Paradigm Shift in the Treatment of Meningiomas.

Meningiomas are the most common brain tumor in adults with rising incidence rates due to an aging population globally, increased availability of neuroimaging, and increased awareness of this condition by treating clinicians and primary care physicians. Surgical resection remains the mainstay of treatment, with adjuvant radiotherapy reserved for higher grade meningiomas or tumors that undergo incomplete resections. Whereas these tumors were classically defined by their histopathological features and subtypes, recent work has uncovered the molecular alterations that may lead to tumor development and have important prognostic implications. However, there remain important clinical questions regarding the management of meningiomas and current clinical guidelines continue to evolve as additional studies add onto the growing body of work that enables us to better understand these tumors.

The Brainstem Cavernoma Case Series: A Formula for Surgery and Surgical Technique.

Background and Objectives: Cavernous malformations (CM) are vascular malformations with low blood flow. The removal of brainstem CMs (BS) is associated with high surgical morbidity, and there is no general consensus on when to treat deep-seated BS CMs. The aim of this study is to compare the surgical outcomes of a series of deep-seated BS CMs with the surgical outcomes of a series of superficially located BS CMs operated on at the Department of Neurosurgery, College of Tuebingen, Germany. Materials and Methods: A retrospective evaluation was performed using patient charts, surgical video recordings, and outpatient examinations. Factors were identified in which surgical intervention was performed in cases of BS CMs. Preoperative radiological examinations included MRI and diffusion tensor imaging (DTI). For deep-seated BS CMs, a voxel-based 3D neuronavigation system and electrophysiological mapping of the brainstem surface were used. Results: A total of 34 consecutive patients with primary superficial (n = 20/58.8%) and deep-seated (n = 14/41.2%) brainstem cavernomas (BS CM) were enrolled in this comparative study. Complete removal was achieved in 31 patients (91.2%). Deep-seated BS CMs: The mean diameter was 14.7 mm (range: 8.3 to 27.7 mm). All but one of these lesions were completely removed. The median follow-up time was 5.8 years. Two patients (5.9%) developed new neurologic deficits after surgery. Superficial BS CMs: The median diameter was 14.9 mm (range: 7.2 to 27.3 mm). All but two of the superficial BS CMs could be completely removed. New permanent neurologic deficits were observed in two patients (5.9%) after surgery. The median follow-up time in this group was 3.6 years. Conclusions: The treatment of BS CMs remains complex. However, the results of this study demonstrate that with less invasive posterior fossa approaches, brainstem mapping, and neuronavigation combined with the use of a blunt "spinal cord" dissection technique, deep-seated BS CMs can be completely removed in selected cases, with good functional outcomes comparable to those of superficial BS CM.

Impact of the weekend effect on outcome after microsurgical clipping of ruptured intracranial aneurysms.

BACKGROUND: The "weekend effect" describes the assumption that weekend and/or on-call duty admission of emergency patients is associated with increased morbidity and mortality rates. For aneurysmal subarachnoid hemorrhage, we investigated, whether presentation out of regular working hours and microsurgical clipping at nighttime correlates with worse patient outcome. METHODS: This is a retrospective review of consecutive patients that underwent microsurgical clipping of an acutely ruptured aneurysm at our institution between 2010 and 2019. Patients admitted during (1) regular working hours (Monday-Friday, 08:00-17:59) and (2) on-call duty and microsurgical clipping performed during (a) daytime (Monday-Sunday, 08:00-17:59) and (b) nighttime were compared regarding the following outcome parameters: operation time, treatment-related complications, vasospasm, functional outcome, and angiographic results. RESULTS: Among 157 enrolled patients, 104 patients (66.2%) were admitted during on-call duty and 48 operations (30.6%) were performed at nighttime. Admission out of regular hours did not affect cerebral infarction (p = 0.545), mortality (p = 0.343), functional outcome (p = 0.178), and aneurysm occlusion (p = 0.689). Microsurgical clipping at nighttime carried higher odds of unfavorable outcome at discharge (OR: 2.3, 95%CI: 1.0-5.1, p = 0.039); however, there were no significant differences regarding the remaining outcome parameters. After multivariable adjustment, clipping at nighttime did not remain as independent prognosticator of short-term outcome (OR: 2.1, 95%CI: 0.7-6.2, p = 0.169). CONCLUSIONS: Admission out of regular working hours and clipping at nighttime were not independently associated with poor outcome. The adherence to standardized treatment protocols might mitigate the "weekend effect."

Retreatment strategies for recurrent and residual aneurysms after treatment with flow-diverter devices.

PURPOSE: The management of residual or persistent intracranial aneurysms after flow-diversion therapy is not well defined in the literature. In this multicentric study, we report clinical and angiographic outcomes of 11 patients that underwent retreatment for 12 aneurysms initially treated with flow-diverter stents. METHODS: The median patient age was 53 years. Aneurysms (median size, 7.3 mm) were located at the internal carotid artery in 9 cases, and at the posterior circulation in 3. Treatment strategies, complications, and angiographic outcome were retrospectively assessed. RESULTS: Retreatment was feasible in all cases and performed by overlapping flow-diverter implantation. Overall, 12 side vessels were covered during retreatment, whereof 10 (83.3%) remained patent until mid-term follow-up. There were no further technical or symptomatic complications and no treatment-related morbidity. Angiographic follow-up (median, 17 months) showed improved aneurysm occlusion in all patients. Complete or near-complete aneurysm occlusion was achieved in 11 aneurysms (91.7%). CONCLUSION: Required retreatment after failed flow-diversion therapy can be performed with adequate safety and efficacy by placement of additional flow-diverter stents.

Flow-regulated versus differential pressure valves for idiopathic normal pressure hydrocephalus: comparison of overdrainage rates and neurological outcome.

BACKGROUND: To compare flow-regulated (FR) and differential pressure (DP) valves for treatment of patients with idiopathic normal hydrocephalus (iNPH) focusing on overdrainage and neurological outcome. METHODS: This is a retrospective study of patients with iNPH treated with FR and DP valves at a single institution between 2008 and 2018. The neurological status was evaluated retrospectively with the Kiefer scale at baseline, after shunt placement and at the 6-month follow-up. Groups were compared using inverse probability of treatment weighting based on propensity scores. RESULTS: The study cohort consisted of 38 patients treated with FR valves and 49 with DP valves. The mean patient age was 72.0 ± 7.6 years. Based on the Kiefer scale score, neurological improvement at the 6-month follow-up was recorded in 79.6% in the DP group and 89.5% in the FR group (p = 0.252). The overdrainage rates were higher among DP valves (10.2%) than among FR valves (2.6%, adjusted p = 0.002). Valve malfunction occurred in 2.0% in the DP group and 5.3% in the FR group (adjusted p = 0.667). CONCLUSIONS: The current study demonstrates a comparable neurological improvement between DP and FR valves, with potentially lower overdrainage rates among FR valves. Long-term studies will be necessary to draw a definite conclusion on FR valves for treatment of iNPH patients.

Does Meningioma Volume Correlate With Clinical Disease Manifestation Irrespective of Histopathologic Tumor Grade?

OBJECTIVES: The aim of the study was to investigate the association between meningioma volume and the occurrence of clinic-radiologic signs of tumor aggressiveness. For volumetric approximation, the authors evaluated the method of semiautomatic image segmentation at hand of high-resolution MRI-image sequences. METHODS: ITK-SNAP was utilized for semiautomatic image segmentation of 58 gadolinium-contrast enhanced T1-weighted thin-slice MRI datasets for volumetric analysis. Furthermore, multimodal imaging datasets (including T2, FLAIR, T1) were evaluated for radiological biomarkers of aggressiveness and growth potential. Thereby generated data was checked for association with retrospectively collected data points. RESULTS: Location (P = 0.001), clinical disease manifestation (P = 0.033), peritumoral edema (P = 0.038), tumor intrinsic cystic degeneration (P = 0.007), three-dimensional complexity (P = 0.022), and the presence of meningioma mass effect (P = 0.001) were statistically associated with higher tumor volumes. There was no association between higher tumor volumes and histopathological tumor grade. CONCLUSION: The size of a meningioma does not seem to reliably predict tumor grade. Growth potential seems to be influenced by tumor location. Higher tumor volumes were significantly associated with the occurrence of clinical symptoms.

Impact of aneurysm shape on morbidity after clipping of unruptured intracranial aneurysms.

BACKGROUND: Complex aneurysm shape is a predominant risk factor for aneurysm rupture but its impact on clinical outcome after clipping remains unclear. The objective of the present study was to compare complications and morbidity after clipping of unruptured single-sac aneurysms (SSAs) and aneurysms with multiple sacs (MSAs). METHODS: A retrospective, single-center study was conducted for patients that were treated between 2010 and 2018. We analyzed surgical parameters, treatment-related complications, and morbidity, defined as any increase in the modified Rankin scale at 3-month follow-up. RESULTS: We identified 101 patients (mean age: 52.9 ± 10.5 years) that underwent clipping for 57 SSAs and 44 MSAs. The two groups were comparable regarding aneurysm size and neck width. Clipping of MSAs was associated with a longer operation time (p = 0.008) and increased use of intraoperative indocyanine green (p = 0.016) than SSAs. Complications occurred more often in the MSA group (29.5%) than in the SSA group (14.0%; p = 0.057). Morbidity was significantly higher in the MSA group (20.5%) than in the SSA group (3.5%, p = 0.009). In the univariate analysis, the odds of morbidity were 7.1 times greater for MSAs than for SSAs (95% CI 1.4-34.7). CONCLUSIONS: Morbidity after microsurgical clipping is significantly increased in MSAs as compared to SSAs. This may be attributed to a more difficult clip placement with stronger manipulation of the aneurysm dome and the surrounding brain tissue.

Interdisciplinary Treatment of Intracranial Infectious Aneurysms.

OBJECTIVE: Intracranial infectious aneurysms (IIAs) are a rare clinical entity without a definitive treatment guideline. In this study, we evaluate the treatment options of these lesions based on our own clinical experience and review the current knowledge of therapy as portrayed in the literature. METHODS: We conducted a single-center retrospective analysis of all patients with an IIA and performed a systematic review of the literature using the MEDLINE database. We undertook a comprehensive literature search using the OVID gateway of the MEDLINE database (1950-October 2015) using the following keywords (in combination): 'infectious', 'mycotic', 'cerebral aneurysm', 'intracranial aneurysm'. 1,721 potentially relevant abstracts were identified and 63 studies were selected for full review. The studies were analysed regarding ruptured versus unruptured aneurysms, aneurysm localization and treatment, as well as clinical and radiological outcome. RESULTS: Our institutional series consisted of 6 patients (median age 57 [32-76]) treated between 2011 and 2015. All patients presented with ruptured IIAs located on the middle cerebral artery (MCA, 5 patients) and anterior cerebral artery (ACA, 1 patient). Five patients were treated by clipping and resecting the aneurysm, 1 patient underwent coiling. All patients received antibiotic therapy and 1 patient died. We further identified 814 patients (median age 35.5 [0-81]) in 63 studies. Locations of the aneurysms were mentioned in 55 studies. The most frequent locations of the aneurysms were: MCA (63.5%), posterior cerebral artery (14%), ACA (9.0%) and others (13.5%). Treatment for IIAs was described in 62 studies: antibiotic treatment (56.1%), a combination of antibiotics and surgery (20.9%) or antibiotics and endovascular treatment (23.0%). Outcome was mentioned in 82.4% of the patients with a mortality rate of 16.8%. An evaluation of treatment outcome was limited due to the heterogeneity of patients in the published case series. CONCLUSION: Antibiotic therapy of patients with IIA is mandatory. However, due to the complexity of the disease and its accompanying comorbidities, a general treatment algorithm could not be defined. Analogous to non-mycotic aneurysms, further treatment decisions require an interdisciplinary approach involving neurosurgeons, interventionists and infectious disease specialists.

Common variant near the endothelin receptor type A (EDNRA) gene is associated with intracranial aneurysm risk.

The pathogenesis of intracranial aneurysm (IA) formation and rupture is complex, with significant contribution from genetic factors. We previously reported genome-wide association studies based on European discovery and Japanese replication cohorts of 5,891 cases and 14,181 controls that identified five disease-related loci. These studies were based on testing replication of genomic regions that contained SNPs with posterior probability of association (PPA) greater than 0.5 in the discovery cohort. To identify additional IA risk loci, we pursued 14 loci with PPAs in the discovery cohort between 0.1 and 0.5. Twenty-five SNPs from these loci were genotyped using two independent Japanese cohorts, and the results from discovery and replication cohorts were combined by meta-analysis. The results demonstrated significant association of IA with rs6841581 on chromosome 4q31.23, immediately 5' of the endothelin receptor type A with P = 2.2 × 10(-8) [odds ratio (OR) = 1.22, PPA = 0.986]. We also observed substantially increased evidence of association for two other regions on chromosomes 12q22 (OR = 1.16, P = 1.1 × 10(-7), PPA = 0.934) and 20p12.1 (OR = 1.20, P = 6.9 × 10(-7), PPA = 0.728). Although endothelin signaling has been hypothesized to play a role in various cardiovascular disorders for over two decades, our results are unique in providing genetic evidence for a significant association with IA and suggest that manipulation of the endothelin pathway may have important implications for the prevention and treatment of IA.

Incidence and Clinical Presentation of Pre- and Postoperative Seizures in Patients With Posterior Fossa Meningiomas.

INTRODUCTION: Seizures are a common symptom of supratentorial meningiomas with pre- and postoperative seizure rates of approximately 30% and 12%, respectively, especially in parasagittal and convexity meningiomas. Less is known about the association between seizures and posterior fossa meningiomas. This study evaluates the prevalence, potential causes, and outcomes of seizures in patients who have undergone surgery for posterior fossa meningioma. METHODS: This is a retrospective, observational, single-center study of consecutive patients who underwent surgical resection of posterior fossa meningiomas between 2009 and 2017. We retrospectively identified patients with seizures and analyzed patient demographics, tumor characteristics, and procedural characteristics. RESULTS: A total of 44 patients (mean age: 59.8 ± 13.5 years) were included. Twenty-six tumors were located at the cerebellar convexity and tentorium (59.1%), 12 at the cerebellopontine angle (27.3%), four at the clivus (9.1%), and two at the foramen magnum (4.5%). Seizures were the presenting symptom of cerebellar meningioma in two patients. Patients were seizure-free after surgery. Three patients had their first seizure after surgery (interval between surgery and first seizure: two days to 17 months). Analysis of these three patients revealed possible causes of postoperative seizures: radiation necrosis and edema, hyponatremia, and preoperative hydrocephalus. In all patients with postoperative seizures, long-term seizure control was achieved with the administration of antiepileptic drugs. CONCLUSIONS: The incidence of seizures in patients with posterior fossa meningiomas is relatively low. Antiepileptic drugs can help to achieve seizure control.

Common genetic polymorphisms in moyamoya and atherosclerotic disease in Europeans.

PURPOSE: Moyamoya is the most common cerebrovascular disease in children in Japan. The disease's etiology is still widely unknown. Several publications describe histopathological changes in the walls of affected vessels similar to those seen in atherosclerosis. In this study, we analyzed the DNA of European patients with Moyamoya disease for single nucleotide polymorphisms associated with atherosclerotic changes. METHODS: We genotyped 17 SNPs in or adjacent to 11 genes (ELN, LIMK1, CDKN2A/B, CXCL12, Pseudogene ENSG00000197218, PSRC1, MTHFD1L, SMAD3, MIA3, PDGF-B, TIMP2) comparing 40 DNA samples of Moyamoya disease patients to 68 healthy controls from central Europe. The mean age of onset of Moyamoya disease (MMD)-related symptoms was 15.4 years of age. Genotyping was performed by sequencing the SNP containing genetic regions with custom-made primers. RESULTS: We found strong association of one SNP (rs599839 [A/G], OR = 2.17, 95% CI = 1.17, 4.05; p = 0.01) with the risk allele G located in the 3' UTR region of the PSRC-1 gene. Three further SNPs (rs8326, rs34208922, rs501120) in or adjacent to the genes ELN and CXCL12 showed tendencies towards risk alleles with p values between 0.1 and 0.2 but did not reach statistical significance in our cohort. CONCLUSIONS: Our results indicate a possible parallel of common processes in the genesis of Moyamoya disease and atherosclerotic disease. Further analyses in larger European cohorts and replication in patients of different ethnicity may lead to possible early detection of patients at risk for developing MMD and subsequently to future causative therapies.

Genetic and clinical characteristics of Moyamoya disease in Europeans.

The European form of Moyamoya disease clearly differs from the Asian form. Clinically the timing of vasculopathy onset and a lower rate of hemorrhage are striking as compared to the Asian Moyamoya disease.Single nucleotide polymorphisms that play a role in atherosclerosis, vascular growth and transformation processes have been found to be associated with the European form. Candidate gene associations found in Asian patients could not be replicated in European patients.To elucidate the characteristics, we describe the clinical features as well as the genetic findings that we have found in our combined cohorts of European patients.

MGMT-Positive vs MGMT-Negative Patients With Glioblastoma: Identification of Prognostic Factors and Resection Threshold.

BACKGROUND: The importance of the O6-methylguanine-DNA methyltransferase (MGMT) promoter methylation status as a predictive factor for the response to chemotherapy with temozolomide is well established. Its significance though at stratifying glioblastoma (GBM) patients in regard to their prognostic factors and the impact of surgical approach on them has not been identified. OBJECTIVE: To reveal possible differences in the prognostic factors and the impact of surgery between GBM patients stratified according to their MGMT status. METHODS: The authors retrospectively analyzed 186 patients with a newly diagnosed primary supratentorial GBM treated with surgical resection followed by standard radiation and chemotherapy. A prospective quantitative volumetric analysis of tumor characteristics identified on magnetic resonance imaging was performed. RESULTS: For the 109 patients with unmethylated MGMT promoter, extent of resection (EOR) represented independent predictor of survival, whereas residual tumor volume (RTV), Karnofsky Performance Score, and age were found to be independent prognostic factors of survival for the 77 patients with methylated MGMT promoter. For the group of patients with unmethylated and the group with methylated MGMT promoter, an EOR threshold of 70% and 98% and an RTV threshold of 1.5 and 1 cm3 were identified, respectively. CONCLUSION: The selection of patients according to the MGMT promoter methylation status resulted in different prognostic factors and different resection thresholds for each patient population. A survival benefit seen from 70% EOR threshold in patients with MGMT unmethylated GBM supports the doctrine of maximum safe resection rather than the "all-or-nothing" approach.

Treatment of recurrent and residual aneurysms with the low-profile Acandis Acclino stent: Multi-center review of 19 patients.

OBJECTIVE: To evaluate the safety and efficacy of the low-profile Acandis Acclino microstent for embolization of recurrent and residual intracranial aneurysms. METHODS: Consecutive patients treated with the Acclino for aneurysm remnants at three German neurovascular centers were enrolled. The technical success, complications, angiographic and clinical outcome were investigated. RESULTS: Nineteen patients (median age: 53 years) with 19 aneurysm remnants (median size: 5 mm, anterior circulation: 14) were included. Initial aneurysm treatment consisted of stand-alone coiling in 14 cases, stent-assisted coiling in 4 and clipping in 1. Acclino stent-assisted coil embolization was performed technically successfully in all patients. Morbidity occurred in one patient (5.3%) due to aneurysm perforation. At the angiographic follow-up with a median follow-up duration of 21 months (range: 5-37 months), complete occlusion was obtained in 76.9%. The retreatment rate was 7.7%. CONCLUSIONS: Retreatment of aneurysm remnants with the Acclino microstent was associated with high aneurysm occlusion rates and acceptable morbidity. Further studies will be necessary to draw a definite conclusion.

Impact of Obesity on Complication Rates, Clinical Outcomes, and Quality of Life after Minimally Invasive Transforaminal Lumbar Interbody Fusion.

BACKGROUND: Percutaneous pedicle screw fixation in obese patients remains a surgical challenge. We aimed to compare patient-reported outcomes and complication rates between obese and nonobese patients who were treated by minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). METHODS: The authors retrospectively reviewed patients who underwent MIS-TLIF at a single institution between 2011 and 2014. Patients were classified as obese (body mass index [BMI] ≥30 kg/m2) or nonobese (BMI < 30 kg/m2), according to their BMI. Outcomes assessed were complications, numerical rating scale (NRS) scores for back and leg pain, Oswestry Disability Index (ODI), and 36-Item Short-Form Survey (SF-36) scores. RESULTS: The final study group consisted of 71 patients, 24 obese (33.8%, 34.8 ± 3.8 kg/m2) and 47 nonobese (66.2%, 25.4 ± 2.9 kg/m2). Instrumentation failures (13.6 vs. 17.0%), dural tears (17.2 vs. 4.0%), and revision rates (16.7 vs. 19.1%) were similar between both groups (p > 0.05). Perioperative improvements in back pain (4.3 vs. 5.4, p = 0.07), leg pain (3.8 vs. 4.2, p = 0.6), and ODI (13.3 vs. 22.5, p = 0.5) were comparable among the groups and persisted at long-term follow-up. Obese patients had worse postoperative physical component SF-36 scores than nonobese patients (36.4 vs. 42.7, p = 0.03), while the mental component scores were not statistically different (p = 0.09). CONCLUSION: Obese patients can achieve similar improvement of the pain intensity and functional status even at long-term follow-up. In patients with appropriate surgical indications, obesity should not be considered a contraindication for MIS-TLIF surgery.

Clipping versus coiling in the treatment of oculomotor nerve palsy induced by unruptured posterior communicating artery aneurysms: A meta-analysis of cohort studies.

BACKGROUND: Although the superiority of clipping compared to coiling on the oculomotor nerve palsy (ONP) recovery for ruptured posterior communicating artery aneurysms (PcomAAs) has been widely accepted, which treatment modality is better in the treatment of ONP induced by unruptured PcomAAs still remains unclear. METHODS: A meta-analysis of studies that compared clipping with coiling was performed after a literature search. Perioperative data and clinical outcome were extracted. Analysis on the effect of the two treatment modalities was then performed. RESULTS: Nine eligible studies with a total of 136 patients met the inclusion criteria. There was a significant difference in the total efficiency (any degree of improvement) on ONP favoring clipping [RR= 1.21, 95%CI (1.01, 1.44), p = 0.04], the effect was most notable for complete recovery of ONP after having suffered preoperative partial palsy [RR= 0.72, 95%CI (0.55, 0.95), p = 0.02]. There was neither a significant difference regarding the complete recovery of ONP [RR= 1.11, 95%CI (0.77, 1.61), p = 0.58] nor the frequency of complications [RR= 0.07, 95%CI (0.00, 1.10), p = 0.06]. Also when subdividing there was no significant difference in complete recovery of ONP in patients who had initially suffered a complete ONP [RR= 0.79, 95%CI (0.38, 1.64), p = 0.53] and partial ONP [RR= 1.16, 95%CI (0.65, 2.08), p = 0.61] between clipping and coiling. CONCLUSIONS: A superiority of clipping over coiling for the improvement of ONP secondary to unruptured PcomAAs was found. Patients with partial ONP were more likely to attain a complete resolution of ONP, as compared to complete ONP.

Woven Endobridge Embolization Versus Microsurgical Clipping for Unruptured Anterior Circulation Aneurysms: A Propensity Score Analysis.

BACKGROUND: Intrasaccular flow-disruption represents a new paradigm in endovascular treatment of wide-necked bifurcation aneurysms. OBJECTIVE: To retrospectively compare Woven Endobridge (WEB) embolization with microsurgical clipping for unruptured anterior circulation aneurysms using propensity score adjustment. METHODS: A total of 63 patients treated with WEB and 103 patients treated with clipping were compared based on the intention-to-treat principle. The primary outcome measures were immediate technical treatment success, major adverse events, and 6-mo complete aneurysm occlusion. RESULTS: The technical success rates were 83% for WEB and 100% for clipping. Procedure-related complications occurred more often in the clipping group (13%) than the WEB group (6%, adjusted P < .01). However, the rates of major adverse events were comparable in both groups (WEB: 3%, clip: 4%, adjusted P = .53). At the 6-mo follow-up, favorable functional outcomes were achieved in 98% of the WEB embolization group and 99% of the clipping group (adjusted P = .19). Six-month complete aneurysm occlusion was obtained in 75% of the WEB group and 94% of the clipping group (adjusted P < .01). CONCLUSION: Microsurgical clipping was associated with higher technical success and complete occlusion rates, whereas WEB had a lower complication rate. Favorable functional outcomes were achieved in ≥98% of both groups. The decision to use a specific treatment modality should be made on an individual basis and in accordance with the patient's preferences.

Impact of aneurysm morphology on aneurysmal subarachnoid hemorrhage severity, cerebral infarction and functional outcome.

OBJECTIVE: Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity. The objective was to evaluate, whether specific morphological aneurysm characteristics could serve as predictive values for aSAH severity, disease-related complications and clinical outcome. METHODS: A total of 453 aSAH patients (mean age: 54.9 ±â€¯13.8 years, mean aneurysm size: 7.5 ±â€¯3.6 mm) treated at a single center were retrospectively included. A morphometric analysis was performed based on angiographic image sets, determining aneurysm location, aneurysm size, neck width, aneurysm size ratios, aneurysm morphology and vessel size. The following outcome measures were defined: World Federation of Neurosurgical Societies (WFNS) grade 4 and 5, Fisher grade 4, vasospasm, cerebral infarction and unfavorable functional outcome. RESULTS: Regarding morphology parameters, aneurysm neck width was an independent predictor for Fisher 4 hemorrhage (OR: 1.1, 95%CI: 1.0-1.3, p = 0.048), while dome width (OR: 0.92, 95%CI: 0.86-0.97, p = 0.005) and internal carotid artery location (OR: 2.1, 95%CI: 1.1-4.2, p = 0.028) predicted vasospasm. None of the analyzed morphological characteristics prognosticated functional outcome. Patient age (OR: 0.95, 95%CI: 0.93-0.96, p < 0.001), WFNS score (OR: 4.8, 95%CI: 2.9-8.0, p < 0.001), Fisher score (OR: 2.3, 95%CI: 1.4-3.7, p < 0.001) and cerebral infarction (OR: 4.5, 95%CI: 2.7-7.8, p < 0.001) were independently associated with unfavorable outcome. CONCLUSIONS: The findings indicate a correlation between aneurysm morphology, Fisher grade and vasospasm. Further studies will be required to reveal an independent association of aneurysm morphology with cerebral infarction and functional outcome.

Microsurgical Clipping versus Advanced Endovascular Treatment of Unruptured Middle Cerebral Artery Bifurcation Aneurysms After a "Coil-First" Policy.

OBJECTIVE: Although intracranial aneurysms are increasingly treated endovascularly, microsurgical clipping has been the standard approach for middle cerebral artery (MCA) aneurysms. We compared microsurgical clipping and state-of-the-art endovascular treatment of unruptured MCA bifurcation aneurysms treated at a neurovascular center following a "coil-first" policy. METHODS: This single-center study included 148 patients treated for 160 unruptured MCA bifurcation aneurysms. Technical success, complications, clinical outcome, and angiographic results were retrospectively compared. RESULTS: Microsurgical clipping was performed for 120 MCA aneurysms (75%) and endovascular treatment for 40 (25%; conventional coiling: 8, stent-assisted coiling: 16, balloon-assisted coiling: 3, and flow-disruption: 13). Technical treatment success was higher in the clipping group (100%) than in the endovascular group (92.5%, P = 0.015). Overall, complications occurred in 16.7% for clipping and in 20.0% for endovascular treatment (P = 0.631). Major ischemic stroke rates were 4.2% in the clipping group and 7.5% in the endovascular group (P = 0.414). At 6 months, a favorable outcome was obtained by 99.2% after clipping and 95.0% after endovascular treatment (P = 0.154). The 6-month complete aneurysm occlusion rates were by trend higher in the clipping group (89.2%) than in the endovascular group (75.9%, P = 0.078). CONCLUSIONS: Microsurgical clipping was associated with a higher technical success rate and tendentially higher complete occlusion than endovascular treatment, with no additional morbidity and similar clinical outcome. On the basis of these results, clipping proves to be the standard treatment option for MCA bifurcation aneurysms. However, endovascular treatment represents a safe and efficient alternative treatment option for patients.