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Changes in volume of giant intracranial aneurysms treated by surgical strategies other than direct clipping

  • Clinical Article - Vascular
  • Published:
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Abstract

Background

Giant intracranial aneurysms (GIA) are often not eligible for direct clip occlusion. Surgical alternatives include partial clip occlusion or the placement of a cerebrovascular bypass or the combination of both. These alternative indirect strategies are expected to lead to a decrease in GIA volume over time rather than instantaneously. To examine whether this is the case, we analyzed follow-up imaging results 1 year after surgery.

Methods

We retrospectively screened the prospective GIA Registry’s imaging database for anterior circulation GIA treated by surgical strategies other than direct clipping. We measured pre- and 1-year post-treatment GIA volume, lateral ventricle volume (LVV), and mid-line shift (MLS) in 19 cases.

Results

After a mean follow-up of 466 days (standard deviation ±171) GIA volumes decreased from 9.6 cm3 (interquartile range (IQR) 6.1–14.1) to 4.3 cm3 (IQR 2.9–5.7; p < 0.01). Ipsilateral LVV increased from 8.6 cm3 (IQR 6.4–24.9) to 16.0 cm3 (IQR 9.1–27.2; p < 0.01) while contralateral LVV increased from 10.3 cm3 (IQR 7.3–20.1) to 11.7 cm3 (IQR 8.2–19.4; p = 0.02). MLS changed from 0.1 mm (IQR −1.9 to 2.0) to −0.9 mm (IQR −1.8 to 0.4; p = 0.03). The decrease in GIA volume correlated with the increase in ipsilateral LVV (rs = 0.60; p = 0.01) but not with the changes in MLS (rs = 0.41; p = 0.08).

Conclusions

In our patient cohort, surgical strategies other that direct clipping for the treatment of anterior circulation GIA lead to a significant decrease in GIA volume over time. The resulting decrease in mass effect was more sensitively monitored by the measurement of changes in ipsilateral LVV than changes in MLS.

Clinical Trial Registration-URL

http://www.clinicaltrials.gov. Unique identifier: NCT02066493.

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Acknowledgments

The Giant Intracranial Aneurysm Registry is funded by the Center for Stroke Research – Berlin.

Statement

All trials based on data from the Giant Intracranial Aneurysm Registry were approved by the ethics committees of all participating centers and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. All patients included gave their informed consent prior to their inclusion in the study.

Conflict of interest

None.

Author information

Authors and Affiliations

  1. Department of Neurosurgery, Charité – Universitätsmedizin Berlin, Berlin, Germany

    Nicolai Maldaner, Peter Vajkoczy & Julius Dengler

  2. Department of Neurosurgery, University of Greifswald, Greifswald, Germany

    Susanne Guhl

  3. Department of Neurosurgery, University of Goettingen, Goettingen, Germany

    Dorothee Mielke

  4. Department of Neurosurgery, Klinikum Stuttgart, Stuttgart, Germany

    Christian Musahl

  5. Department of Neurosurgery, Universitätsklinikum Hamburg Eppendorf, Hamburg, Germany

    Nils Ole Schmidt

  6. Department of Neurosurgery, Technical University of Munich, Munich, Germany

    Maria Wostrack

  7. Department of Neuroradiology, Klinik Hirslanden, Zurich, Switzerland

    Daniel A. Rüfenacht

Authors
  1. Nicolai Maldaner
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  2. Susanne Guhl
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  3. Dorothee Mielke
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  4. Christian Musahl
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  5. Nils Ole Schmidt
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  6. Maria Wostrack
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  7. Daniel A. Rüfenacht
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  8. Peter Vajkoczy
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  9. Julius Dengler
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For the Giant Intracranial Aneurysm Study Group

Corresponding author

Correspondence to Julius Dengler.

Additional information

Comment

The giant intracranial aneurysm is a complex neurosurgical pathology with extraordinarily high associated morbidity and multiple factors that must be kept in mind during treatment, including both risk of rupture, as well as mass effect, as the authors thoroughly investigate. Through volumetric and linear measurements, the authors utilize the Giant Intracranial Aneurysm Registry to assess the amount of brain compression caused by these aneurysms after treatment by indirect surgical management with or without bypass. Through this retrospective study, with inclusion criteria of at least a 9-month follow-up MRI (although cited in the abstract to be 1 year), the authors correlate decreasing anterior circulation giant aneurysm volume with increasing ipsilateral ventricular volume, thus serving as a measure for the amount of mass effect an aneurysm is imparting onto the surrounding brain and potentially a proxy for aneurysmal involution, which may be obscured on imaging due to metallic artifact post-treatment.

While the authors pose an interesting question, the clinical application of this data is not thoroughly explored, although it is noted that the outcomes will be discussed in another publication. Given that the average modified Rankin scale prior to treatment of the studied patient population is less than 1, the mass effect of the aneurysms is clinically negligible pre-procedurally, so monitoring only the radiographic finding has minimal clinical application. In addition to minimal clinical information being reported, no angiographic imaging is reported, and given that decreasing mass effect of giant aneurysms is not necessarily associated with cessation of blood flow into the lesion, it is unclear how the results of this paper lends to conclusions applicable to patient care (Darsaut 2011).

The authors choose to correlate aneurysm volume to midline shift and both ipsilateral and contralateral lateral ventricular volume, citing that these measurements have been correlated to intracranial hemorrhage outcomes in the past. However, it should be kept in mind the difference in the slow-growing pathologies of a giant intracranial aneurysm, especially in the setting of wall calcifications, and that of an acute intracranial hemorrhage. There is an inverse correlation between ipsilateral ventricular volume and aneurysm volume, but additionally, a paradoxical midline shift towards the treated aneurysm should be more thoroughly investigated, because while a 1-mm pre-treatment midline shift is most often clinically insignificant, typically a 9-mm midline shift, which was found in post-treatment analysis, would need to be intervened on in most neurosurgical settings. Additionally, the patients with bilateral aneurysms should be excluded from analysis because of the significant confounding nature of bilateral compressive pathologies on midline shift and contralateral ventricular volume.

Given the small sample size of patients and the heterogeneity of both aneurysm location and treatment approach in this study, computational flow dynamic studies would be valuable in understanding how these complex aneurysms responded to indirect treatment, and could direct future surgical management of these lesions (Lawton 2011). However, to that end, the likely future of treatment of these highly morbid lesions, often necessitating surgical intervention shown to be fraught with potential for clinical and neurologic complications, will likely be exclusively endovascular, since the advent of the flow-diverting stent. Although the specific locations of these aneurysms are not discussed in this study, it is likely that many, if not all, of the internal carotid artery lesions could have been treated via flow-diverting stent constructs, with not only exceptional aneurysmal occlusion outcomes but also with even more decrease in aneurysmal volume than seen in this trial (Szikora 2013).

As endovascular therapies, including flow-diverter stents, continue to evolve, they will likely become the preferred treatment for not only giant internal carotid artery aneurysms but also for more distal anterior circulation, as well as posterior circulation, aneurysms, where the obstacles related to flow demand to perforators will likely be overcome with further innovation. As with indirect bypass, flow diverters aim for endoluminal remodeling, rather than abrupt aneurysmal occlusion, so involved blood vessels may either maintain patency or develop collateral perfusion, as seen in the ophthalmic artery aneurysm flow-diversion experience (Zanaty 2015).

The authors are to be commended on their thorough objective study of giant intracranial aneurysm mass effect. With inclusion of clinical data and angiographic outcomes, and understanding of the implications resultant from paradoxical midline shift towards the treated aneurysm, this paper will be a fine addition to the literature. As giant aneurysms treated with flow diverters are added to the Giant Intracranial Aneurysm Registry, this paper will serve as a resource on how to compare radiographic outcomes of this pathology with a changing treatment paradigm in the future.

Daniel M. Heiferman, Dustin M. Hayward, Christopher M. Loftus

Illinois, USA

References

Darsaut TE, Darsaut NM, Chang SD, Silverberg GD, Shuer LM, Tian L, Dodd RL, Do HM, Marks MP, Steinberg GK (2011) Predictors of clinical and angiographic outcome after surgical or endovascular therapy of very large and giant intracranial aneurysms. Neurosurgery 68:903–915

Sughrue ME, Saloner D, Rayz VL, Lawton MT (2011) Giant intracranial aneurysms: evolution of management in a contemporary surgical series. Neurosurgery 69:1261–1270

Szikora I, Marosfoi M, Salomváry B, Berentei Z, Gubucz I (2013) Resolution of mass effect and compression symptoms following endoluminal flow diversion for the treatment of intracranial aneurysms. AJNR Am J Neuroradiol 34:935–939.

Zanaty M, Chalouhi N, Barros G, Schwartz EW, Saigh MP, Starke RM, Whiting A, Tjoumakaris SI, Hasan D, Rosenwasser RH, Jabbour P (2015) Flow-diversion for ophthalmic segment aneurysms. Neurosurgery 76:286–290.

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Maldaner, N., Guhl, S., Mielke, D. et al. Changes in volume of giant intracranial aneurysms treated by surgical strategies other than direct clipping. Acta Neurochir 157, 1117–1123 (2015). https://doi.org/10.1007/s00701-015-2448-y

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  • DOI: https://doi.org/10.1007/s00701-015-2448-y

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