with a residual class III Raymond-Roy occlusion partially coiled aneurysm at the left middle cerebral artery bifurcation (Video 1). Faced with the risks of rerupture, the patient underwent microsurgical treatment after providing consent. Despite successful initial microsurgical clipping, postoperative complications arose due to coil protrusion into the middle cerebral artery bifurcation, resulting in thrombotic occlusion of the frontal M2 branch. Emergency repeat microsurgical intervention and administration of a thrombolytic agent were performed to address complications, ultimately preserving blood flow. Subsequent endovascular placement of a flow-diverting stent 7 weeks after discharge confirmed complete occlusion of the aneurysm. The patient had no neurological deficit on follow-up. When planning microsurgical clipping of an aneurysm previously treated with coils, it is critical to consider coil placement, as there is a risk of prolapse if the coil is in the neck of the aneurysm. Thrombosis of the cerebral arteries is a potential complication of microsurgical clipping of partially coiled intracranial aneurysms, and injection of a fibrinolytic agent into thrombosed arterial branches may be an effective intraoperative method for treating intra-arterial thrombosis.3 This case illustrates the challenges associated with treating partially coiled aneurysms, highlighting the significance of careful planning when considering microsurgical treatment.

A comprehensive numerical approach to coil placement in cerebral aneurysms: mathematical modeling and in silico occlusion classification.

Endovascular coil embolization is one of the primary treatment techniques for cerebral aneurysms. Although it is a well-established and minimally invasive method, it bears the risk of suboptimal coil placement which can lead to incomplete occlusion of the aneurysm possibly causing recurrence. One of the key features of coils is that they have an imprinted natural shape supporting the fixation within the aneurysm. For the spatial discretization, our mathematical coil model is based on the discrete elastic rod model which results in a dimension-reduced 1D system of differential equations. We include bending and twisting responses to account for the coils natural curvature and allow for the placement of several coils having different material parameters. Collisions between coil segments and the aneurysm wall are handled by an efficient contact algorithm that relies on an octree based collision detection. In time, we use a standard symplectic semi-implicit Euler time stepping method. Our model can be easily incorporated into blood flow simulations of embolized aneurysms. In order to differentiate optimal from suboptimal placements, we employ a suitable in silico Raymond-Roy-type occlusion classification and measure the local packing density in the aneurysm at its neck, wall region and core. We investigate the impact of uncertainties in the coil parameters and embolization procedure. To this end, we vary the position and the angle of insertion of the micro-catheter, and approximate the local packing density distributions by evaluating sample statistics.

Multiple Intracranial Aneurysms Associated With Brain Arteriovenous Malformation: A Case Report and Treatment Strategies.

In the field of cerebrovascular neurosurgery, intracranial aneurysms (IAs) have been occasionally associated with brain arteriovenous malformations (BAVMs), indicating a more aggressive clinical course, and increased rates of hemorrhage and rehemorrhage. Treatment of flow-related IAs in BAVMs remains debatable, with considerations for preventive intervention versus concurrent BAVM treatment. Managing such situations might be challenging, especially in determining which of the IAs or BAVMs should be treated first, and which treatment strategy would be most appropriate for each situation. A precise identification of the rupture site is required, whether it is the AVM nidus or the IA, for choosing the best treatment plans. We present a case of a 29-year-old male patient diagnosed with several intracranial vascular conditions: a ruptured anterior communicating artery (ACoA) aneurysm and an unruptured ophthalmic artery aneurysm, associated with a frontal BAVM. Moreover, we discussed the possible scenarios regarding the association of these conditions, highlighting their manifestations and the most suitable therapeutic approach for each. Thus, our exploration of the challenges and considerations involved in treating these intricate neurovascular conditions underscores the need for a customized approach for each patient's situation.

Coil Embolization Is Not Justified for Treating Patients with Veno-Occlusive Dysfunction: Case Series and Narrative Literature Review.

Introduction: Herein, we explore whether coil embolization (CE) is effective in treating veno-occlusive dysfunction (VOD). We present five cases with seven CE episodes and a narrative literature review. Methods: From 2013 to 2018, refractory impotence prompted five men to seek penile vascular stripping (PVS), although seven CE episodes were included. All received dual cavernosography in which erection-related veins and VOD were documented. PVS entailed the venous stripping of one deep dorsal vein and two cavernosal veins. The abridged five-item version of the International Index of Erectile Function (IIEF-5) score system and the erection hardness scale (EHS) were used, and yearly postoperative follow-ups were conducted via the Internet. Using Pub Med, a narrative literature review was performed on CE treatment for VOD or varicocele. Results: Inserted coils were scattered along the erection-related veins, including the deep dorsal veins (n = 4), periprostatic plexus (n = 5), iliac vein (n = 5), right pulmonary artery (n = 2), left pulmonary artery (n = 2), and right ventricle (n = 1). PVS resulted in some improvements in the IIEF-5 score and EHS scale. Six articles highly recommend CE treatment for VOD. All claimed it is a minimally invasive effective treatment for varicocele. Conclusions: CE is not justified as a VOD treatment, regardless of its viability in the treatment of varicocele.