6. 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, PhD
Department 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
7. ISAT has demonstrated that endovascular coiling of ruptured
intracranial aneurysms has a significant advantage over neurosurgical
clipping in the first year after treatment. After 5 years, the benefit
seems to have vanished, and no significant difference in either
disability or mortality remains between the 2 treatment modalities.
Therefore, for everyday clinical practice and decision making, coiling
and clipping are to be considered equivalent in the long term.
Disclosure
The authors have no personal financial or institutional interest in any of the
drugs, materials, or devices described in this article.
8.
9. OUTCOME OF OCULOMOTOR NERVE PALSY FROM POSTERIOR COMMUNICATING ARTERY
ANEURYSMS: COMPARISON OF CLIPPING AND COILING
Robert 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
10.
11. Effect of Flow Diversion Treatment on Very Small Ruptured Aneurysms
Zsolt Kulcsár, MD
Department of Neuroradiology,
Hirslanden Clinic, BACKGROUND: Ruptured aneurysms of < 2 mm are not amenable to endovascular coiling
Zurich, Switzerland and therefore pose a significant treatment challenge.
Stephan G. Wetzel, MD OBJECTIVE: To test recently introduced flow diverters that allow endovascular reconstruction
Department 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 subarachnoid
Luca 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 patients
Cardiovascular Technology, and on the basilar bifurcation in the other. All patients had failed early endovascular treatment
Federal Institute of Technology,
Lausanne, Switzerland attempts. Flow diversion with the SILK flow diverter was offered as an alternative in
Andreas Gruber, MD, PhD each patient.
Department of Neurosurgery, RESULTS: SILK deployment successfully eliminated the aneurysms in all 3 instances. One
University of Vienna, of the aneurysms was excluded from contrast material visualization immediately after
Vienna, Austria
stent deployment. Transient thrombotic complication was observed in the case of the basilar
Isabel Wanke, MD, PhD
Department of Neuroradiology, artery aneurysm. It resolved with the administration of intraarterial tirofiban. There was
Hirslanden Clinic, no treatment-related morbidity, and none of the aneurysms reruptured after SILK implantation
Zurich, Switzerland; and during a clinical follow-up of at least 4 months (range, 4-10 months). Imaging followup
Department of Neuroradiology, showed complete vessel remodeling in all cases.
University of Essen,
Essen, Germany CONCLUSION: Flow diversion treatment prevented rebleeding during the
Daniel Andre Rüfenacht,
MD, PhD
follow-up period. Reverse remodeling of the concerned vascular segment with
Department of Neuroradiology, delayed disappearance of the aneurysm was observed in each case.
Hirslanden Clinic, KEY WORDS: Cerebral aneurysm, Flow diversion, SILK, Subarachnoid hemorrhage, Uncoilable
Zurich, Switzerland
Neurosurgery 67:789-793, 2010 DOI: 10.1227/01.NEU.0000372920.39101.55 www.neurosurgery- online.com
22. 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.com
Kenji Yagi, MD Yoshiteru Tada, MD Keiko T. Kitazato, BS Tetsuya Tamura, MD Junichiro Satomi, MD, PhD Shinji Nagahiro, MD,
PhD
Department of Neurosurgery, Institute of Health Biosciences, The University of Tokushima Graduate School,
Tokushima, Japan
27. NASCET
North American Symptomatic Carotid Endarterectomy Trial
Completed
1991
Status
Trial complete. Initial results published 8/91.
Trial Phase
Phase III
Sponsor
National Institute of Neurologic Disorders and Stroke, NIH
Results
The risk of ipsilateral stroke was reduced significiantly (p=0.045)
in patients with carotid stenosis 50-69% who received carotid
endarterectomy. Patients with stenosis of 70-99% showed the
most significant reduction(p < 0.001) in the rate of ipsilateral
stroke while patients with stenosis of <50% did not show a
significantly lower rate of ipsilateral stroke.
28. Perspect Vasc Surg Endovasc Ther. 2006 Dec;18(4):300-3; discussion 304-5. Links
Carotid stent trials: past, present, and future.
Quirel K
Division of Surgery, Cleveland Clinic, Cleveland, Ohio 44195, USA. ourielk@ccf.org
Carotid stenting has emerged as a therapeutic alternative to standard carotid
endarterectomy in patients with carotid bifurcation disease. The percutaneous
modality holds the potential to replace a large proportion of the carotid surgical
procedures performed throughout the world.
Carotid stenting has undergone technologic advances in the last decade, including
improved sheaths and guides, lower profile balloons and stents, and the almost
ubiquitous use of dependable distal embolization protection devices.
Contemporary data confirm the safety and efficacy of the procedure for patients with
high-grade lesions who are at higher-than-normal risk for standard open carotid
repair.
Whether lower-risk patients should be offered stenting as an alternative to carotid
endarterectomy is a question that must await the results of ongoing clinical trials
29. Carotid Endarterectomy Vs Endovascular Stenting:
Recent Results From ICSS and CREST
Recently, short-term results (120 days) of the International Carotid Stenting Study (ICSS), a
randomized multicentrer, international, controlled trial with blinded adjudication of outcomes
comparing stenting vs endarterectomy for recently symptomatic carotid artery stenosis
demonstrated no significant difference in disabling stroke or death in patients receiving
stenting (4.0%) as compared with CEA (3.2%;
The rate of any stroke or death within 30 days of treatment in the stenting group
was more than twice the rate recorded in the CEA group and there were also more fatal
strokes and fatal myocardial infarctions in the stenting group.
As expected, cranial nerve deficits and hematomas were significantly more common in the
CEA group.
30. 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
31. Perioperative Ischemic Complications of the Brain After Carotid Endarterectomy
BACKGROUND: The potential morbidity of cerebral ischemia after carotid endarterectomy
Matthew O. Hebb, MD, PhD
Division 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 complications
Current: 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 were
London, Ontario, Canada studied with perioperative diffusion-weighted imaging of the brain and standardized neurological
Joseph E. Heiserman, MD, PhD
Division 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 the
St 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 24
Division of Neuroradiology,
Barrow Neurological Institute, hours of surgery. A second study was obtained within 24 (92% of patients), 48 (4% of
St Joseph’s Hospital and Medical Center, patients), or 72 (4% of patients) hours after surgery. Intraluminal shunting was used in 1 patient
Phoenix, Arizona
Current Address: (2%), and patch angioplasty was used in 2 patients (4%). No patient had diffusion-weighted
Department of Neuroradiology, imaging evidence of procedure-related cerebral ischemia. Nonischemic complications
Institute of Neurological Sciences,
Glasgow, Scotland consisted of postoperative confusion in an 87-year-old man with a urinary tract infection
Joseph M. Zabramski, MD and a marginal mandibular nerve paresis in another patient. Radiological studies were
Division 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 acceptable
Phoenix, Arizona
Robert F. Spetzler, MD risk of cerebral ischemia in select patients. The low rate of ischemic complications
Division of Neurological Surgery, associated with CEA sets a standard to which other carotid revascularization techniques should
Barrow Neurological Institute,
St Joseph’s Hospital and Medical Center, be held. The current results are presented with a discussion of the senior author’s preferred
Phoenix, 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
35. How Safe Is Arteriovenous Malformation Surgery? A Prospective, Observational
Study of Surgery As First-Line Treatment for Brain Arteriovenous Malformations
Andrew S. Davidson, MS., Michael K. Morgan, MD
Australian School of Advanced Medicine,Macquarie University, Sydney, Australia
OBJECTIVES: Existing studies reporting the risk of surgery for brain arteriovenous malformations
(AVMs) are often biased by the exclusion of patients not offered surgery. In this
study, we examine the risk of surgery, including cases excluded from surgery because of
the high surgical risk.
METHODS: Data were collected on 640 consecutively enrolled AVMs in a database that
included all patients not considered for surgery.
RESULTS: Patients with Spetzler-Martin grade 1 to 2 AVMs (n = 296) were treated with a surgical
risk of 0.7% (95% confidence interval [CI], 0%-3%); patients with Spetzler-Martin grade
3 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% of
patients in this series with similar AVMs were refused surgery because of perceived surgical
risk, 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 a
preferred treatment option for Spetzler-Martin grade 1 to 2 AVMs. This study also reinforces
the predictive value of the Spetzler-Martin grading system, with some caveats .
KEY WORDS: Intracranial arteriovenous malformations, Neurosurgical procedures, Research design
Neurosurgery 66:498-505, 2010 DOI: 10.1227/01.NEU.0000365518.47684.98 www.neurosurgery- online.com
36. CONCLUSIONS
To undertake a valid discussion of the risks of treatment in brain AVMs, an accurate knowledge of the risks and benefits of all
management strategies including the natural history is essential. Surgical series are typically limited by biases that affect their
validity, and our analysis confirms that a significant selection bias for surgical treatment exists for selected groups of patients with
AVMs in this series. In an attempt to compensate for these biases, we describe a rational approach to reporting surgical morbidity
by 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 AVMs
with 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 may
be as high as 41%.
The results of this series are sufficiently reassuring that it remains reasonable to continue to offer surgery as our
preferred 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 the
generalizability of surgical series where a significant number of patients may have been excluded from the reported results.
47. VE SON SÖZ......
Bir saatliğine mutlu olmak için, şekerleme yapın
Bir günlüğüne mutlu olmak için, balık avlamaya gidin
Bir aylığına mutlu olmak için, evlenin
Bir yıllığına mutlu olmak için, bir servete konun
Tüm yaşam boyunca mutlu olmak için,
işinizi sevin...
ÇİN
ATASÖZÜ
