Clinical StudyOutcomes for unruptured ophthalmic segment aneurysm surgery
Introduction
When intervention is deemed appropriate, understanding the risk for aneurysm repair is confounded by the choice between an endovascular option and a microsurgical option. The management of unruptured ophthalmic segment aneurysms remains at the forefront of this controversy. Audits, such as the International Study of Unruptured Intracranial Aneurysms (ISUIA)1 and the California unruptured aneurysm database2 have provided evidence that endovascular therapy may be safer than open microsurgical clipping for many patients with unruptured aneurysms. Such large multi-centre studies can offer statistical power and evidence-based robustness. However, as these studies are audits, the decision biasing the selection of treatments has not been eliminated. Factors influencing the recommendation for a selection of treatment option may also impact upon the risks of this treatment (such as larger size favouring a recommendation to treat by microsurgery rather than endovascular therapy). Contextually important information may explain the differences between modes of treatment, but are often difficult to extract from such multi-centred audits where contexts are subjected to a Gaussian blur. Therefore, treatment recommendations for unruptured intracranial aneurysms cannot be based solely on the results presented in decontextualised audits because the aneurysms selected for microsurgical or endovascular treatment may differ. There remains an important place to combine information from larger audits with case series where contextual richness is preserved.3, 4, 5, 6, 7
We present our experiences with surgical repairs of unruptured ophthalmic segment aneurysms over a 20 year period in an institution that continues to provide microsurgery as a primary treatment modality. Clinical results, complications and prognostic factors for surgical outcomes are presented.
Section snippets
Methods
This study was approved by the Macquarie University Human Ethics Committee and performed in accordance with institutional Ethics Committee guidelines. All patients who underwent treatment of unruptured ophthalmic segment aneurysms by the senior author (M.K.M.) between April 1992 and August 2012 were eligible for review. Data were collected prospectively in a specifically designed database that included patient demographics, clinical presentation, radiological features, aneurysm size and
Results
From April 1992 to August 2012, 198 patients with 217 ophthalmic segment aneurysms were surgically treated by the senior author (M.K.M.). Twenty-nine patients with 35 aneurysms were excluded from the current study, including acute subarachnoid haemorrhages in 16 patients, multiple aneurysms treated in the same operative session (nine patients), fusiform aneurysm (one patient), dissecting aneurysm (one patient) and traumatic aneurysms (two patients). This resulted in a total of 169 patients with
Discussion
In the current study, we analysed 169 patients with 182 unruptured ophthalmic segment aneurysms of the ICA surgically treated in 173 operations by a single surgeon. Our results revealed a procedure-related 6.4% permanent new neurological deficit, 10.4% transient morbidity and 0.6% mortality. Factors that were associated with poor surgical outcomes were recognised for advanced age (>50 years), larger aneurysm size (>15 mm), and when temporary clipping was necessary. When direct surgical clipping
Study limitations
The current study is subjected to a number of limitations. First, while this is a large series of ophthalmic segment artery aneurysms, the results presented in this study reflect a single surgeon’s operative experience over a 20 year period. Examining outcomes over an extended period of time may be difficult to account for changes in operative techniques and technology that may impact on patient care. Microsurgical techniques and neuroanaesthesia has evolved significantly during this period of
Conclusion
Based on our institutional experience, surgical repairs of unruptured ophthalmic segment aneurysms were associated with 6.4% permanent morbidity and 0.6% mortality. The age of the patient (>50 years) and the need for temporary clipping during surgery were associated with a poor outcome. The robustness of aneurysm repair as achieved by open microsurgical repair is an important consideration. For patients with aneurysms less than 15 mm diameter and who are less than 50 years of age the permanent
Conflicts of interest/disclosures
The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.
Acknowledgment
Leon T. Lai has received the Carl Zeiss Doctorate of Philosophy Research Scholarship.
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