Small (< 10-mm) incidentally found intracranial aneurysms, Part 1: reasons for detection, demographics, location, and risk factors in 212 consecutive patients.

OBJECT: The widespread use of imaging techniques for evaluating nonspecific symptoms (vertigo, dizziness, memory concerns, unsteadiness, and the like) and focal neurological symptoms related to cerebrovascular disease has led to increased identification of asymptomatic incidentally discovered unruptured intracranial aneurysms (UIAs). The management of these incidental aneurysms is controversial and many factors need to be considered. The authors describe reasons leading to diagnosis, demographics, and risk factors in a large consecutive series of patients with small incidentally found UIAs. METHODS: The authors prospectively evaluated 335 patients harboring 478 small (< 10-mm) UIAs between January 2008 and May 2011. Patients with known aneurysms, possibly symptomatic aneurysms, arteriovenous malformation-related aneurysms, patients with a history of subarachnoid hemorrhage from another aneurysm, and patients harboring extradural aneurysms were excluded from the analysis. Only truly incidental small aneurysms (272 aneurysms in 212 patients) were considered for the present analysis. Data regarding the reason for detection, demographics, location, and presence of potential risk factors for aneurysm formation were prospectively collected. RESULTS: There were 158 female (74.5%) and 54 male (25.5%) patients whose mean age was 60.6 years (median 62 years). The most common reason for undergoing the imaging study that led to a diagnosis of the aneurysms was evaluation for nonspecific spells and symptoms related to focal cerebrovascular ischemia (43.4%), known/possible intracranial or neck pathology (24%), and headache (16%). The most common location (27%) of the aneurysm was the middle cerebral artery; the second most common (22%) was the paraclinoid internal carotid artery (excluding cavernous sinus aneurysms). Sixty-nine percent of patients were current or prior smokers, 60% had a diagnosis of hypertension, and 23% had one or more relatives with a history of intracranial aneurysms with or without subarachnoid hemorrhage. CONCLUSIONS: Small incidental UIAs are more commonly diagnosed in elderly individuals during imaging performed to investigate ill-defined spells or focal cerebrovascular ischemic symptoms, or during the evaluation of known or probable unrelated intracranial/neck pathology. Hypertension, smoking, and family history of aneurysms are common in this patient population, and the presence of these risk factors has important implications for treatment recommendations. Although paraclinoid aneurysms (excluding intracavernous aneurysms) are uncommon in patients with ruptured intracranial aneurysms, this location is very common in patients with small incidental UIAs.

Conversion of external ventricular drains to ventriculoperitoneal shunts after aneurysmal subarachnoid hemorrhage: effects of site and protein/red blood cell counts on shunt infection and malfunction.

OBJECT: The purpose of this study was to determine the incidence of shunt infection in patients with subarachnoid hemorrhage (SAH) after converting an external ventricular drain (EVD) to a ventriculoperitoneal (VP) shunt using the existing EVD site. The second purpose was to assess the risk of shunt malfunction after converting the EVD to a permanent shunt irrespective of the cerebrospinal fluid (CSF) protein and red blood cell (RBC) counts. METHODS: Data obtained in 80 consecutive adult patients (18 men and 62 women, mean age 60.8 years, range 33-85 years) who underwent direct conversion of an EVD to a VP shunt for post-SAH hydrocephalus between August 2002 and March 2007 were retrospectively reviewed. In each patient, the existing EVD site was used to pass the proximal shunt catheter. In no patient was VP shunt insertion delayed based on preoperative RBC or protein counts. RESULTS: The mean period of external ventricular drainage before VP shunt placement was 14.1 days (range 3-45 days). No patient suffered ventriculitis. The mean perioperative CSF protein level was 124 mg/dl (range 17-516 mg/dl). The mean and median perioperative RBC values in CSF were 14,203 RBCs/mm(3) and 4600 RBCs/mm(3) (range 119-290,000/mm(3)), respectively. No patient was lost to follow-up. The mean follow-up duration was 24 months (range 2-53 months). Three patients (3.8%) had shunt malfunction related to obstruction of the shunt system after 15 days, 2 months, and 18 months, respectively. There were no shunt-related infections. No patient suffered a clinically significant hemorrhage from ventricular catheter placement after VP shunt insertion. CONCLUSIONS: In adult patients with aneurysmal SAH, conversion of an EVD to a VP shunt can be safely done using the same EVD site. In this defined patient population, protein and RBC counts in the CSF do not seem to affect shunt survival adversely. Thus, conversion of an EVD to VP shunt should not be delayed because of an elevated protein or RBC count.

Treatment of ruptured intracranial aneurysms since the International Subarachnoid Aneurysm Trial: practice utilizing clip ligation and coil embolization as individual or complementary therapies.

OBJECT: The aim of this study was to analyze the therapeutic decision-making process and outcome in 100 consecutive patients with aneurysmal subarachnoid hemorrhage (SAH) treated since the completion of the International Subarachnoid Aneurysm Trial (ISAT). All patients were evaluated and treated by a neurosurgeon with subspecialty training in both cerebrovascular and neuroendovascular surgery. METHODS: One hundred consecutive patients with aneurysmal SAH who had been admitted within 1 week posthemorrhage and who had been treated using either surgical clip application or endovascular coil embolization were included in this analysis. All patients underwent a uniform perioperative protocol. All surviving patients were given a questionnaire to assess their modified Rankin Scale score (mRS) and to grade themselves at 6 months and 1 year postintervention. The cohort consisted of 73 women and 27 men with a mean age of 57.27 years (range 27-87 years). Twenty-nine percent of the patients had a World Federation of Neurosurgical Societies (WFNS) Grade IV or V SAH. Forty-seven patients underwent direct surgical clip application, 41 endovascular embolization, and 12 a combination of the two procedures. Good functional outcome--indicated by mRS scores of 0 to 2 after at least 6 months--was achieved in 71% of patients. CONCLUSIONS: Data from the ISAT demonstrated a better functional outcome following endovascular embolization in a selected group of patients with aneurysmal SAH. In routine clinical practice, however, a significant number of patients still benefit from direct surgical clip ligation. Excellent functional results can be realized in a complementary clip ligation and coil occlusion practice in which each patient and aneurysm is evaluated and the two treatment modalities are used individually or, when needed, in combination.

Safety of early ambulation after diagnostic and therapeutic neuroendovascular procedures without use of closure devices.

OBJECTIVE: To evaluate the safety of manual compression and early ambulation after diagnostic and therapeutic neuroendovascular procedures. METHODS: Data were prospectively collected and retrospectively analyzed for consecutive patients undergoing diagnostic or therapeutic neuroendovascular procedures. Manual compression at the femoral access site was applied. The target for early ambulation was 2 hours after compression. RESULTS: Three hundred forty-three patients were enrolled, of whom 295 were eligible for early ambulation. Diagnostic procedures totaled 214 (72.5%); therapeutic procedures, 81 (27.5%). Ambulation occurred at 2 hours for 82 patients who underwent a diagnostic and 11 patients who underwent a therapeutic procedure. Overall, 142 patients (66.4%) after a diagnostic and 21 patients (25.9%) after a therapeutic procedure ambulated within 3 hours; 94% of outpatients ambulated within 2 to 3 hours and were dismissed shortly thereafter. Delayed ambulation was related to nursing staff delays, recovery from general anesthesia, or patient preference. Fourteen patients (4.7%)--9 (4.2%) who had a diagnostic and 5 (6.2%) who had a therapeutic procedure--required delayed ambulation because of local oozing (8 patients), a hematoma of less than 5 cm (3 patients), a pseudoaneurysm (2 patients), or a large hematoma requiring surgical evacuation (1 patient). CONCLUSION: Early ambulation is feasible and safe after diagnostic and therapeutic procedures and manual compression. A longer period of bed rest or the routine use of closure devices is often not required; thereby avoiding the costs associated with bed rest and the complications associated with closure devices.

Antimicrobial-impregnated external ventricular catheters: does the very low infection rate observed in clinical trials apply to daily clinical practice?

OBJECTIVE: A recent multicenter, randomized, prospective study using antimicrobial-impregnated ventricular catheters (AIVCs) has demonstrated a dramatic reduction in the incidence of catheter-related infections. By necessity, such trials are subject to notoriously close and careful monitoring; thus, the results of multicenter, randomized clinical trials do not automatically apply to daily clinical practice. The aim of the present study was to establish whether the very low incidence of ventriculitis with AIVCs reported in these trials is also observed in routine clinical practice. METHODS: Data on 139 consecutive patients admitted to a Neurocritical Intensive Care Unit who underwent placement of 154 AIVCs were reviewed. All patients included in the data analysis had an AIVC for at least 48 hours, and cultures as well as cell counts were obtained from the CSF at various intervals after placement of the AIVC. RESULTS: One hundred thirteen catheters in 100 patients met criteria for inclusion in the analysis. There were four positive cultures. In three patients, the culture result was thought to be a contaminant (because it was not corroborated by clinical findings or cell count or because of the characteristics of the culture). Only one gram-negative infection was considered to be clinically significant (0.88% of catheters, 1.00% of patients) and confirmed on clinical and other laboratory grounds. CONCLUSION: The very low infection rate with currently available AIVCs observed in rigorously controlled clinical trials translates to routine clinical practice.