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The long-term stability of coil embolization (CE) of complex intracranial aneurysms (CIAs) is fraught with high rates of recanalization. Surgery of precoiled CIAs, however, deviates from a common straightforward procedure, demanding sophisticated strategies. To shed light on the scope and limitations of microsurgical re-treatment, we present our experiences with precoiled CIAs. We retrospectively analysed a consecutive series of 12 patients with precoiled CIAs treated microsurgically over a 5-year period, and provide a critical juxtaposition with the literature. Five aneurysms were located in the posterior circulation, 8 were large-giant sized, 5 were calcified/thrombosed. One presented as a dissecting-fusiform aneurysm, 9 ranked among wide neck aneurysms. Eight lesions were excluded by neck clipping (5 necessitating coil extraction); 1 requiring adjunct CE. The dissecting-fusiform aneurysm was resected with reconstruction of the parent artery using a radial artery graft. Three lesions were treated with flow alteration (parent artery occlusion under bypass protection). Mean interval coiling-surgery was 4.6 years (range 0.5-12 years). Overall, 10 aneurysms were successfully excluded; 2 lesions treated with flow alteration displayed partial thrombosis, progressing over time. Outcome was good in 8 and poor in 4 patients (2 experiencing delayed neurological morbidity), and mean follow-up was 24.3 months. No mortality was encountered. Microsurgery as a last resort for precoiled CIAs can provide-in a majority of cases-a definitive therapy with good outcome. Since repeat coiling increases the complexity of later surgical treatment, we recommend for this subgroup of aneurysms a critical evaluation of CE as an option for re-treatment.

Objective: To evaluate the incidence of nonconvulsive status epilepticus (NCSE) after surgery for ruptured intracranial aneurysms, to define factors associated with this complication, and to determine its impact on the outcome., Patients and Methods: Clinical and neurophysiological data of 66 patients with aneurysmal subarachnoid hemorrhage (aSAH) who underwent continuous EEG (cEEG) monitoring after microsurgical clipping (53 cases) or endovascular coiling (13 cases) of the ruptured aneurysm were analyzed retrospectively. The diagnosis of NCSE was based on the American Clinical Neurophysiology Society and Salzburg Consensus criteria., Results: NCSE was revealed in 10 patients (15 %), all of whom underwent craniotomy and aneurysm clipping. In comparison to the subgroup without NCSE, among those who were diagnosed with this complication there was a significantly greater proportion of men (70 % vs. 34 %; P = 0.041), cases with the Glasgow Coma Scale score at admission < 13 (90 % vs. 36 %; P = 0.004), the Hunt and Hess aSAH grades 3-5 (90 % vs. 45 %; P = 0.013), and hydrocephalus (70 % vs. 29 %; P = 0.044). In addition, they required a significantly longer hospital stay (medians, 62.5 vs. 39.5 days; P = 0.015) and showed trend for the lower rate of favorable disability outcomes (20 % vs. 54 %; P = 0.084)., Conclusions: NCSE is encountered rather often after the microsurgical clipping of ruptured intracranial aneurysms, especially in severely disabled patients with high-grade aSAH and/or associated hydrocpephalus, and may significantly affect the clinical course and prolong recovery. cEEG monitoring may be helpful for timely diagnosis and treatment of this complication., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: To evaluate the results of microsurgical clipping for single intracranial aneurysm (SIA) and multiple intracranial aneurysms (MIA) and compare the outcomes., Methods: All patients who underwent surgery for intracranial aneurysm (IA) at our institution over a 3-year period (June 2013 to May 2016) were included in this study., Results: A total of 157 patients with 225 IAs were included. Forty-one of these patients had MIA (109 IAs, mean, 2.7 ± 1.2; range, 2-7), and remaining 116 had SIA. In the patients with MIA, all aneurysms were secured during the same admission whenever possible. Depending on the locations of the IAs and condition of brain during surgery (tense/lax), all aneurysms were secured on same day (in a single session, single or multiple craniotomy in 28 patients) or on different days (multiple sessions in 13 patients). Postoperative control angiography (DSA) before discharge could be done for 216 aneurysms (MIA, n = 105; SIA, n = 111). Successful occlusion of the aneurysm from circulation was noted in 96.2% (101/105) of MIA and 93.7% (104/111) of SIA. Follow-up of 6 months or longer was available for 146 patients. A modified Rankin Scale score ≤2 was considered a good outcome. Univariate analysis of the entire group revealed no significant difference in clinical outcomes between patients with SIA and MIA both at discharge (good outcome: MIA, 82.9%; SIA, 93.1%; P = 0.068) and at a final follow-up of ≥6 months (good outcome: MIA, 87.2%; SIA, 94.4%; P = 0.164). Clipping for MIA was not associated with poor outcome in multivariate analysis., Conclusions: Comparable clinical outcomes and high rates of complete aneurysm occlusion following microsurgical clipping can be expected in patients with SIA and patients with MIA., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: The repair of unruptured intracranial aneurysms has increased since 2000. In this study, we analyzed the Nationwide Readmission Database (NRD) to determine the rate of 90-day readmission. Our objective is to examine readmission trends after unruptured aneurysm repair., Methods: This study used the 2013 and 2014 NRD. Patient data included standard demographic, comorbidity, and payer information. We selected patients who had undergone microsurgical or endovascular repair for a nonruptured aneurysm. We excluded patients who were under 18 years of age, had a subarachnoid hemorrhage, or were discharged to home the same day. Readmission was calculated by counting the number of days between the end of the index visit and earliest readmission date., Results: A total of 2180 of 29,694 patients (7.34%) were readmitted within 90 days of their initial hospitalization. They were younger (mean, 52.6 years; 95% confidence interval [CI], 51.4-53.8) than patients not readmitted (mean, 57.4 years; 95% CI, 57.1-57.8; P < 0.0001). In total, endovascular repair was more frequent than microsurgery (79.8% vs. 20.2%, respectively). Mean days to readmission was 41.8 (95% CI, 39.7-43.9) and was higher for women (P < 0.0001). The odds ratio for readmission after an endovascular repair was 1.54 (95% CI, 1.27-1.86)., Conclusions: In this study of over 28,000 patients treated for an unruptured aneurysm, the 90-day readmission rate was 7.34%. Endovascular patients had higher odds of readmission than microsurgical patients. Patients with common medical comorbidities (hypertension, obesity, renal failure, and diabetes) were less likely to be readmitted than patients without those conditions., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Ideal management of unruptured intracranial aneurysms (UIAs) and ruptured intracranial aneurysms (RIAs) is a controversial issue. Over the last few decades, a significant paradigm shift has occurred away from open microsurgical clipping toward endovascular coil embolization. Multiple studies have been performed with mixed results. Some studies suggest that endovascular treatment produces better clinical and functional outcomes, but is associated with increased need for retreatment. Other studies report increased durability in aneurysms treated with microsurgical clipping, but that clipping may be associated with worse functional outcomes in some cases. Further complicating the dialogue are variable costs associated with different treatment modalities, including country-dependent cost differences. Here we provide a review of some of the major studies comparing open surgery versus endovascular treatment for both RIAs and UIAs to distill their key findings and corresponding implications for clinical practice. We relate these research results to our institution's experience with RIAs and UIAs and describe our approach to treatment of these conditions. Finally, we discuss implications of the paradigm shift for both open and endovascular surgery, including educational initiatives directed toward preserving important microsurgical tenets in the setting of diminishing surgical volume., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Giant intracranial aneurysms (GIAs), if left untreated, have an extremely poor natural history. Despite many reports about the surgical treatment of GIAs, their long-term clinical and angiographic results are unclear. To our knowledge, this study reports the longest clinical and angiographic follow-up of microsurgically treated GIAs in the English literature., Methods: Between January 1997 and December 2017, 70 patients with giant anterior circulation aneurysms treated using microsurgery were retrospectively reviewed. The applied microsurgical techniques and especially long-term clinical and angiographic follow-up data were evaluated., Results: The mean aneurysm size was 29.2 mm (range, 25-58 mm). The aneurysm neck was occluded in 61 patients (87.2%). Nine aneurysms were clipped using an aneurysm clip compression technique. In 8 patients (11.4%), the aneurysm neck was found smaller at surgery than expected according to angiographic findings. Postoperative angiograms showed complete occlusion in 52 of 61 patients (85.2%). The treatment results at discharge were excellent-good (modified Rankin Scale score ≤2) in 75.3% of the patients. The overall mortality was 7.6%. At long-term clinical follow-up (mean, 105.2 months), 48 patients (78.6%) showed excellent-good outcome. At late angiographic follow-up (mean, 98.0 months), no recurrence was seen in patients with complete aneurysm closure., Conclusions: Most giant anterior circulation aneurysms can be successfully clipped, with acceptable morbidity and mortality. Some giant aneurysms have a smaller neck than expected. The aneurysm clip compression technique is useful in clipping of GIAs. This longest clinical and angiographic follow-up in the literature shows that clip ligation has excellent durability in GIAs, also., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Aim: To summarize the clinical outcomes, follow-up results and to discuss the optimal therapeutic strategy for pericallosal artery aneurysms (PAAs)., Material and Methods: From January 2013 to May 2017, the charts of 49 patients with PAAs, representing 2.43% of 2,018 consecutive patients with intracranial aneurysms (IAs) were reviewed. The clinical and radiological data of these patients were retrospectively analyzed., Results: There were no technical failures in the clipping group, but one patient in the coiling group presented rebleeding during the operation, resulting in a poor prognosis. Although the difference was not significant, the coiling group had a better complete recovery rate than the clipping group [overall: coiling, n=20 (87.0%) vs clipping, n=11 (68.8%), p=0.33; unruptured PAAs: coiling, n=12 (92.3%) vs clipping, n=5 (83.3%); ruptured PAAs: coiling, n=8 (80%) vs clipping, n=6 (60%), p=0.63]. One patient in the coiling group exhibited recurrence. No patients experienced rebleeding during the follow-up period in either group., Conclusion: In our study, both endovascular coiling and microsurgery were technically feasible and achieved favorable clinical outcomes in patients with PAAs. Longer radiological follow-up is necessary. Patients should be evaluated by a multidisciplinary team prior to determining the optimal treatment modality.

Background: Evaluation of differences in neuropsychological outcomes in patients undergoing surgical clipping (SC) vs endovascular coiling (EC) for unruptured cerebral aneurysms is essential in guiding patients seeking treatment of asymptomatic cerebral aneurysms., Objective: To perform a prospective longitudinal analysis of neuropsychological outcomes in patients who underwent microsurgery or coiling for unruptured cerebral aneurysms., Methods: SC (50 patients), EC (35 patients), and healthy controls (43 individuals) were included. A detailed neuropsychological evaluation was performed at baseline and at 2 wk, 3 mo, 6 mo, and 12 mo. Student's t-test was utilized for comparing neuropsychological outcomes among the 3 groups. A mixed-effects model allowed for evaluation of neuropsychological outcome changes among the groups over time., Results: Both the SC and EC groups had nonsignificant differences in procedure-related complications. SC patients had the greatest initial declines in short-term memory, fine motor control, and executive functioning; however, these patients also recovered to a greater degree in neuropsychological functionality. Over the next year, all groups achieved similar neuropsychological outcomes with no significant differences among groups., Conclusion: Whereas the initial decline in neuropsychological functioning was greater for SC patients, 1 yr after treatment there was no significant difference in neuropsychological outcome among the SC, EC, and healthy control groups., (Copyright © 2018 by the Congress of Neurological Surgeons.)

Purpose: To develop a better understanding of pediatric intracranial aneurysms (PIAs)., Methods: All PIAs treated in our center from January 2012 to April 2017 were retrospectively included. Clinical data, treatment summaries, and follow-up outcomes were retrieved and analyzed., Results: A total of 66 PIAs were found in 64 patients with a mean age of 11.4 ± 5.7 years, 68.8% of whom were male. The most common symptoms were seizure (n = 7, 63.6%) for the 0-5 age group and headache (n = 38, 71.7%) for the 6-18 age group. Fifty-one PIAs (77.3%) were located in the anterior circulation, with the middle cerebral artery (MCA) being the most common site (n = 28, 42.4%). Fifteen patients (23.4%) had PIAs that were pseudoaneurysms, and nine of them (60%) had a combined history of head trauma. Thirty-five patients (54.7%) had distal arterial aneurysms, and 21 of them (60%) presented with seizure. During a mean follow-up time of 1.6 ± 1.2 years, 79.7% of patients (n = 51) had favorable outcomes, 5 patients (7.8%) died, and the remaining 8 patients (12.5%) had unfavorable outcomes with severe neurological deficits., Conclusion: Apart from characteristics consistent with previous studies, several new findings regarding PIAs were reported, including a difference in the most common symptoms in different age groups, the MCA as the predominant location of PIAs, the high ratio of pseudoaneurysms and their head trauma etiology, and the incidence of distal arterial aneurysms and their relationship with the risk of seizures.

Evolution in the surgical treatment of intracranial aneurysms is driven by the need to refine and innovate. From an early application of the Hunterian carotid ligation to modern-day sophisticated aneurysm clip designs, progress has been made through dedication and technical maturation of cerebrovascular neurosurgeons to overcome challenges in their practices. The global expansion of endovascular services has challenged the existence of aneurysm surgery, changing the complexity of the aneurysm case mix and volume that are referred for surgical repair. Concepts of how to best treat intracranial aneurysms have evolved over generations and will continue to do so with further technological innovations. As with the evolution of any type of surgery, innovations frequently arise from the criticism of current techniques., (Copyright © 2017 Elsevier Inc. All rights reserved.)

For more than two decades, surgical clipping of ruptured intracranial aneurysms was considered the stan-dard of care. However, as technology improved, a new treatment option was developed, endovascular emoblization. The treatment of cerebral aneurysms, is now in an era where deciding when to clip versus coil can be difficult. Today's cerebrovascular specialist must consider a multitude of factors when developing the best treatment strategy for an individual patient. Optimal management requires a thorough understanding of the natural history of aneurysms as well as risks and benefits related to the different treatment modalities. The purpose of this article is not to proclaim one treatment better than the other, but rather to provide the reader with an up-to-date, comprehensive insight into the management of cerebral aneurysms. We will review data regarding the natural history of aneurysms along with the effectiveness of both surgical clipping and endovascular embolization. We will further discuss our current management strategy for some of the most common aneurysms encountered. The successful treatment of intracranial aneurysms requires a multidisciplinary approach, where surgery and endovascular therapies are viewed as complimentary instead of competing.

Objectives: Coexisting intracerebral aneurysms and meningiomas occur relatively rarely, without a clear relationship, although an aneurysm can be located within a meningioma. The aim of this retrospective study was to identify possible explanations for the coexistence of these conditions and to present a rationale for treatment strategies., Patients and Methods: Ninety-five patients with coexistent meningioma and aneurysm were found in the National Library of Medicine, and 11 more patients were retrieved from our own database., Results: Co-occurrence of both pathologies, sometimes solitary, sometimes multiple, was mostly found in women (3:1). Clinical symptoms in the majority of patients were caused by tumour growth, whereas aneurysm rupture was seen only in a few cases. Consequently tumour resection was performed first in 58 out of the 95 patients, and aneurysm treatment in 38 patients. From available data, the mortality rate three decades before was approximately 40%, but decreased in the last years, due to microsurgical and endovascular techniques. All of our patients were alive after 1 year of follow-up. In patients with intratumoural aneurysms, only three published and one our own case, were treated for both pathologies., Conclusions: The coexistence of meningioma and aneurysm seems to be a coincidence. Treatment should primary focus on the cause of presenting symptoms, but in cases with intratumoural aneurysm, the aneurysm should be treated first. Due to the development of microsurgical and endovascular techniques peri-procedural mortality and morbidity has decreased.

Background: With the progressive refinement of endovascular techniques, fewer IAs are being treated with open microsurgery. There is limited information regarding the impact of this trend on the ability of younger neurosurgeons to achieve proficiency in the surgical management of IAs. We describe a consecutive series of patients with unruptured IAs treated by a neurosurgeon initiating a dedicated cerebrovascular practice in the "endovascular era.", Methods: We retrospectively reviewed the records of all patients who had undergone surgical repair of a saccular IA by one neurosurgeon upon completion of neurosurgical training in July 1997 until April 2005. Patients with ruptured IAs were excluded from review., Results: Of the 1450 patients with IAs treated during this period, 376 underwent microsurgical repair of 450 unruptured IAs. Microsurgical aneurysm neck clipping was possible in most cases, although distal revascularization with proximal occlusion was used in many of the more complicated aneurysms. Major complications occurred in 6 (1.60%) patients, and 1 (0.27%) patient died. At the time of 6-month follow-up, 4 (1.06%) patients were left with a new focal neurologic deficit related to surgery., Conclusions: Despite the growing role of endovascular therapy in the management of IAs, it is possible for young neurovascular surgeons to achieve acceptable results with open microsurgical treatment of IAs. The factors that were deemed important in achieving success in this series included a collaborative approach with endovascular colleagues, careful surgical judgment, continual reanalysis of personal results, and early support from experienced mentors.

Surgical treatment of paraclinoid aneurysms is considered to be difficult due to their complicated anatomical location in the vicinity of important neural, vascular and bony structures. We present our clinical experience of the past 10 years of conventional microsurgical treatment of 81 paraclinoid aneurysms in 75 patients with the use of selective extradural anterior clinoidectomy SEAC and discuss the method of therapy option by reviewing recent reports on results of endovascular coiling method and the combination of these with conventional microsurgical therapy. The favorable surgical results with the use of SEAC and no recurrence of the treated aneurysm after clipping procedure in our series indicate that direct surgery can still be a standard technique for paraclinoid aneurysms in view of the fact that the endovascular aneurysm coiling methods are still associated with a considerable percentage of incomplete occlusion and present the problem of coil packing.

Endovascular treatment by balloon angioplasty or intra-arterial papaverine infusion has been established as a valuable treatment option in patients with cerebral vasospasm refractory to maximal medical therapy. A summary of the indications, applications and limitations is provided for microcatheter guided selective papaverine infusion and transluminal balloon angioplasty in patients who sustain cerebral vasospasm following subarachnoid haemorrhage. Structured neuro-intensive and endovascular treatment of imminent vasospasm integrate papaverine administration and balloon angioplasty as complimentary rather than alternative techniques.

Objective: The surgical treatment of basilar bifurcation aneurysms is challenging, and many of these aneurysms are currently treated by endovascular means. However, the complete closure of the aneurysm by surgical clipping still remains the best and most permanent cure for the aneurysm. The "gold standard", subtemporal approach was established and introduced by Drake and it has been adapted by the senior author Hernesniemi. We describe our present modified technique of this approach based on clinical experience., Methods: The subtemporal approach to basilar bifurcation aneurysms has been regularly used by the senior author Hernesniemi in recent 15 years in over 200 operations in Kuopio and Helsinki, Finland., Results: This approach is suitable in most basilar bifurcation aneurysms except for those high above the posterior clinoid process. To avoid temporal lobe damage, cerebrospinal fluid drainage is necessary. Benefits of subtemporal approach are short operative and retraction times, and no need for skull base resection., Conclusion: The subtemporal approach is simple and safe in experienced hands, and should be considered the standard method to approach most basilar bifurcation aneurysms.