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Predictors of Clinical and Angiographic Outcome After Surgical or Endovascular Therapy of Very Large and Giant Intracranial Aneurysms

Darsaut, Tim E MD*; Darsaut, Nicole M RN*; Chang, Steven D MD*; Silverberg, Gerald D MD*¶; Shuer, Lawrence M MD*; Tian, Lu PhD§; Dodd, Robert L MD, PhD*‡; Do, Huy M MD‡; Marks, Michael P MD‡; Steinberg, Gary K MD, PhD*

doi: 10.1227/NEU.0b013e3182098ad0
Research-Human-Clinical Studies

BACKGROUND: Risk factors for poor outcome in the treatment of very large (≥20-24 mm) and giant (≥25 mm) intracranial aneurysms remain incompletely defined.

OBJECTIVE: To present an aggregate clinical series detailing a 24-year experience with very large and giant aneurysms to identify and assess the relative importance of various patient, aneurysm, and treatment-specific characteristics associated with clinical and angiographic outcomes.

METHODS: The authors retrospectively identified 184 aneurysms measuring 20 mm or larger (85 very large, 99 giant) treated at Stanford University Medical Center between 1984 and 2008. Clinical data including age, presentation, and modified Rankin Scale (mRS) score were recorded, along with aneurysm size, location, and morphology. Type of treatment was noted and clinical outcome measured using the mRS score at final follow-up. Angiographic outcomes were completely occluded, occluded with residual neck, partly obliterated, or patent with modified flow.

RESULTS: After multivariate analysis, risk factors for poor clinical outcome included a baseline mRS score of 2 or higher (odds ratio [OR], 0.23; 95% confidence interval [CI]: 0.08-0.66; P = .01), aneurysm size of 25 mm or larger (OR, 3.32; 95% CI: 1.51-7.28; P < .01), and posterior circulation location (OR, 0.18; 95% CI: 0.07-0.43; P < .01). Risk factors for incomplete angiographic obliteration included fusiform morphology (OR, 0.25; 95% CI: 0.10-0.66; P < .01), posterior circulation location (OR, 0.33; 95% CI: 0.13-0.83; P = .02), and endovascular treatment (OR, 0.14; 95% CI: 0.06-0.32; P < .01). Patients with incompletely occluded aneurysms experienced higher rates of posttreatment subarachnoid hemorrhage and had increased mortality compared with those with completely obliterated aneurysms.

CONCLUSION: Our results suggest that patients with poor baseline functional status, giant aneurysms, and aneurysms in the posterior circulation had a significantly higher proportion of poor outcomes at final follow-up. Fusiform morphology, posterior circulation location, and endovascular treatment were risk factors for incompletely obliterated aneurysms.

Departments of *Neurosurgery, ‡Radiology, and §Health Research and Policy, Stanford Stroke Center and Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine, Stanford, California; ¶Current address: Department of Neurosurgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island

Received, December 29, 2009.

Accepted, July 6, 2010.

Correspondence: Gary K. Steinberg, MD, PhD, Department of Neurosurgery, R231A, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305-5325. E-mail: gsteinberg@stanford.edu

Copyright © by the Congress of Neurological Surgeons