Elsevier

World Neurosurgery

Volume 84, Issue 6, December 2015, Pages 1726-1738
World Neurosurgery

Original Article
Clinical and Radiological Outcomes After Treatment of Unruptured Paraophthalmic Internal Carotid Artery Aneurysms: a Comparative and Pooled Analysis of Single-Center Experiences

https://doi.org/10.1016/j.wneu.2015.07.036Get rights and content

Objective

Unruptured paraophthalmic aneurysms present unique challenges, and the ideal management remains unknown.

Methods

We performed a pooled analysis of single-center experiences to compare the risks and effectiveness involving patients with unruptured paraophthalmic aneurysms treated with clipping, coiling alone, stent-assisted coiling, and flow-diversion. The MEDLINE database was searched and thirty-three series (including our institutional experience) were included.

Results

Clipping caused more intracranial hemorrhage (ICH) and neurologic complications (NCs) than coiling alone (ICH: odds ratio [OR] = 3.058, P = 0.013; NC: OR = 5.809, P < 0.001), stent-assisted coiling (ICH: P = 0.018; NC: OR = 7.367, P < 0.001), and flow-diversion (ICH: P = 0.006; NC: OR = 16.954, P < 0.001). Clipping also caused more unfavorable visual outcomes than both coiling alone (OR = 3.037, P = 0.001) and stent-assisted coiling (OR = 6.055, P = 0.005). Clipping resulted in a lower reoperation rate than coiling alone in large/giant aneurysm group, which approached statistical significance (OR = 0.133, P = 0.057). Clipping, stent-assisted coiling, and flow-diversion all showed higher occlusion rates compared with coiling alone (OR [clipping vs. coiling alone] = 2.852, P ≤ 0.001; OR [coiling alone vs. stent-assisted coiling] = 0.302, P = 0.003; OR [coiling alone vs. flow-diversion] = 0.400, P = 0.013). Flow-diversion showed comparative complication rate, clinical outcomes, and angiographic result compared with stent-assisted coiling. No significant differences were found among all 4 treatment modalities on mortality and poor outcome.

Conclusions

Endovascular therapies have benefits over surgical clipping in terms of fewer intracranial hemorrhage complications, fewer NCs, and lower unfavorable visual outcome rate. Flow diversion showed comparative safety and effectiveness to stent-assisted coiling, and they both achieved better radiologic results than coiling alone. Further validation by randomized cohort studies is still needed to provide robust evidence.

Introduction

Unruptured intracranial aneurysms (UIAs) have been diagnosed with greater frequency in the most recent decade. As a result of the continuing evolution of endovascular therapy, treatment strategies for UIAs have substantially changed and more aneurysms are now referred for endovascular coiling. However, the management of unruptured paraophthalmic aneurysms remains controversial. From the perspective of microsurgical clipping, several characteristics of paraophthalmic aneurysms, including their proximal location, close relationships with the cavernous sinus, and the covering of the aneurysm base by the optic nerve, can all add technical challenges to the treatment and make clipping rather risky 7, 24, 39. In contrast, paraophthalmic aneurysm embolization may also lead to hazardous results, such as retinal artery occlusion and delayed optic ischemia 38, 43. Moreover, visual function outcome and completeness of occlusion are major concerns of endovascular therapy. The advent of stent-assisted coiling and flow diversion offered new strategies for the treatment of aneurysms, especially for those large and complex aneurysms or aneurysms with wide necks (5); however, the safety issues and efficiency of these technologies remain a major concern.

Therefore in this study we retrospectively analyzed our single-center experience of 13 cases with paraophthalmic UIAs over a 4-year period, and a pooled analysis of the literature was performed to compare the benefits and risks among neurosurgical clipping, coiling alone, stent-assisted coiling, and flow diversion in treating patients with unruptured paraophthalmic aneurysms.

Section snippets

Current Series

Between January 2009 and October 2013, a total of 13 patients were diagnosed with unruptured paraophthalmic intracranial aneurysms and treated in our institution. All patients underwent digital subtraction angiography before treatment, and formal neuro-ophthalmologic examinations before and after surgery were performed if possible. At the time of the initial angiogram, paraophthalmic aneurysms were distinguished from other aneurysms by the principal neurosurgeon. The indication for treatment

Current Series

A total of 13 patients (2 men and 11 women; mean age, 48.4 ± 11.3 years; age range, 30–68 years) with 13 unruptured paraophthalmic aneurysms were admitted to our hospital, and endovascular intervention was performed on all of the patients. Table 1 details demographic, angiographic, and clinical features of 13 patients in the current series.

Of the 13 aneurysms, 7 originated from the right ophthalmic segment and 6 from the left. Only 1 patient presented with diplopia. Other presentations at

Discussion

In this study we provided our institutional experience of coiling, as well as the first comprehensive comparative and pooled analysis, comparing clipping, coiling alone, stent-assisted coiling, and flow diversion in patients with unruptured paraophthalmic aneurysms. Because no randomized controlled trials have been conducted comparing outcomes of intervention modalities for the controversial issue of treating paraophthalmic aneurysms, the present pooled analysis, which included mostly

Conclusion

Our results suggest that endovascular therapies, including coiling alone, stent-assisted coiling, and flow diversion, have benefits over surgical clipping in the treatment of unruptured paraophthalmic aneurysms based on fewer intracranial hemorrhage complications, fewer NCs, and a lower unfavorable visual outcomes rate. Clipping showed a lower reoperation rate, which approached statistical significance, compared with coiling alone in treatment of large/giant aneurysms. No significant difference

Ethics Statement

The study was approved by the Ethics Committee of the First Affiliated Hospital of Zhejiang University School of Medicine. The Ethics Committee waived the need for informed consent because the study was retrospective and the data were analyzed anonymously and de-identified before analysis.

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    Conflict of interest statement: We confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome.

    Yu Zhu, Jianwei Pan and Jian Shen contributed equally to this work.

    Jianwei Pan and Jian Shen are the co-first authors.

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