Anevrizma TedavisiCerrahi KliplemeEndovasküler tedavi
Nicolaas A. Bakker, MD, PhD, Jan D.M. Metzemaekers, MD, PhD Rob J.M. Groen, MD, PhD,Jan Jakob A. Mooij, MD, PhD, J. Marc C. Van Dijk, MD, PhDDepartment of Neurosurgery, University Medical Center Groningen, Groningen, The Netherlands International Subarachnoid Aneurysm Trial 2009: Endovascular Coiling of Ruptured Intracranial Aneurysms Has No Significant Advantage Over Neurosurgical Clipping In the May 2009 issue of The Lancet Neurology, the 5-year follow-up results of the International Subarachnoid Aneurysm Trial (ISAT) were published. The authors concluded that, although the significant difference between coiling and neurosurgical clipping of ruptured intracranial aneurysms in terms of death and severe disability after 1 year has vanished (primary endpoint), coiling should still be favored over neurosurgical clipping because mortality rates significantly favored coiling. In this commentary, it is this particular conclusion that is challenged by combining data from previous ISAT publications with the current 5-year follow-up results. This modified intent-to-treat analysis clearly demonstrates that the significant advantage in terms of mortality in favor of the endovascularly treated patients is no longer present, with a hazard ratio of 0.80 in favor of endovascular treatment (95% confidence interval: 0.60-1.05; P = .10). Therefore, for everyday clinical practice and decision making, coiling and clipping are to be considered equivalent in the long term. Neurosurgery 66:961-962, 2010 DOI: 10.1227/01.NEU.0000368152.67151.73 www.neurosurgery- online.com
ISAT has demonstrated that endovascular coiling of rupturedintracranial aneurysms has a significant advantage over neurosurgicalclipping in the first year after treatment. After 5 years, the benefitseems to have vanished, and no significant difference in eitherdisability or mortality remains between the 2 treatment modalities.Therefore, for everyday clinical practice and decision making, coilingand clipping are to be considered equivalent in the long term.DisclosureThe authors have no personal financial or institutional interest in any of thedrugs, materials, or devices described in this article.
OUTCOME OF OCULOMOTOR NERVE PALSY FROM POSTERIOR COMMUNICATING ARTERYANEURYSMS: COMPARISON OF CLIPPING AND COILINGRobert F. Spetzler, M.D. Division of Neurological Surgery,Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center,Phoenix, Arizona OBJECTIVE: Recovery of posterior communicating artery aneurysm-induced oculomotor nerve palsy (ONP) after aneurysm coiling has been reported. However, the coil mass may compromise recovery of the nerve. Therefore, we compared the outcome of coiling and clipping for this indication. METHODS: We retrospectively compared the outcomes of ONP in 13 patients, six of whom underwent endovascular coiling and seven of whom underwent surgical clipping. RESULTS: Six of the seven surgical patients with ONP recovered completely, compared with two of the six patients in the endovascular group. Of the patients with more than 1 year of follow-up, all six surgical patients recovered completely, compared with two of four endovascular patients (P 0.05). In addition, preoperative complete or partial ONP also was associated with degree of resolution by survival analysis (P 0.03). All patients with partial ONP in the surgical group and two of three patients in the endovascular group recovered without residual deficits, whereas three of the four patients with complete ONP in the clipping group and none in the coiling group recovered completely. Regardless of the treatment method, time to complete resolution of ONP was 6 months in both groups. CONCLUSION: Clipping posterior communicating artery aneurysms was associated with a higher probability of complete recovery from ONP than coiling. Degree of preoperative ONP also affected recovery. If patients can tolerate surgery, it should be considered the treatment of choice. KEY WORDS: Endovascular coiling, Oculomotor nerve palsy, Posterior communicating artery aneurysm, Surgical clipping Neurosurgery 58:1040-1046, 2006 DOI: 10.1227/01.NEU.0000215853.95187.5E www.neurosurgery-online.com
Effect of Flow Diversion Treatment on Very Small Ruptured AneurysmsZsolt Kulcsár, MDDepartment of Neuroradiology,Hirslanden Clinic, BACKGROUND: Ruptured aneurysms of < 2 mm are not amenable to endovascular coilingZurich, Switzerland and therefore pose a significant treatment challenge.Stephan G. Wetzel, MD OBJECTIVE: To test recently introduced flow diverters that allow endovascular reconstructionDepartment of Neuroradiology,University Hospital of Basel, via another method and may represent a new treatment option for such lesions.Basel, Switzerland PATIENTS AND METHODS: Three female patients presented with acute subarachnoidLuca Augsburger, PhD hemorrhage. An aneurysm of < 2 mm was identified in all patients as the cause of bleeding.Laboratory of Hemodynamics and The aneurysms were located at the C2 segment of the internal carotid in 2 patientsCardiovascular Technology, and on the basilar bifurcation in the other. All patients had failed early endovascular treatmentFederal Institute of Technology,Lausanne, Switzerland attempts. Flow diversion with the SILK flow diverter was offered as an alternative inAndreas Gruber, MD, PhD each patient.Department of Neurosurgery, RESULTS: SILK deployment successfully eliminated the aneurysms in all 3 instances. OneUniversity of Vienna, of the aneurysms was excluded from contrast material visualization immediately afterVienna, Austria stent deployment. Transient thrombotic complication was observed in the case of the basilarIsabel Wanke, MD, PhDDepartment of Neuroradiology, artery aneurysm. It resolved with the administration of intraarterial tirofiban. There wasHirslanden Clinic, no treatment-related morbidity, and none of the aneurysms reruptured after SILK implantationZurich, Switzerland; and during a clinical follow-up of at least 4 months (range, 4-10 months). Imaging followupDepartment of Neuroradiology, showed complete vessel remodeling in all cases.University of Essen,Essen, Germany CONCLUSION: Flow diversion treatment prevented rebleeding during theDaniel Andre Rüfenacht,MD, PhD follow-up period. Reverse remodeling of the concerned vascular segment withDepartment of Neuroradiology, delayed disappearance of the aneurysm was observed in each case.Hirslanden Clinic, KEY WORDS: Cerebral aneurysm, Flow diversion, SILK, Subarachnoid hemorrhage, UncoilableZurich, Switzerland Neurosurgery 67:789-793, 2010 DOI: 10.1227/01.NEU.0000372920.39101.55 www.neurosurgery- online.com
Ibudilast Inhibits Cerebral Aneurysms by Down-Regulating Inflammation-Related Molecules in the Vascular Wall of Rats OBJECTIVE: Phosphodiesterase-4 (PDE-4) is a cyclic adenosine monophosphate–specific enzyme involved in various inflammatory diseases. We studied its role in and the effect of ibudilast, which predominantly blocks PDE-4, on rat cerebral aneurysms. METHODS: Cerebral aneurysms were induced at the anterior cerebral artery–olfactory artery bifurcation of female rats subjected to hypertension, increased hemodynamic stress, and estrogen deficiency. The effect of ibudilast (30 or 60 mg/kg/d for 3 months) on their cerebral aneurysms was studied by morphological and immunohistochemical assessment and quantitative real-time polymerase chain reaction assay. In our in vitro study, we grew endothelial cells stimulated by angiotensin II under estrogen-free conditions and examined the effect of ibudilast on PDE-4 activation and the cyclic adenosine monophosphate level. RESULTS: Morphological evaluation using vascular corrosion casts showed ibudilast significantly suppressed cerebral aneurysms in a dose-dependent manner. In rats with induced cerebral aneurysms, the gene and protein expression of PDE-4 was high, and endothelial leukocyte adhesion molecules (P-selectin, intracellular adhesion molecule 1, and vascular adhesion molecule 1), matrix metalloproteinase-9, and tumor necrosis α were expressed. Macrophage migration was also increased. Treatment with ibudilast down-regulated these molecules, suppressed macrophage migration into the aneurysm wall, and inhibited PDE-4 activation and the elevation of cyclic adenosine monophosphate in endothelial cells. CONCLUSION: These results suggest that blocking of PDE4 is associated with the reduction of inflammation-related molecules and macrophage migration, thereby reducing the progression of cerebral aneurysms. It may represent a new conservative therapy to treat patients with cerebral aneurysms. KEY WORDS: Cerebral aneurysm, Ibudilast, Leukocyte adhesion molecules, Phosphodiesterase inhibitor, Vascular inflammation Neurosurgery 66:551-559, 2010 DOI: 10.1227/01.NEU.0000365771.89576.77 www.neurosurgery- online.comKenji Yagi, MD Yoshiteru Tada, MD Keiko T. Kitazato, BS Tetsuya Tamura, MD Junichiro Satomi, MD, PhD Shinji Nagahiro, MD,PhDDepartment of Neurosurgery, Institute of Health Biosciences, The University of Tokushima Graduate School,Tokushima, Japan
Karotis Stenozu1- Cerrahi tedavi2- Endovasküler tedavi
NASCETNorth American Symptomatic Carotid Endarterectomy TrialCompleted1991StatusTrial complete. Initial results published 8/91.Trial PhasePhase IIISponsorNational Institute of Neurologic Disorders and Stroke, NIHResultsThe risk of ipsilateral stroke was reduced significiantly (p=0.045)in patients with carotid stenosis 50-69% who received carotidendarterectomy. Patients with stenosis of 70-99% showed themost significant reduction(p < 0.001) in the rate of ipsilateralstroke while patients with stenosis of <50% did not show asignificantly lower rate of ipsilateral stroke.
Perspect Vasc Surg Endovasc Ther. 2006 Dec;18(4):300-3; discussion 304-5. LinksCarotid stent trials: past, present, and future.Quirel KDivision of Surgery, Cleveland Clinic, Cleveland, Ohio 44195, USA. firstname.lastname@example.orgCarotid stenting has emerged as a therapeutic alternative to standard carotidendarterectomy in patients with carotid bifurcation disease. The percutaneousmodality holds the potential to replace a large proportion of the carotid surgicalprocedures performed throughout the world. Carotid stenting has undergone technologic advances in the last decade, includingimproved sheaths and guides, lower profile balloons and stents, and the almostubiquitous use of dependable distal embolization protection devices. Contemporary data confirm the safety and efficacy of the procedure for patients withhigh-grade lesions who are at higher-than-normal risk for standard open carotidrepair. Whether lower-risk patients should be offered stenting as an alternative to carotidendarterectomy is a question that must await the results of ongoing clinical trials
Carotid Endarterectomy Vs Endovascular Stenting:Recent Results From ICSS and CRESTRecently, short-term results (120 days) of the International Carotid Stenting Study (ICSS), arandomized multicentrer, international, controlled trial with blinded adjudication of outcomescomparing stenting vs endarterectomy for recently symptomatic carotid artery stenosisdemonstrated no significant difference in disabling stroke or death in patients receivingstenting (4.0%) as compared with CEA (3.2%;The rate of any stroke or death within 30 days of treatment in the stenting groupwas more than twice the rate recorded in the CEA group and there were also more fatalstrokes and fatal myocardial infarctions in the stenting group. As expected, cranial nerve deficits and hematomas were significantly more common in theCEA group.
Carotid Endarterectomy Vs Endovascular Stenting:Recent Results From ICSS and CREST In-depth functional outcomes may also be important in weighing the risks and benefits of treatments. Previous studies have shown significantly increased rates of non-disabling stroke in patients receiving endovascular therapy,11,13 and recent studies show that these strokes may have significant long- term impact on development of dementia. 14 Furthermore, new stents coming to the market already raise the question as to whether results will already be outdated by the time of CREST publication. In conclusion, the new data from ICSS and CREST continue to support the practice that most patients with carotid stenosis are best treated with endarterectomy, but that stenting is a safe and efficacious alternative in those patients who are deemed poor candidates for surgery. RICARDO J. KOMOTAR ROBERT M. STARKE E. SANDER CONNOLLY International Carotid Stenting Study (ICSS), Carotid Revascularization Endarterectomy vs Stenting Trial (CREST) N12 | VOLUME 66 | NUMBER 6 | JUNE 2010 www.neurosurgery-online.com
Perioperative Ischemic Complications of the Brain After Carotid Endarterectomy BACKGROUND: The potential morbidity of cerebral ischemia after carotid endarterectomyMatthew O. Hebb, MD, PhDDivision of Neurological Surgery, (CEA) has been recognized, but its reported incidence varies widely.Barrow Neurological Institute,St Joseph’s Hospital and Medical Center,Phoenix, Arizona OBJECTIVE: To prospectively evaluate the development of cerebral ischemic complicationsCurrent: in patients treated by CEA at a high-volume cerebrovascular center.Division of Neurosurgery,University of Western Ontario, METHODS: Fifty patients with moderate or severe carotid stenosis awaiting CEA wereLondon, Ontario, Canada studied with perioperative diffusion-weighted imaging of the brain and standardized neurologicalJoseph E. Heiserman, MD, PhDDivision of Neuroradiology, evaluations. Microsurgical CEA was performed by 1 of 2 vascular neurosurgeons.Barrow Neurological Institute, Radiological studies were evaluated by faculty neuroradiologists who were blinded to theSt Joseph’s Hospital and Medical Center,Phoenix, Arizona details of the clinical situation.Kirsten P. N. Forbes, MD RESULTS: Preoperative diffusion-weighted imaging studies were performed within 24Division of Neuroradiology,Barrow Neurological Institute, hours of surgery. A second study was obtained within 24 (92% of patients), 48 (4% ofSt Joseph’s Hospital and Medical Center, patients), or 72 (4% of patients) hours after surgery. Intraluminal shunting was used in 1 patientPhoenix, ArizonaCurrent Address: (2%), and patch angioplasty was used in 2 patients (4%). No patient had diffusion-weightedDepartment of Neuroradiology, imaging evidence of procedure-related cerebral ischemia. Nonischemic complicationsInstitute of Neurological Sciences,Glasgow, Scotland consisted of postoperative confusion in an 87-year-old man with a urinary tract infectionJoseph M. Zabramski, MD and a marginal mandibular nerve paresis in another patient. Radiological studies wereDivision of Neurological Surgery,Barrow Neurological Institute, normal in both patients.St Joseph’s Hospital and Medical Center, CONCLUSION: CEA is a relatively safe procedure that may be performed with an acceptablePhoenix, ArizonaRobert F. Spetzler, MD risk of cerebral ischemia in select patients. The low rate of ischemic complicationsDivision of Neurological Surgery, associated with CEA sets a standard to which other carotid revascularization techniques shouldBarrow Neurological Institute,St Joseph’s Hospital and Medical Center, be held. The current results are presented with a discussion of the senior author’s preferredPhoenix, Arizona surgical technique and a brief review of the literature. KEY WORDS: Atherosclerosis, Emboli, Brain, Stroke, Diffusion-weighted imaging Neurosurgery 67:286-294, 2010 DOI: 10.1227/01.NEU.0000371970.61255.39 www.neurosurgery- online.com
How Safe Is Arteriovenous Malformation Surgery? A Prospective, ObservationalStudy of Surgery As First-Line Treatment for Brain Arteriovenous MalformationsAndrew S. Davidson, MS., Michael K. Morgan, MDAustralian School of Advanced Medicine,Macquarie University, Sydney, AustraliaOBJECTIVES: Existing studies reporting the risk of surgery for brain arteriovenous malformations(AVMs) are often biased by the exclusion of patients not offered surgery. In thisstudy, we examine the risk of surgery, including cases excluded from surgery because ofthe high surgical risk.METHODS: Data were collected on 640 consecutively enrolled AVMs in a database thatincluded all patients not considered for surgery.RESULTS: Patients with Spetzler-Martin grade 1 to 2 AVMs (n = 296) were treated with a surgicalrisk of 0.7% (95% confidence interval [CI], 0%-3%); patients with Spetzler-Martin grade3 to 4 AVMs in noneloquent cortex (n = 65) were treated with a surgical risk of 17% (95%CI, 10%-28%). Patients with Spetzler-Martin grade 3 to 5 AVMs in eloquent cortex (n = 168)were treated with a surgical risk of 21% (95% CI, 15%-28%). However, because 14% ofpatients in this series with similar AVMs were refused surgery because of perceived surgicalrisk, these results are not generalizable to the population of patients with similar AVMs.CONCLUSION: The results of this series suggest that it is reasonable to offer surgery as apreferred treatment option for Spetzler-Martin grade 1 to 2 AVMs. This study also reinforcesthe predictive value of the Spetzler-Martin grading system, with some caveats .KEY WORDS: Intracranial arteriovenous malformations, Neurosurgical procedures, Research designNeurosurgery 66:498-505, 2010 DOI: 10.1227/01.NEU.0000365518.47684.98 www.neurosurgery- online.com
CONCLUSIONSTo undertake a valid discussion of the risks of treatment in brain AVMs, an accurate knowledge of the risks and benefits of allmanagement strategies including the natural history is essential. Surgical series are typically limited by biases that affect theirvalidity, and our analysis confirms that a significant selection bias for surgical treatment exists for selected groups of patients withAVMs in this series. In an attempt to compensate for these biases, we describe a rational approach to reporting surgical morbidityby studying the upper 95% CIs and considering patients excluded from treatment.This approach reveals that surgery can be performed on an unselected group of patients with Spetzler-Martin grade 1 to 2 AVMswith a risk of downgrade due to surgery of less than 3%.In patients with Spetzler-Martin grade 3 to 4 AVMs in noneloquent cortex, the risk of surgery is less than 30%.In patients with Spetzler- Martin grade 3 to 5 AVMs in eloquent cortex, the risk of surgery is certainly greater than 16% and maybe as high as 41%.The results of this series are sufficiently reassuring that it remains reasonable to continue to offer surgery as ourpreferred treatment options for all Spetzler-Martin grade 1 to 2 AVMs.This study also reinforces the predictive value of the Spetzler- Martin grading system, with some caveats relating to thegeneralizability of surgical series where a significant number of patients may have been excluded from the reported results.
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