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Objectives: The aim of this study is to analyze the effectiveness of our protocol of the use of multimodality tools, namely indocyanine green-dual image video angiography, neuroendoscope, neuromonitoring with motor-evoked potential, micro-Doppler in the microsurgical clipping of unruptured anterior circulation aneurysms, operated at our institute from January 2016 to December 2018. Materials and Methods: We performed a retrospective analysis of all cases of unruptured anterior circulation aneurysms, operated at Fujita Health University Banbuntane-Hotokukai Hospital, Japan, from January 2016 to December 2018. We assessed outcome at immediate postoperative, at discharge, and at 3 months follow-up by defining permanent morbidity as drop in Modified Rankin Scale (MRS) by 1 at 3 months follow-up and transient morbidity as temporary deficit that improved at discharge or follow-up. Postoperative events, namely seizures, infection that did not affect/change. Preoperative MRS and discharge timing were excluded. We concluded poor outcome as MRS ≥3 and good outcome as MRS < 3 (0–2). All patients had a minimum of 3 months follow-up before outcome conclusion. Results: In 2016, a total of 98 cases were operated with no mortality or permanent morbidity (i.e., change in preoperative MRS), only transient morbidity was seen in (two cases) 2.04%. In 2017, a total of 119 cases were operated with no mortality or morbidity. In 2018, a total of 130 cases were operated with no mortality or permanent morbidity, only transient morbidity 0.7%. Summarizing from January 2016 to December 2018, a total of 347 cases of anterior circulation aneurysms were operated. Mostly, in the female sex (73.3%), the most common was middle cerebral artery aneurysm (39.1%). The mean size was 5.3 mm with no mortality or permanent morbidity with only transient morbidity in 0.9%. No poor outcome (MRS ≥3) was seen in our series. Conclusion: In our center for most unruptured anterior circulation aneurysms, microsurgical clipping is the treatment of choice. We believe our protocol of the intra-operative usage of multimodality tools have aided in the safe microsurgical clipping and have consistently resulted in good operative outcomes. Hence, we recommend and continue to use our Fujita-Bantane Protocol in all cases of micro-surgical clipping of aneurysms to consistently achieve good operative outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Endovascular treatment of cerebral aneurysms includes follow-up imaging to identify aneurysms that may need retreatment. The aim of this study was to determine predictors of incomplete aneurysm occlusion at 1 year after endovascular coiling for ruptured cerebral aneurysms. Methods: In 129 patients of the Prospective Registry of Subarachnoid Aneurysms Treatment cohort, ruptured aneurysms were coiled within 14 days of onset and both initial post-coiling and 1-year follow-up digital subtraction angiography or magnetic resonance angiography were obtained. Factors predicting 1-year incomplete aneurysm occlusion (retreatment within 1-year or residual aneurysms at 1 year) were determined using multivariate logistic regression analyses. Results: One-year incomplete aneurysm occlusion was identified in 59 patients, including ten patients who were retreated within 1-year post-coiling. Dome size ≥7.5 mm ( P = 0.007, odds ratio (OR) = 5.00, 95% confidence interval (CI) = 1.55-16.15), pre-treatment aneurysm re-rupture ( P = 0.023, OR = 3.50, 95% CI = 1.19-10.31), non-small size/small neck aneurysm (dome size, ≥10 mm or neck size, ≥4 mm; P = 0.022, OR = 3.26, 95% CI = 1.19-8.96), and residual aneurysms on immediate post-coiling angiograms ( P = 0.017, OR = 1.43, 95% CI = 1.07-1.93) significantly predicted incomplete aneurysm occlusion at 1-year post-coiling. Conclusions: In addition to the characteristics of aneurysm and initially incomplete aneurysm occlusion, this study showed pre-treatment aneurysm re-rupture to be a predictor that favors closer imaging follow-ups for coiled aneurysms. [ABSTRACT FROM AUTHOR]

Background: Decision-making during the management of unruptured cerebral aneurysms is a delicate process for both neurosurgeons and patients. Guidelines are evidence-based references that can aid in making decisions. However, neurosurgeons do not always follow guidelines in clinical practice. The purpose of this study is to verify the hypothesis that there is substantial dissociation between treatment guidelines and practical decision-making due to a bias in treatment selection for unruptured cerebral aneurysms. This bias is dependent upon clinician-driven factors such as experience and specialty, and patient-driven factors such as patient preference. Methods: This study was performed using internet questionnaires. A total of 282 randomly selected, qualified Japanese neurosurgeons (out of approx. 6,000 registered neurosurgeons), including 45 endovascular specialists, participated in this study. Radiological and demographic data from 88 cases of unruptured cerebral aneurysm were opened on the Web. Participating neurosurgeons decided on the treatment for each case (clipping, coiling or observation). Results: Variations in treatment selection were not significant between neurosurgeons and endovascular specialists, except for aneurysms such as anterior choroidal artery aneurysm. However, contrary to the guidelines, aneurysms larger than 10 mm tended to be treated conservatively because the risk of treatment is high, while aneurysms smaller than 5 mm in diameter were often selected for intervention (clipping or coiling). Conclusions: This study revealed that in real-world clinical practice, physicians are not always faithful to the current guidelines. In making practical treatment decisions for unruptured cerebral aneurysms, the patient's will and the recognition of unavoidable, treatment-related risks seriously influence neurosurgeons' decisions. Copyright © 2010 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]