Asymptomatic Intracranial Aneurysms in the Elderly: Long-Term Clinical and Radiologic Follow-Up of 193 Consecutive Patients.

BACKGROUND: Evidence is lacking regarding the role of radiologic surveillance for asymptomatic intracranial aneurysms (AIAs) in the elderly (≥65 years). We sought to establish if long-term clinical and radiologic observation is warranted for older patients with AIAs. METHODS: A retrospective cohort of 193 consecutive patients with 255 AIAs were clinically and radiologically observed between January 2011 and January 2019. The primary end points were documented aneurysm growth, subarachnoid hemorrhage, or definitive treatment with microsurgical clipping or endovascular coiling. Baseline patient and aneurysm characteristics were obtained. Univariate and multivariate comparisons were performed. RESULTS: Aneurysm growth was observed in 8 patients (4.2%) at a median follow-up of 58.2 months (interquartile range, 38.4-78.5 months). The median aneurysm size at initial diagnosis was 3.5 mm (interquartile range, 2.2-5 mm). Aneurysms larger than 7 mm selected for surveillance were noted in 37 patients (19.2%). The growth rate was estimated at 0.2 mm per person-year. At the end of the study period, 175 patients (90.7%) were alive, 6 (3.1%) were lost to follow-up, and 12 (6.2%) died of unrelated causes. During the 1025.2 person-years follow-up, no patient had experienced subarachnoid hemorrhage, and none required definitive treatment. The presence of aneurysmal bleb (odds ratio, 6.02; 95% confidence interval, 1.15-31.43; P = 0.033) and multiple intracranial aneurysms (odds ratio, 10.98; 95% confidence interval, 1.27-94.91; P = 0.029) were associated with growth. CONCLUSIONS: AIAs in older patients deemed suitable for conservative management do not require robust follow-up. The current study suggests a potential role for closer surveillance for patients with multiple intracranial aneurysms or aneurysms with bleb morphology.

Influence of comorbidities on treatment of unruptured intracranial aneurysms in the elderly.

Current evidence does not conclusively justify conservative management of unruptured intracranial aneurysms (UIA) in the elderly (age ≥ 65 years). To rationalise intervention, the authors investigated the role of age and comorbidity burden on treatment outcomes. A retrospective chart review for consecutive cases of UIAs treated in the elderly between 2007 and 2018 was performed. Preoperative Charlson Comorbidity Index (CCI) and Neurovascular Comorbidities Index (NCI) were calculated. Standard statistical methods with univariate and multiple logistic regression were used. A total of 123 patients (46 surgery, 77 endovascular) with 131 UIAs were treated. The mean age was 70.6 ±â€¯4.1 years, and 90 patients were female (73.1%). The mean aneurysm size was 8.6 ±â€¯5.0 mm, and the mean follow up period was 22.9 ±â€¯21.3 months. The rates of poor outcome (mRS > 1) at discharge, 6 weeks and 6 months were 9.8%, 5.8% and 3.6%, respectively. There was no difference in outcomes between surgical and endovascular treatment. Correlation and regression analyses revealed that aneurysm size, higher preoperative comorbidity index (CCI > 4), and endovascular treatment with a stent or flow diverter (p = 0.009, 0.02, and 0.005, respectively) were associated with a poor outcome. When adjusted in a multivariate analysis, only high comorbidity burden (CCI > 4) predicted unfavourable outcome (p = 0.01). Elderly patients who undergo treatment for UIAs are at high risk of postoperative deterioration. Careful preoperative case selection based on comorbidity burden, rather than chronological age, would be useful for improved risk stratification.

Natural history of incidental colloid cysts of the third ventricle: A systematic review.

OBJECTIVE: Clinical significance and management of asymptomatic colloid cysts of the third ventricle is not well defined. The aim of this study was to investigate the risk of cyst progression necessitating surgical intervention during a surveillance period. METHODS: A systematic pooled analysis of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search (conducted in December 2017) in MEDLINE and EMBASE databases, identified eligible studies. Data related to demographic (sex, age, size), clinical (surgical intervention, acute neurological deterioration, cyst related mortality) and radiological outcomes (cyst stability, progression, regression) were extrapolated and analysed. RESULTS: Of the 134 manuscripts identified, only 4 retrospective studies (176 patients) met the inclusion criteria. The level of evidence provided by these studies was low. During a median follow up of 61.2 months (IQR 41.6-70.1), 11 patients (8.6%, 95% CI 4.7-14.9) required surgical intervention due to either clinical or radiological progression. One patient experienced an acute neurological decline (0.8%, 95% CI -0.3-4.7), which eventuated in death a few years later. There were no reported cases of sudden death during this period. On radiological follow up, 86.7% (95% CI 78.5-92.2) of cysts remained stable, 11.2% (95% CI 6.2-19.2) progressed, and 2.0% (95% CI 0.1-7.6) regressed in size. CONCLUSION: For incidental colloid cysts deemed appropriate for conservative management, there is a 5-15% risk of future progression necessitating operative intervention in the 5 years following diagnosis. The data presented supports the need for ongoing surveillance neuroimaging for asymptomatic colloid cysts.

Intramedullary spinal cord metastasis from thyroid carcinoma: Case report and a systematic pooled analysis of the literature.

Intramedullary spinal cord metastasis (ISCM) is rare and occurs most commonly in the setting of advanced malignancy. The optimal management pathways are not well defined and treatment outcomes from contemporary therapies remain variable. We report a case of a 49-year-old woman with known primary papillary thyroid carcinoma, who presented with rapidly progressive clinical features of Brown-Sequard syndrome. A detailed pooled analysis of the literature was conducted to characterise the clinical and demographic features, management options, and expected survival outcomes for cases of ISCM. We secondarily performed a subgroup analysis on the incidence, clinical and management characteristics of thyroid carcinoma ISCM.

Feasibility of Real-Time Angiographic Perfusion Imaging in the Treatment of Cerebral Vasospasm.

BACKGROUND: Objective assessment and quantification of the severity of cerebral vasospasm following aneurysmal subarachnoid hemorrhage is not routinely utilized. We investigated the feasibility of angiographic perfusion imaging derived from digital subtraction angiography (DSA) following endovascular vasospasm treatment procedures. METHODOLOGY: Real-time blood flow analysis was performed using parametric color coding on pre- and postintervention DSA. Semiquantitative parenchymal perfusion parameters (arrival time [AT] of contrast, time to peak [TTP] opacification, and mean transit time [MTT] of contrast) were calculated across 3 vascular territories (anterior cerebral artery [ACA], middle cerebral artery [MCA], and lenticulostriate arteries) using standard 2-D angiographic perfusion software. The pre- and postintervention arterial vessel diameters were compared. RESULTS: Twelve endovascular vasospasm treatments in 6 patients were performed. All patients received intra-arterial vasodilator therapy with either nimodipine, milrinone, or both. Following intra-arterial intervention, parenchymal flow analysis showed improvement in TTP and MTT across all vascular territories (p < 0.002) and improvement in AT in the ACA and MCA territories (p < 0.03). Improvement in parenchymal perfusion parameters was associated with improvement in vessel diameters in all territories following treatment (p < 0.05). CONCLUSION: Real-time parenchymal perfusion imaging during endovascular vasospasm treatment procedures is feasible and provides reliable semiquantitative measurement of angiographic treatment response.

Unruptured Paraclinoid Aneurysm Treatment Effects on Visual Function: Systematic Review and Meta-analysis.

OBJECTIVE: Postoperative visual outcomes following repair of unruptured paraclinoid aneurysms (UPAs) are not well defined. We aim to investigate the influence of treatment modality on visual function. METHODS: A systematic literature analysis using the Ovid Medline and EMBASE databases was performed, encompassing English language studies (published between 1996 and 2016) reporting treatment outcomes for UPAs. Rates of visual morbidity (new, permanent postoperative deficit, worsening preoperative deficit); angiographic (occlusion, recurrence, retreatment) and clinical outcomes (death, disability, post-treatment subarachnoid hemorrhage) were recorded. Random effects meta-analysis was performed. RESULTS: Twenty-eight studies reported visual outcomes, with data for 1013 endovascular and 691 microsurgical patients. In patients with normal vision undergoing elective repair of UPAs, rates of postoperative visual morbidity were higher following microsurgical (10.8%; 95% confidence interval [CI] 8.5-13.7) than endovascular (2.0%; 95% CI 1.2-3.2) interventions, P < 0.001. In those presenting with preoperative visual impairment, surgery was associated with a modest advantage in visual recovery compared with endovascular therapies (65.2% vs. 48.9%, P < 0.03). There were no differences in visual morbidity following treatment with any of the endovascular modalities. Meta-analysis of comparative studies suggested a trend toward poor visual (ES = 0.42; 95% CI 0.08-2.09) and clinical outcomes (ES = 0.57; 95% CI 0.07-4.44) following microsurgery and a trend toward angiographic recurrence (ES = 2.52; 95% CI 0.80-7.90) and retreatment (ES = 1.62; 95% CI 0.46-5.67) after endovascular interventions. CONCLUSION: In patients with normal vision undergoing repairs for UPAs, there is a positive correlation between visual outcomes and endovascular treatments. When visual compromise is present, surgery provided modest advantage in visual recovery. However, definitive conclusions were not possible due to data heterogeneity.

Glioblastoma presenting as spontaneous intracranial haemorrhage: Case report and review of the literature.

Glioblastoma (GB) classically presents with symptoms of raised intracranial pressure and gradual progressive neurological deficits. An acute presentation, with intracerebral haemorrhage (ICH) and rapid clinical deterioration, occurs infrequently. Contemporary imaging modalities do not reliably reflect underlying mass lesions in parenchymal brain haemorrhage at first presentation. We report a delayed diagnosis of GB in a 21-year-old patient presenting with spontaneous ICH and a negative initial neurovascular workup. A comprehensive literature review was performed to investigate the incidence of malignant aetiology for spontaneous ICH in young adults, and to underscore the importance of early utilisation of diagnostic magnetic resonance imaging (MRI) in such cases.

History, Evolution, and Continuing Innovations of Intracranial Aneurysm Surgery.

Evolution in the surgical treatment of intracranial aneurysms is driven by the need to refine and innovate. From an early application of the Hunterian carotid ligation to modern-day sophisticated aneurysm clip designs, progress has been made through dedication and technical maturation of cerebrovascular neurosurgeons to overcome challenges in their practices. The global expansion of endovascular services has challenged the existence of aneurysm surgery, changing the complexity of the aneurysm case mix and volume that are referred for surgical repair. Concepts of how to best treat intracranial aneurysms have evolved over generations and will continue to do so with further technological innovations. As with the evolution of any type of surgery, innovations frequently arise from the criticism of current techniques.

Safety and effectiveness of microsurgical clipping, endovascular coiling, and stent assisted coiling for unruptured anterior communicating artery aneurysms: a systematic analysis of observational studies.

OBJECTIVE: Treatment outcomes for unruptured anterior communicating artery (ACoA) aneurysms are not well established. We aimed to investigate the safety and effectiveness of microsurgical clipping (MC), endovascular coiling (EC), and stent assisted coiling (SAC) of unruptured ACoA aneurysms to aid pretreatment clinical decisions. METHODS: A systematic review of the literature was conducted using the Ovid Medline and EMBASE electronic databases, encompassing all English language studies reporting treatment outcomes for unruptured ACoA aneurysms published between 2005 and 2015. The analyses were directed towards patient focused outcomes: good therapeutic outcome (Glasgow Outcome Score of 5 (GOS 5), modified Rankin Scale (mRS) score of 0-1), poor therapeutic outcome (GOS 1-4, mRS 2-6), 30 day mortality, recurrence/retreatment rates, and post-treatment subarachnoid hemorrhage (SAH). RESULTS: 14 studies with 862 treated aneurysms were included (EC, n=372; MC, n=401; SAC, n=89). EC resulted in significantly lower treatment related morbidity compared with MC or SAC (EC 0.8%, MC 4.4%, SAC 7.9%; p=0.001); treatment related mortality occurred in 0%, 0.3%, and 1.1%, for EC, MC, and SAC, respectively. MC resulted in significantly lower angiographic recurrence (EC 7.2%, MC 0%, SAC 12.3%; p<0.001) and retreatment (EC 4.9%, MC 0%, SAC 6.8%; p=0.001). SAH from the treated aneurysm was not reported with any treatment modality. CONCLUSIONS: While there are limitations to the data, EC resulted in a more favorable clinical outcome, and MC resulted in more robust aneurysm repair, for unruptured ACoA aneurysms. SAC had a higher treatment morbidity risk than EC, without reduction in retreatment rate. All treatments were effective in preventing SAH. The current pooled analysis of treatment outcomes provides a useful aid to pretreatment clinical decision making.