Outcomes of microsurgical clipping of recurrent aneurysms after endovascular coiling

OBJECT: The outcomes of microsurgery of previously coiled aneurysms are poorly described and little is known about what factors predict poor outcome. Therefore, we set out studying our case series to identify predictors of poor outcome following microsurgery for previously coiled recurrent aneurysms. METHODS: A retrospective cohort study from a prospectively maintained vascular database reviewing presentations, recurrent aneurysms measurements, surgery and outcomes of microsurgical clipping of recurrent previously coiled intracranial aneurysms. RESULTS: 39 patients (mean age 49 years, range 22-70 years) underwent microsurgical clipping of 40 previously coiled intracranial aneurysms. One patient suffered seizures, one transient neurological worsening and one hyponatraemia, none of whom had long-term sequelae. Two patients suffered postoperative infarcts giving an overall incidence of permanent morbidity of 5.1%. There were no deaths or rebleeds on follow up. In three patients, an attempt was made to remove the coil ball. These included the two patients with infarct and one with transient deficit. These patients had larger aneurysms (1106mm3 vs 135 mm3, p=0.005), with larger coil balls (257 mm3 vs 52 mm3, p=0.01) and wider necks (7.09 mm vs 2.69 mm, p=0.02) but smaller remnant heights (1.59mm vs 1.99mm, p=0.04). They were also more likely to have prolapsing coil loops (3/3 vs 3/27, p=0.016). CONCLUSIONS: Our study demonstrates good clinical outcomes from microsurgical clipping of recurrent aneurysms. In the vast majority of cases, clips can be applied primarily. Coil ball removal was associated with increased morbidity and should only be considered as a second line option and its likely need identified before surgery

Systematic review and meta-analysis of the diagnostic accuracy of ultrasonography for deep vein thrombosis

Background Ultrasound (US) has largely replaced contrast venography as the definitive diagnostic test for deep vein thrombosis (DVT). We aimed to derive a definitive estimate of the diagnostic accuracy of US for clinically suspected DVT and identify study-level factors that might predict accuracy. Methods We undertook a systematic review, meta-analysis and meta-regression of diagnostic cohort studies that compared US to contrast venography in patients with suspected DVT. We searched Medline, EMBASE, CINAHL, Web of Science, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, Database of Reviews of Effectiveness, the ACP Journal Club, and citation lists (1966 to April 2004). Random effects meta-analysis was used to derive pooled estimates of sensitivity and specificity. Random effects meta-regression was used to identify study-level covariates that predicted diagnostic performance. Results We identified 100 cohorts comparing US to venography in patients with suspected DVT. Overall sensitivity for proximal DVT (95% confidence interval) was 94.2% (93.2 to 95.0), for distal DVT was 63.5% (59.8 to 67.0), and specificity was 93.8% (93.1 to 94.4). Duplex US had pooled sensitivity of 96.5% (95.1 to 97.6) for proximal DVT, 71.2% (64.6 to 77.2) for distal DVT and specificity of 94.0% (92.8 to 95.1). Triplex US had pooled sensitivity of 96.4% (94.4 to 97.1%) for proximal DVT, 75.2% (67.7 to 81.6) for distal DVT and specificity of 94.3% (92.5 to 95.8). Compression US alone had pooled sensitivity of 93.8 % (92.0 to 95.3%) for proximal DVT, 56.8% (49.0 to 66.4) for distal DVT and specificity of 97.8% (97.0 to 98.4). Sensitivity was higher in more recently published studies and in cohorts with higher prevalence of DVT and more proximal DVT, and was lower in cohorts that reported interpretation by a radiologist. Specificity was higher in cohorts that excluded patients with previous DVT. No studies were identified that compared repeat US to venography in all patients. Repeat US appears to have a positive yield of 1.3%, with 89% of these being confirmed by venography. Conclusion Combined colour-doppler US techniques have optimal sensitivity, while compression US has optimal specificity for DVT. However, all estimates are subject to substantial unexplained heterogeneity. The role of repeat scanning is very uncertain and based upon limited data

Ruptured Intracranial Dermoid Cyst

Background: A 27-year-old man presented at the emergency room with episodic acute headaches and nausea for a few weeks. Neurological examination was normal

Endovascular occlusion of high-flow intracranial arteriovenous shunts: technical note

Endovascular closure of high-flow arteriovenous (AV) shunts in intracranial AV malformations or pial fistulas is technically challenging. In this paper, we illustrate two simple methods to occlude large high-flow AV shunts in a controlled manner

Vascular Perforation During Coil Embolization of an Intracranial Aneurysm: the Incidence, Mechanism, and Clinical Outcome

PurposeThe occurrence of a vascular perforation during an endovascular procedure is an unexpected and feared complication which can be fatal. However, the incidence, risk or the mechanism of vascular perforation which can occur in the endovascular management of aneurysms remains unclear. The purpose of the present study was to evaluate the incidence of vascular perforation during endovascular coil embolization of a cerebral aneurysm, and to reveal characteristics and clinical outcomes.Materials and MethodsWe reviewed the endovascular coil embolization procedures performed for the treatment of 459 aneurysms. Incidence and clinical, radiological and technical data of patients concerning the vascular perforation were reviewed from medical records and radiological findings.ResultsThe incidence of procedure-related vascular perforation in our patient group was 0.87% (4/459). For all four occurrences, the cause of vascular perforation involved the guidewire or microcatheter. Clinical outcome was poor in 2 cases and favorable in 2 cases.ConclusionAlthough rare, the occurrence of vascular perforation during coil embolization for treatment of an aneurysm may be fatal. Therefore, careful management of the guidewire is suggested for the prevention of vascular rupture during an endovascular procedure

Volume versus standard coils in the treatment of intracranial aneurysms

Background Volume coils were developed to improve occlusion rates of intracranial aneurysms. Previous studies have shown increased packing density and comparable occlusion rates, but subgroup analyses of aneurysm size have not been carried out. Objective To evaluate the safety and efficacy of the Penumbra Coil 400 (PC400) system in treating intracranial aneurysms compared with standard diameter coils. Methods A monocentric retrospective case review of 260 aneurysms in 233 patients was carried out. In 37 aneurysms the PC400 system was used, while 223 aneurysms were treated with conventional coils. Previously treated aneurysms and aneurysms treated with flow diverters were excluded. Aneurysm and procedure characteristics, packing density, postprocedural and follow-up occlusion grades as well as coil compaction were evaluated. Results Aneurysms treated with PC400 coils had higher volume (218.9 vs 47.1mm(3), p<0.001), wider necks (3.0 vs 2.5mm, p=0.005), and greater dome/neck ratio (2.0 vs 1.6, p=0.001) in comparison with aneurysms treated with conventional coils. Compared with controls, in the PC400 group we achieved higher packing densities (43.2% vs 34.4%, p<0.001;in aneurysms 7mm 42.2% vs 27.8%, p<0.001). On follow-up angiography we observed less coil compaction (23.8% vs 64.3%, p=0.003) and less aneurysm recurrence (14.3% vs 40.5%, p=0.046) in aneurysms 7mm when using the PC400 system. Conclusions Use of the PC400 system as opposed to conventional coils suggests that the PC400 system is safe and effective in treating intracranial aneurysms. Despite having been applied in a potentially more difficult-to-treat group, the use of PC400 was associated with less coil compaction and aneurysm recurrence in aneurysms 7mm