Journal of the Louisiana State Medical Society
mortality rates were 5.1% and 6% for ruptured and unrup- tured aneurysms, respectively. 21 These results indicate that although periprocedural morbidity and mortality due to intraprocedural rupture during endovascular coiling is low, the overall morbidity and mortality is high due to the high risk of thromboembolic complications. In our series, the immediate angiographic obliteration rate was 98% (n=98) and at one year was 97.7% (n=44 out of 45 patients). Brinjikji et al. reported an overall occlusion rate of 82.4% following endovascular therapy at immediate postoperative angiography. In his series, in 12.7% patients, the aneurysm had been incompletely occluded and in 4.8%, the therapy had failed. 21 At follow-up, 9.3% aneurysms had minor recurrence, and 9.5% aneurysms had significant recanalization requiring treatment. In other series’ of stent- assisted coiling, complete aneurysm occlusion rates were 60.9% and 67%, and recanalization rates were 17% and 13%, respectively. 10,22 Additionally, in one study, the recanaliza- tion rate in MCA bifurcation aneurysms was 75% (mean follow-up duration 26.4 months). 23 In the ISAT study, rebleeding occurred in 2.6% of pa- tients who underwent coiling or attempted coiling and in 1% of those who underwent surgery or attempted surgery; this difference was found to be significant. The majority of patients in both groups rebleed in the first month after treat- ment. However, this difference did not affect the outcome at one year, and the endovascular group had a better outcome than the surgery group. 24 When long-term follow-up was considered, there was a higher risk of recurrent bleeding froma coiled aneurysm comparedwith a clipped aneurysm. However, the risk of death at five years was significantly lower in coiled group than it was in the clipped group. 25 In the CARAT (Cerebral AneurysmRupture After Treatment), the annual rate of retreatment was 13.3% in the coiling group and 2.6% in the clipping group and the difference was sig- nificant (P<0.0001). In the second year, 4.5% patients in the coiling group underwent retreatment, whereas no patient in the clipping group underwent retreatment. 26 It remains to be determined whether the clinical outcome, obliteration rate, rebleeding rate, and recanalization rate of MCA aneu- rysms treated with endovascular therapy are maintained in long-term follow-up. Guresir et al. reported an obliteration rate of 98% in surgically clipped aneurysms vis-a-vis 68% for coiled aneurysms in the time period between three and five years after treatment. They also noted that aneurysm size > 15 mmwas associated with aneurysm remnants after surgical treatment and “broad neck” and “unruptured sta- tus” were related to aneurysm remnants after endovascular treatment. 27 In our series, we had 0% rebleed rate and 1.9% (n=1) recurrence rate at one-year follow-up. This patient had a small residual neck on the postoperative angiogram and was followed-up. Angiogram repeated after one year revealed mild increase in the residual neck. The patient, however, opted for conservative management. At last follow-up, 83.8% patients had a good outcome. Although the endovascular therapy for MCA aneu- rysms is fraught with a higher risk of procedure-related
thromboembolic complications, lower rate of aneurysm obliteration, and a higher recanalization rate, recent develop- ments in endovascular therapy have improved the results. 28 Management of complex MCA aneurysms with combined microneurosurgical and endovascular techniques provides the best results. 29 In our opinion, although microsurgical clipping carries better outcome following treatment of MCA aneurysms, a combined team approach is required to achieve optimal results, and the treatment modality should be individualized keeping in mind the various patient and aneurysm factors. We suggest the following instances where surgical clipping with or without revascularization in a patient with newly diagnosed MCA aneurysm may be considered as against endovascular therapy: 1. giant aneurysm (>25mm) 2. incorporation of one of the branches or the parent vessel 3. aneurysm located at MCA trifurcation 4. origin of a branch from the aneurysm 5. aneurysm of the M3 and M4 segment 6. associated hematoma causing significant mass effect CONCLUSIONS Surgical clipping remains the standard of care for MCA aneurysms. Current data suggests that the aneurysm occlusion rate is lower; procedure-related morbidity and recanalization rates are higher with endovascular therapy for these aneurysms. Appropriate selection of patients and a team approach should be employed for optimal manage- ment of these aneurysms. REFERENCES 1. Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet . 2005 Sep 3-9;366(9488):809-17. 2. Regli L, Dehdashti AR, UskeA, de Tribolet N. Endovascular coiling compared with surgical clipping for the treatment of unruptured middle cerebral artery aneurysms: an update. Acta Neurochirurgica Supplement . 2002;82:41-6. 3. Doerfler A, Wanke I, Goericke SL, Wiedemayer H, Engelhorn T, Gizewski ER, et al. Endovascular treatment of middle cerebral artery aneurysms with electrolytically detachable coils. AJNR American Journal of Neuroradiology . 2006 Mar;27(3):513-20. 4. Quadros RS, Gallas S, Noudel R, Rousseaux P, Pierot L. Endovascular treatment of middle cerebral artery aneurysms as first option: a single center experience of 92 aneurysms. AJNR American Journal of Neuroradiology . 2007 Sep;28(8):1567-72. 5. Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. Journal of Neurosurgery . 1968 Jan;28(1):14-20. 6. van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J. Interobserver agreement for the assessment of handicap in stroke
166 J La State Med Soc VOL 166 July/August 2014
Made with FlippingBook - Online catalogs