Feasibility of frailty screening among patients with advanced heart failure.

BACKGROUND: Frailty is common among patients with advanced heart failure (HF), and screening for frailty to guide care is recommended. Although multiple tools are available to screen for frailty, the feasibility of routinely incorporating frailty screening into daily clinical practice among hospitalised advanced HF patients has not been rigorously tested. METHODS: This was a prospective, single-centre, quality improvement study. Two brief frailty screening tools were incorporated into palliative care consultations for all patients ≥50 years from August 2021 to October 2022. In the first phase, the Clinical Frailty Scale (CFS) was implemented, followed by the Study of Osteoporotic Fracture (SOF) tool or a modified SOF (mSOF) version in the second phase. The primary outcome was feasibility (%) of performing frailty screenings for this high-risk population. RESULTS: A total of 212 patients (mean age 69±10 years, 69% male, 79% white, 30% with ischaemic HF) were referred for palliative care consultation during the study period. Overall, frailty screens were completed in 86% (n=183) of patients. CFS and mSOF reached >80% of adoption, while SOF adoption was 54%. Altogether, 52% of the population screened frail by use of CFS and 52% also by mSOF. All clinicians (n=6) participating in the study reported that frailty screening tools were useful and acceptable, and 83% reported plans for continued utilisation in future clinical practice. CONCLUSIONS: Frailty screening with CFS or mSOF tools was feasible in hospitalised patients with advanced HF. Tools that require physical assessment were more challenging to implement. These data support the feasibility of incorporating questionnaire-based frailty screening in a busy hospital setting.

Outcomes after coronary artery bypass grafting and percutaneous coronary intervention in diabetic and non-diabetic patients.

AIMS: To assess the prognosis of patients with coronary heart disease (CHD) after first myocardial revascularisation procedure in real-world practice and to compare the differences in outcomes of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) among diabetic and non-diabetic patients. METHODS AND RESULTS: A database was compiled from the national hospital discharge register to collect data on all cardiac revascularisations performed in Finland in 2000-2015. The outcomes (all-cause deaths, cardiovascular (CV) deaths, major CV events and need for repeat revascularisation) after the first revascularisation were identified from the national registers at 28 day, 1 year, and 3 year time points.A total of 139 242 first-time revascularisations (89 493 PCI and 49 749 CABG) were performed during the study period. Of all the revascularised patients, 24% had diabetes, and 76% were non-diabetic patients. At day 28, the risk of fatal outcomes was lower after PCI than after CABG among non-diabetic patients, whereas no difference was seen among diabetic patients. In long-term follow-up the situation was reversed with PCI showing higher risk compared with CABG for most of the outcomes. In particular, at 3 year follow-up the risk of all-cause deaths was elevated among diabetic patients [HR 1.30 (95% CI 1.22-1.38) comparing PCI with CABG] more than among non-diabetic patients [HR 1.09 (1.04-1.15)]. The same was true for CV deaths [HR 1.29 (1.20-1.38) among diabetic patients, and HR 1.03 (0.98-1.08) among non-diabetic patients]. CONCLUSION: Although PCI was associated with better 28 day prognosis, CABG seemed to produce better long-term prognosis especially among diabetic patients.

Comparing health-related quality of life in modified Rankin Scale grades: 15D results from 323 patients with brain arteriovenous malformation and population controls.

BACKGROUND: We wanted to understand how patients with different modified Rankin Scale (mRS) grades differ regarding their health-related quality of life (HRQoL) and how this affects the interpretation and dichotomization of the grade. METHODS: In 2016, all adult patients in our brain arteriovenous malformation (AVM) database (n = 432) were asked to fill in mailed letters including a questionnaire about self-sufficiency and lifestyle and the 15D HRQoL questionnaire. The follow-up mRS was defined in 2016 using the electronic patient registry and the questionnaire data. The 15D profiles of each mRS grade were compared to those of the general population and to each other, using ANCOVA with age and sex standardization. RESULTS: Patients in mRS 0 (mean 15D score = 0.954 ± 0.060) had significantly better HRQoL than the general population (mean = 0.927 ± 0.028), p < 0.0001, whereas patients in mRS 1-4 had worse HRQoL than the general population, p < 0.0001. Patients in mRS 1 (mean = 0.844 ± 0.100) and mRS 2 (mean = 0.838 ± 0.107) had a similar HRQoL. In the recently published AVM research, the most commonly used cut points for mRS dichotomization were between mRS 1 and 2 and between mRS 2 and 3. CONCLUSIONS: Using 15D, we were able to find significant differences in the HRQoL between mRS 0 and mRS 1 AVM patients, against the recent findings on stroke patients using EQ-5D in their analyses. Although the dichotomization cut point is commonly set between mRS 1 and 2, patients in these grades had a similar HRQoL and a decreased ability to continue their premorbid lifestyle, in contrast to patients in mRS 0.

Clinical practice patterns in revascularization of diabetic patients with coronary heart disease: nationwide register study.

Aims: To compare diabetic patients with coronary heart disease (CHD) needing revascularization to corresponding non-diabetic patients in terms of revascularization methods, comorbidities and urgency of procedure. We also examined the impact of patient characteristics and comorbidities on the revascularization method.Methods: We identified all diabetic (n = 33,018) and non-diabetic (n = 106,224) patients with first-ever, percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) from electronic health records in Finland between 2000 and 2015.Results: Overall, PCI was the most common revascularization method. PCI outnumbered CABG in women and men both in diabetic and non-diabetic patients. However, diabetic patients were more likely to undergo CABG than PCI (OR 1.30; 95% CI 1.27-1.34, adjusted for age, gender, region of residence and procedure year). Moreover, 26.9% of diabetic patients' urgent procedures were CABG compared to 21.6% in non-diabetic patients (p<.001). Among diabetic patients, prior myocardial infarction was associated with increased odds of CABG, whereas female gender, atrial fibrillation, congestive heart failure, hypertension and later procedure year were associated with lower odds of CABG.Conclusions: CABG has been performed more frequently in diabetic than in non-diabetic CHD patients. Nevertheless, PCI was the dominant revascularization method over CABG both in diabetic and non-diabetic patients. KEY MESSAGESPCI was the dominant revascularization method in both diabetic and non-diabetic patients. Diabetic patients were more likely to undergo CABG than PCI when compared to non-diabetic patients (OR: 1.30; CI 1.27-1.34).Diabetic patients underwent urgent CABG procedures more often than non-diabetic patients and had more comorbidities compared to non-diabetic patients.

Long-term health-related quality of life in 262 patients with brain arteriovenous malformation.

OBJECTIVE: To discover the health-related quality of life (HRQOL) of patients with treated arteriovenous malformation (AVM), we used the self-applicable HRQOL instrument, the 15D, and analyzed the scores in both in the whole study population and specified cohorts. METHODS: The 15D questionnaires were mailed to adult patients with AVM alive in 2016 (n = 432) in our database. Patients with completely eradicated AVM (n = 262) were included in a subsequent analysis. The results were compared with those of the general population standardized for age and sex. Subgroup analyses were conducted for epilepsy, number of bleeding episodes, location of the lesion, modified Rankin Scale score, and Spetzler-Ponce classification (SPC) using independent-samples t test or analysis of covariance. Tobit regression was used to explain the variance in the 15D score. RESULTS: Patients had impaired HRQOL compared to the reference population (p < 0.0001). Deep location, multiple bleeding episodes, and refractory epilepsy were associated with impaired HRQOL. Patients in SPC A and B had similar posttreatment 15D scores, whereas those in class C had an impaired HRQOL. Significant explanatory variables in the regression model were age, sex, number of bleeding episodes, refractory epilepsy, and SPC. CONCLUSIONS: With careful patient selection, patients in SPC B can reach as favorable HRQOL as those in SPC A provided the operation is successful. Multiple bleeding episodes should be prevented with effective treatment aiming at complete AVM obliteration. The postoperative treatment of patients with AVM should focus on preventing depressive symptoms, anxiety, and epileptic seizures. We encourage other research groups to use HRQOL instruments to fully understand the consequences of neurologic and neurosurgical diseases on patients' HRQOL.

Characteristics and Long-Term Outcome of 127 Children With Cerebral Arteriovenous Malformations.

BACKGROUND: Population-based long-term data on pediatric patients with cerebral arteriovenous malformations (AVMs) are limited. OBJECTIVE: To clarify the characteristics and long-term outcome of pediatric patients with AVM. METHODS: A retrospective analysis was performed on 805 consecutive brain AVM patients admitted to a single center between 1942 and 2014. The patients were defined as children if they were under 18 yr at admission. Children were compared to an adult cohort. Changing patterns of presentation were also analyzed by decades of admission. RESULTS: The patients comprised 127 children with a mean age of 12 yr. The mean follow-up time was 21 yr (range 0-62). Children presented more often with intracerebral hemorrhage (ICH) but less often with epilepsy than adults. Basal ganglia, cerebellar, and posterior paracallosal AVMs were more common in pediatric than in adult patients. Frontal and temporal AVMs, in contrast, were more common in adult than in pediatric patients. As the number of incidentally and epilepsy-diagnosed AVMs increased, ICH rates dropped in both cohorts. In total, 22 (82%) pediatric and 108 (39%) adult deaths were assessed as AVM related. After multivariate analysis, small AVM size and surgical treatment correlated with a favorable long-term outcome. CONCLUSION: Hemorrhagic presentation was more common in children than in adults. This was also reflected as lower prevalence of epileptic presentation in the pediatric cohort. Lobar and cortical AVM locations were less frequent, whereas deep and cerebellar AVMs were more common in children. Hemorrhagic presentation correlated negatively with incidentally and epilepsy-diagnosed AVMs. In children, AVM was a major cause of death, but in adults, other factors contributed more commonly to mortality.

Riskier-than-expected occlusive treatment of ruptured posterior communicating artery aneurysms: treatment and outcome of 620 consecutive patients.

OBJECTIVE: Occlusive treatment of posterior communicating artery (PCoA) aneurysms has been seen as a fairly uncomplicated procedure. The objective here was to determine the radiological and clinical outcome of patients after PCoA aneurysm rupture and treatment and to evaluate the risk factors for impaired outcome. METHODS: In a retrospective clinical follow-up study, data were collected from 620 consecutive patients who had been treated for ruptured PCoA aneurysms at a single center between 1980 and 2014. The follow-up was a minimum of 1 year after treatment or until death. RESULTS: Of the 620 patients, 83% were treated with microsurgical clipping, 8% with endovascular coiling, 2% with the two procedures combined, 1% with indirect surgical methods, and 6% with conservative methods. The most common procedural complications were treatment-related brain infarctions (15%). The occurrence of artery occlusions (10% microsurgical, 8% endovascular) was higher than expected. Most patients made a good recovery at 1 year after aneurysmal subarachnoid hemorrhage (modified Rankin Scale [mRS] score 0-2: 386 patients [62%]). A fairly small proportion of patients were left severely disabled (mRS score 4-5: 27 patients [4%]). Among all patients, 20% died during the 1st year. Independent risk factors for an unfavorable outcome, according to the multivariable analysis, were poor preoperative clinical condition, intracerebral or subdural hematoma due to aneurysm rupture, age over 65 years, artery occlusion on postoperative angiography, occlusive treatment-related ischemia, delayed cerebral vasospasm, and hydrocephalus requiring a shunt. CONCLUSIONS: Even though most patients made a good recovery after PCoA aneurysm rupture and treatment during the 1st year, the occlusive treatment-related complications were higher than expected and caused morbidity even among initially good-grade patients. Occlusive treatment of ruptured PCoA aneurysms seems to be a high-risk procedure, even in a high-volume neurovascular center.

Arteriovenous Malformations of the Posterior Fossa: Focus on Surgically Treated Patients Presenting with Hemorrhage.

BACKGROUND: Arteriovenous malformations (AVMs) of the posterior fossa are demanding lesions that often present with rupture. Studies including outcome analyses in surgically operated patients with ruptured infratentorial AVMs are scarce. Certain anatomic and demographic features have shown associations with postoperative outcomes. METHODS: Eighty-six patients with infratentorial AVM were collected from our AVM database. Fifty-four patients were admitted from 1990 onward, and their demographic, lesion, and treatment characteristics were analyzed. The cohort was further refined to 38 consecutive patients with surgically treated ruptured infratentorial AVM admitted to our center between 1990 and 2014, and statistical analyses of factors influencing outcomes were conducted. RESULTS: Twenty-seven patients (69%) had a favorable outcome at early follow-up and 24 (67%) had a favorable outcome at final follow-up. Factors associated with poor outcome in early recovery on univariate analyses were deep venous drainage of the lesion (odds ratio [OR], 5.3; P = 0.037) and high Hunt & Hess score (P = 0.003). In the multivariate model, independent predictors for poor outcome were deep venous drainage (OR, 14.5; P = 0.010) and older age at admission (OR, 1.06; P = 0.028). The sole independent predictor for poor outcome at last follow-up was deep venous drainage (OR, 5.00; P = 0.046). The total follow-up time was 370 person-years. CONCLUSIONS: AVMs of the posterior fossa usually present with rupture and thus require prompt clinical treatment. The majority of surgically treated patients recover favorably. Our data show that venous drainage patterns have the greatest influence on the patient's postoperative condition. Other influencing factors include the severity of hemorrhage and patient age at admission.

Size of Ruptured Intracranial Aneurysms Is Decreasing: Twenty-Year Long Consecutive Series of Hospitalized Patients.

BACKGROUND AND PURPOSE: Decrease in the incidence of subarachnoid hemorrhage over the past decades has been related to decreased smoking rates, especially among <50-year-old people. We studied whether these epidemiological changes are reflected in changes in the size and location of ruptured intracranial aneurysms (RIAs). METHODS: We identified consecutive patients admitted to a nonprofit academic hospital with saccular RIAs between 1989 and 2008. We averaged and analyzed mean sizes of RIAs in 4-year admission groups. In statistical analysis, we used the χ2 test for categorical variables and the Kruskal-Wallis test to assess differences between continuous and categorical variables. For linear trend assessments, we used the linear-by-linear association and ANOVA tests. RESULTS: Of 2660 consecutive patients (59% women) with RIAs, 1176 (44%) were <50 years on admission. In people <50 years, the averaged annual mean size of RIAs decreased 16% from 9.2 mm in 1989 to 1992 to 7.7 mm in 2005 to 2008 in women and 13% (from 9.3 to 8.1 mm) in men (decreasing linear trend; P=0.001). RIA sizes did not change in 50-year-old or older patients, whereas the proportion of posterior circulation RIAs almost tripled to 13%, also with a linear relationship (P<0.001). CONCLUSIONS: The size of RIAs seems to be decreasing among younger generations of hospital-admitted subarachnoid hemorrhage patients, whereas 50-year-old and older subarachnoid hemorrhage patients have an increasing proportion of posterior circulation RIAs. These epidemiological changes are noteworthy, especially if they are universal and ongoing.

Simple Lateral Suboccipital Approach and Modification for Vertebral Artery Aneurysms: A Study of 52 Cases Over 10 Years.

INTRODUCTION: Complex skull base approaches are frequently used to treat intracranial vertebral artery (VA) and proximal posterior inferior cerebellar artery (PICA) aneurysms. These complex procedures are associated with higher risk of neurovascular injury. Hence, a less-invasive surgical approach is needed to improve the efficacy and safety of treatment. METHODS: A retrospective analysis was conducted on clinical and radiologic data from surgeries in which simple lateral suboccipital and "lateral-enough" approaches were used to clip VA aneurysms in the Department of Neurosurgery at Helsinki University Central Hospital from 2000 to 2009. RESULTS: Fifty-two VA or PICA aneurysms were treated using the simple lateral suboccipital approach. Sixteen patients (31%) presented with an unruptured aneurysm, 21 patients (40%) with World Federation of Neurosurgical Societies (WFNS) grade 1-3, and 15 patients (29%) with World Federation of Neurosurgical Societies grade 4-5. The aneurysms were saccular in 48 cases (92%), dissecting in 3 cases (6%), and fusiform in 1 case (2%). The most common aneurysm location was the VA-PICA junction (81%). The mean final modified Rankin Scale score was 2, and in unruptured cases, all patients had favorable clinical outcomes. The main causes of unfavorable outcome were poor preoperative clinical grade (P = 0.002), preoperative intraventricular hemorrhage (P = 0.008), postoperative hydrocephalus (P = 0.003), brain infarction (P = 0.005), and postoperative pneumonia (P < 0.001). CONCLUSIONS: We describe a 10-year experience using a simple lateral suboccipital approach and its modification by the senior author (J.H.) to treat VA and proximal PICA aneurysms. Unfavorable outcome was related to the poor preoperative clinical grade, preoperative intraventricular hemorrhage, and postoperative pneumonia.

CTA analysis and assessment of morphological factors related to rupture in 413 posterior communicating artery aneurysms.

Posterior communicating artery (PcomA) aneurysms are frequently encountered, but there are few publications on their morphology. A growing number of aneurysms are incidental findings, which makes evaluation of rupture risk important. Our goal was to identify morphological features and anatomical variants associated with PComA aneurysms and to assess parameters related to rupture. We studied CT angiographies of 391 consecutive patients treated between 2000 and 2014 at a single institution. We determined clinically important morphological parameters and performed univariate and multivariate analysis. There were a total of 413 PComA aneurysms: 258 (62%) were ruptured and 155 (38%) unruptured. Ruptured PComA aneurysms had the potential to cause severe bleeding with IVH and/or temporal ICH (n = 170, 66% of ruptured). The main types of PComA origin were classified as follows: (1) separate (32%), (2) side by side (21%) and (3) a joint neck with the aneurysm (6%). After the multivariate logistic regression, the morphological parameters related to PComA aneurysm rupture were an irregular aneurysm dome, neck diameter, and aspect ratio >1.5. The most marked morphological features of the PComA aneurysms were: saccular nature (99%), infero-posterior dome orientation (42%), infrequency of large or giant aneurysms (4%), narrow neck compared to the aneurysm size, PComA originating directly from the aneurysm neck or the dome (28%), and fetal or dominant PComA on the side of the aneurysm (35%). There were location-related parameters that were more strongly associated with PComA aneurysm rupture than aneurysm size: an irregular aneurysm dome, larger diameter of the aneurysm neck and aspect ratio >1.5.

Anatomic Features of Paraclinoid Aneurysms: Computed Tomography Angiography Study of 144 Aneurysms in 136 Consecutive Patients.

BACKGROUND: Paraclinoid aneurysms are among the most challenging aneurysms to treat. Computed tomography (CT) angiography helps in evaluating the radiological characteristics of these aneurysms next to bony structures. OBJECTIVE: To present the CT angiography characteristics of paraclinoid aneurysms in order to better understand such pathology. METHODS: The study examined CT angiography-based anatomical characteristics obtained retrospectively from 136 patients with 144 paraclinoid aneurysms selected from single-defined catchment populations in Finland. We examined the diameters of the parent artery (internal carotid artery), the location of the aneurysm, its dimensions (width, height, neck), and aneurysm wall irregularity. RESULTS: We analyzed 144 paraclinoid aneurysms in 136 patients admitted to the hospital during 2000-2014. Multivariable analysis reveals that rupture aneurysms have the following radiological features: aneurysm larger than 5 mm in diameter (P = .006), irregular wall (P = .046), superior location, larger aspect ratio (P = .039), and neck wider than parent artery (P < .001). CONCLUSION: Smaller diameter of the internal carotid artery and superior location, as well as a large and irregular aneurysm wall, are radiological characteristics of ruptured paraclinoid aneurysms, which CT angiography can measure easily.

Natural History of Ruptured but Untreated Intracranial Aneurysms.

BACKGROUND AND PURPOSE: Knowledge on a natural history of untreated ruptured intracranial aneurysms is based on a small historical cohort from 1960s. We calculated mortality rates for patients with untreated ruptured intracranial aneurysms using a more recent and relatively large hospital cohort. METHODS: Patients admitted to the study hospital between 1968 and 2007 with saccular but untreated ruptured intracranial aneurysms were identified from the hospital aneurysm registry of 6850 patients. The study cohort included only patients who were followed up until death and for whom the date of symptom onset and the date of hospital admission were available. RESULTS: For 510 patients identified, the median survival time from symptom onset to death was 20 days. The 1-year mortality rate was 65%, but varied substantially by admission delays and clinical status on admission, being lowest (13%) for patients admitted later than a month after symptom onset and highest (89%) for poor-grade patients. The 1-year mortality rate was 75% for good-grade patients admitted within a week. CONCLUSIONS: Mortality rates for patients with untreated ruptured intracranial aneurysms are even worse than presented in the historical study. When discussing with subarachnoid hemorrhage patients and their relatives about treatment options, the presented natural history figures are of use.

Size and location of ruptured intracranial aneurysms: consecutive series of 1993 hospital-admitted patients.

OBJECTIVE Large consecutive series on the size and location of ruptured intracranial aneurysms (RIAs) are limited, and therefore it has been difficult to estimate population-wide effects of size-based treatment strategies of unruptured intracranial aneurysms. The authors' aim was to define the size and location of RIAs in patients diagnosed with subarachnoid hemorrhage due to aneurysm rupture in a high-volume academic center. METHODS Consecutive patients admitted to a large nonprofit academic hospital with saccular RIAs between 1995 and 2009 were identified, and the size, location, and multiplicity of RIAs were defined and reported by patient sex. RESULTS In the study cohort of 1993 patients (61% women) with saccular RIAs, the 4 most common locations of RIAs were the middle cerebral (32%), anterior communicating (32%), posterior communicating (14%), and pericallosal arteries (5%). However, proportional distribution of RIAs varied considerably by sex; for example, RIAs of the anterior communicating artery were more frequently found in men than in women. Anterior circulation RIAs accounted for 90% of all RIAs, and 30% of the patients had multiple intracranial aneurysms. The median size (measured as maximum diameter) of all RIAs was 7 mm (range 1-43 mm), but the size varied considerably by location. For example, RIAs of the ophthalmic artery had a median size of 11 mm, whereas the median size of RIAs of the pericallosal artery was 6 mm. Of all RIAs, 68% were smaller than 10 mm in maximum diameter. CONCLUSIONS In this large consecutive series of RIAs, 83% of all RIAs were found in 4 anterior circulation locations. The majority of RIAs were small, but the size and location varied considerably by sex. The presented data may be of help in defining effective prevention strategies.

Incidence of subarachnoid hemorrhage is decreasing together with decreasing smoking rates.

OBJECTIVE: To determine the nationwide incidence of subarachnoid hemorrhage (SAH) and report nationwide changes in smoking rates between 1998 and 2012 in Finland. METHODS: In this register-based study, we utilized the nationwide Causes of Death Register and Hospital Discharge Register in identifying SAH events between 1998 and 2012. Population statistics in Finland, which were obtained through a database of Statistics Finland, were used to calculate crude annual incidence rates of SAH. For the direct age standardization of crude incidence rates, we used the European Standard Population (ESP) 2013. Data on changes in nationwide smoking rates between 1998 and 2012 were extracted from a database of the National Institute for Health and Welfare. RESULTS: For the total of 79,083,579 cumulative person-years, we identified 6,885 people with SAH. Sudden deaths from SAH away from hospitals or in emergency rooms accounted for 1,771 (26%) of the events. Crude nationwide annual incidence rates varied between 6.2 and 10.0 per 100,000 persons, and increased by age particularly in women. Among 70- to 75-year-old women, the incidence of SAH was highest (22.5 per 100,000 persons). The 3-year average of ESP standardized incidence decreased 24% from 11.7 in 1998-2000 to 8.9 per 100,000 persons in 2010-2012. Daily smoking decreased 30% between 1998 and 2012. CONCLUSIONS: The incidence of SAH seems to be decreasing. This tendency may be coupled with changes in smoking rates. The incidence of SAH in Finland is similar to other Nordic countries.

Shared Genetic Risk Factors of Intracranial, Abdominal, and Thoracic Aneurysms.

BACKGROUND: Intracranial aneurysms (IAs), abdominal aortic aneurysms (AAAs), and thoracic aortic aneurysms (TAAs) all have a familial predisposition. Given that aneurysm types are known to co-occur, we hypothesized that there may be shared genetic risk factors for IAs, AAAs, and TAAs. METHODS AND RESULTS: We performed a mega-analysis of 1000 Genomes Project-imputed genome-wide association study (GWAS) data of 4 previously published aneurysm cohorts: 2 IA cohorts (in total 1516 cases, 4305 controls), 1 AAA cohort (818 cases, 3004 controls), and 1 TAA cohort (760 cases, 2212 controls), and observed associations of 4 known IA, AAA, and/or TAA risk loci (9p21, 18q11, 15q21, and 2q33) with consistent effect directions in all 4 cohorts. We calculated polygenic scores based on IA-, AAA-, and TAA-associated SNPs and tested these scores for association to case-control status in the other aneurysm cohorts; this revealed no shared polygenic effects. Similarly, linkage disequilibrium-score regression analyses did not show significant correlations between any pair of aneurysm subtypes. Last, we evaluated the evidence for 14 previously published aneurysm risk single-nucleotide polymorphisms through collaboration in extended aneurysm cohorts, with a total of 6548 cases and 16 843 controls (IA) and 4391 cases and 37 904 controls (AAA), and found nominally significant associations for IA risk locus 18q11 near RBBP8 to AAA (odds ratio [OR]=1.11; P=4.1×10(-5)) and for TAA risk locus 15q21 near FBN1 to AAA (OR=1.07; P=1.1×10(-3)). CONCLUSIONS: Although there was no evidence for polygenic overlap between IAs, AAAs, and TAAs, we found nominally significant effects of two established risk loci for IAs and TAAs in AAAs. These two loci will require further replication.

The orbitozygomatic stich: A technical modification of the lateral supraorbital approach.

BACKGROUND: The lateral supraorbital approach (LSO) provides access to a variety of pathologies including anterior and some posterior circulation aneurysms, sellar and suprasellar lesions, and anterior fossa tumors. Technical modifications of LSO improve the surgical exposure of the skull base. METHODS: We retrospectively analyzed 73 consecutive patients treated by the senior author (Juha A. Hernesniemi), at the Department of Neurosurgery, Helsinki University Hospital in Helsinki, Finland from May 2013 to October 2013. This study cohort underwent a modified LSO to access anterior circulation aneurysms, sellar and suprasellar tumors, and anterior fossa tumors. The studied population comprised 30 men and 43 women, with a mean age at treatment of 54 years (9-83 years). RESULTS: LSO was successfully used to access anterior circulation aneurysms in 59 (81%) patients, 10 (14%) patients with anterior cranial fossa tumors, and 4 (5%) patients with suprasellar tumors. The skull base drilling provided a mean of 6.8 mm (1.7-22 mm) in increased exposure. CONCLUSION: LSO provides adequate access to vascular and neoplastic lesions of the anterior cranial fossa, by drilling approximately 6.8 mm (1.7-22 mm) of the lateral orbital wall and sphenoid wing. This enhances surgical exposure and trajectory. An additional trick while performing an LSO is to place a single or multiple stiches (orbitozygomatic stich) at the base of the dura once opened, eliminating the dead space between the dura and anterior skull base.

Presigmoid Approach to Vertebrobasilar Artery Aneurysms: A Series of 31 Patients and Review of the Literature.

OBJECTIVE: The presigmoid approach can be used to treat vertebrobasilar artery aneurysms when circumstances require more operative exposure. High morbidity and mortality in these cases have been reported. In this study, we describe our modified presigmoid approach for vertebrobasilar artery aneurysms and our clinical results. METHODS: This series includes patients with vertebrobasilar aneurysms clipped via the modified presigmoid approach at the Department of Neurosurgery at Helsinki University Hospital from 1998 to 2014. Data were collected from the operating record books, patients' medical records, and a radiologic database server. RESULTS: Thirty-three presigmoid procedures of 31 patients were performed to treat 34 aneurysms (14 ruptured, 20 unruptured). The aneurysms had a mean distance from the posterior clinoid process to the aneurysm neck of 12.2 mm (range, 0-26.6 mm). A favorable outcome was achieved in 21 patients (64%). A favorable outcome was achieved in 74% of unruptured and good-grade patients, whereas favorable outcome was achieved in only 36% of poor-grade patients. Complete or near-complete occlusion was achieved in 79%. Larger aneurysms, fusiform morphology, and anterior dome projection had lower occlusion rates. CONCLUSIONS: We have described our experiences of using the presigmoid approach to treat vertebrobasilar aneurysms. The clinical and radiographic results are acceptable given the complex location and configuration of the treated aneurysms. Unfavorable outcomes are related to the poor admission Hunt and Hess grade, aneurysm morphology, and aneurysm size.

Posterior Cerebral Artery Aneurysms: Treatment and Outcome Analysis in 121 Patients.

OBJECTIVE: Aneurysms of the posterior cerebral artery (PCA) are uncommon. Because of their low incidence, only 5 series with more than 30 patient cases have been reported. The treatment of PCA aneurysms is challenging because of the high frequency of fusiform aneurysms and closeness to important neuroanatomic structures. METHODS: A total of 121 patients with 135 PCA aneurysms were reviewed. The clinical and radiologic data, treatment strategies, and 1-year outcomes were analyzed. Patients with giant aneurysms, associated aneurysms, and aneurysms on arteriovenous malformation-feeding PCAs were considered as complex cases. Outcomes were categorized into 3 groups: good (modified Rankin Scale [mRS], score 0-1), moderate (mRS score, 2-4), and poor (mRS score, 5-6). RESULTS: There were 52 ruptured (39%) and 83 unruptured (61%) PCA aneurysms in 121 patients, with the following distribution: P1 (n = 53), P1/2 (n = 39), P2 (n = 28), and P3 (n = 15). The incidence of fusiform PCA aneurysms was high (24%). Microsurgical treatment was applied to 63 aneurysms and endovascular treatment to 19 aneurysms; 55 aneurysms were treated conservatively. The following treatment results were achieved: for patients with unruptured PCA aneurysms, n = 19; 12 good outcomes, 63%; 6 moderate, 31%; 1 poor, 1%; for patients with ruptured PCA aneurysms, n = 27; 10 good, 37%; 9 moderate, 33%; 8 poor, 30%; and for patients with complex neurovascular diseases and PCA aneurysms, n = 96; 42 good, 43%; 40 moderate, 42%; 14 poor, 15%. CONCLUSIONS: Aneurysms of the PCA are infrequent and often associated with other vascular diseases. Microsurgery and endovascular treatment are effective for the occlusion of PCA aneurysms. The preservation or reconstruction of the parent vessel is crucial for favorable treatment outcomes.

Long-Term Causes of Death and Excess Mortality After Carotid Artery Ligation.

OBJECTIVE: Carotid artery ligation (CAL) is used to treat large and complex intracranial aneurysms. However, little is known about long-term survival and causes of death in patients who undergo the procedure. This study was intended to evaluate if patients who have undergone CAL have long-term excess mortality and what the causes of death are. METHODS: All patients were treated at Helsinki University Hospital between 1937 and 2009. Patients who had undergone CAL and survived ≥1 year after the procedure were included in the cohort. Follow-up was until death or 2015 (2711 patient-years). Causes of death were reviewed and relative survival ratios calculated using the Ederer II method and a matched population. RESULTS: There was 12% excess mortality in all patients 20 years after CAL and 22% after 30 years. A higher proportion of the patients who had subarachnoid hemorrhage (SAH) died during follow-up compared with unruptured patients undergoing CAL. Cardiovascular disease and cerebrovascular accident were the leading causes of death. CONCLUSIONS: Patients with unruptured aneurysms did not experience as much excess mortality as those who had an SAH. The higher proportion of deaths observed in ruptured patients may be partly because of long-term excess mortality conferred by the SAH itself or SAH risk factors. Although the entire population did display excess mortality compared with the general population, this may be because of shared risk factors for aneurysm development and rupture and the cause of death.