Another option in the treatment of intracranial aneurysms is the use of flow-diverting devices. These endovascular devices are endoluminal implants placed in the parent artery rather than in the aneurysmal sac. They redirect the flow past the aneurysm and into the normal distal artery, resulting in gradual thrombosis and involution of the aneurysm. Subsequent inflammation and endothelialization occur, with the vessel intima overgrowing the device while preserving the perforators and side branches in most cases (Fig. 7) (64–66). Flow diverters frequently allow treatment of previously deemed untreatable wide neck and giant aneurysms. One of the drawbacks of stent-assisted coiling and flow diversion is the need for dual antiplatelet therapy, which complicates the management of patients with SAH.
Decisions regarding the choice of aneurysm therapy are ideally made by a team of experienced clinicians who consider the clinical status of the patient, the availability of surgical and endovascular expertise, and the anatomic characteristics of the aneurysm. Aneurysms in the distal arterial segments are typically not amenable to endovascular therapy, and surgical therapy is usually preferred in these cases (67). Surgical therapy may also be preferred for aneurysms at the bifurcation of the MCA, which are difficult to coil without complication (68). In contrast, some intracranial aneurysm locations in the posterior circulation are typically less amenable to surgical treatment, and endovascular treatment is generally preferred (69).
Risks associated with surgical treatment include new or worsened neurologic deficits related to brain manipulation or retraction, temporary arterial occlusion, and intraoperative hemorrhage (70). The most devastating technical complication during surgery is intraprocedural aneurysm rupture, which is associated with periprocedural disability and, at times, death (71). Intraoperative hemorrhage during surgery can usually be handled without sequelae, particularly if the aneurysm ruptures after it has been exposed, which is most common. Intraprocedural hemorrhage during endovascular therapy can be more difficult but is often managed by rapidly coiling the remaining sac. In a prospective study comparing surgical clipping and coiling in patients with similar baseline characteristics and aneurysms judged to be treatable by either clipping or coiling, surgical treatment was associated with a higher postprocedural disability score, longer length of stay and number of days in intensive care, and higher hospital costs (72). In a large, national, multihospital database study in the United States, there was no difference in in-hospital mortality rates between patients with aneurysms treated with clipping or coiling but surgical clipping patients had a significantly higher likelihood of unfavorable outcomes, including discharge to long-term care, ischemic complications, postoperative neurologic complications, and ventriculostomy (73). The major risks associated with endovascular therapy are thromboembolism and intraprocedural aneurysm rupture, with the greatest risk of rupture occurring with aneurysms greater than 10 mm and with a neck size of greater than 4 mm (72–74). Both risks are greater in those patients with SAH compared with those with unruptured aneurysms. Coiled aneurysms also appear to be more likely than surgically clipped aneurysms to recur and require additional intervention (75,76). In a systematic review that assessed aneurysm reopening after coiling in 8,161 aneurysms, reopening occurred in 21% and retreatment was performed in 10% (77). Although generally safe, risks of flow diverters include perforator occlusion, device migration, wire perforation, in-stent thrombosis, distal emboli, and perianeurysmal edema with local compression (78). A rare complication of flow diversion for ophthalmic artery aneurysms is permanent occlusion of the ophthalmic artery (79). Dual antiplatelet therapy is mandatory with flow diverters, and delayed fatal hemorrhages have been reported with their use. All treatments for intracranial aneurysms carry a risk of neuro-ophthalmologic complications, such as new-onset or worsening CNPs and retinal or cerebral ischemia.
When specifically considering the treatment of aneurysms causing neuro-ophthalmologic signs, the goal is not only to treat the aneurysm to prevent SAH but also to maximize the chances of functional neuro-ophthalmic recovery. All reports in the literature comparing surgical clipping vs endovascular coiling for the treatment of aneurysms causing neuro-ophthalmologic conditions are retrospective studies. Because of an increased interest in this topic, a few comprehensive reviews and meta-analyses have been published over the past few years (80–83).
Surgical clipping for the treatment of aneurysms causing third nerve palsies evaluated in several retrospective studies has been summarized in Table 3 (45,96–107). Among a total of 186 patients, complete recovery of the third nerve palsy was achieved in 142 (76%). Predictors of recovery were partial third nerve palsy and a shorter interval to surgery (96,99,100). No difference was found in cases in which the aneurysm was simply clipped at the neck vs those in which the sac was punctured and decompressed after surgical clipping (101).
Endovascular coiling evaluated for the treatment of aneurysms causing third, fourth, or sixth nerve palsies in 20 retrospective studies is summarized in Table 4 (108–127). Among 314 patients (most had a third nerve palsy), 155 (49%) had a complete recovery and 111 (42%) had a partial recovery. In 2 publications, the mean time to resolution of symptoms was reported to be 69 days and 3.8 months (112,115). Ptosis was the first symptom to resolve in 2 of the case series (118,123), whereas pupillary function recovered first in another (125). Five studies found that the most consistent predictor of recovery was partial third nerve palsy at onset (110–113,115).
Anterior visual pathway compression by intracranial aneurysms is also amenable to treatment with either surgical or endovascular techniques (Table 6). In 5 studies directly comparing surgical clipping with endovascular treatment for patients with visual symptoms due to aneurysm compression of the optic pathways, resolution or improvement in symptoms was achieved in 36 of 49 (73%) patients by surgical clipping alone and in 10 of 22 (50%) patients by endovascular coiling (132–136). Studies that reviewed the outcomes of surgical clipping found resolution or improvement of symptoms in 64 of 99 (65%) patients (106,137–146). Slightly lower results of resolution or improvement of visual symptoms in 28 of 54 (52%) patients were found in studies assessing outcomes of endovascular coiling (109,119,121,147–151). Very few studies specifically reported the visual outcome of patients treated with a flow-diverting device, and 3 of 9 patients (33%) with compressive optic neuropathies had resolution of their symptoms (128,130).
Previous reports and systematic reviews have found no significant relationship between aneurysm location, aneurysm size, or the presence of SAH on visual outcome (133). A shorter time to treatment after onset of symptoms has been reported to be a positive predictive factor for visual outcome in several studies (14,141,149), but this was not confirmed in a multivariate analysis combining many studies (133), probably because of the difficulty in precisely identifying the timing of onset of symptoms.
Intracranial aneurysms are frequently discovered because of neuro-ophthalmologic symptoms and signs. A higher rate of complete recovery has been reported with surgical clipping of aneurysms causing ocular motor CNPs and those causing compressive optic neuropathies, but most studies are retrospective. Although numerous studies provided information on the visual outcomes of patients with unruptured aneurysms, the lack of detail regarding the type of visual deficit in many studies limits the number of studies analyzed in this review. Decisions regarding the choice of therapy should be made at high-volume centers that have access to both neurosurgical and endovascular treatments. Neuro-ophthalmologists, neurologists, interventional radiologists, and neurosurgeons should work collaboratively to best treat patients with ruptured and unruptured intracranial aneurysms (59). Clinicians must consider the condition of the patient and the location, size, and configuration of the aneurysm when deciding on the preferred treatment to optimize the neurologic and visual outcome of the patient. Clinical tools such as the PHASES (36) and the UIATS (40) scores can help factor in these variables. Certainly, if an aneurysm is amenable to either treatment option, the higher risk of serious complications and the longer hospital stay and costs associated with neurosurgical treatment should be considered in the decision-making process.
References for this review were identified by searches of Ovid MEDLINE from 1946 to October 10, 2016, and Ovid EMBASE from 1980 to October 10, 2016, with the terms “intracranial aneurysm*,” “subarachnoid hemorrhage,” “Terson syndrome,” “third nerve palsy,” “sixth nerve palsy,” “fourth nerve palsy,” “optic neuropathy,” “optic atrophy,” “endovascular treatment,” and “surgical clipping.” Additional references were identified by hand search of journals and relevant articles. Only articles published in English were reviewed. The final reference list was generated on the basis of originality and relevance to the topics covered in the review. Priority was given to the most recent references and those specifically addressing the issue of visual symptoms and signs. Cavernous sinus aneurysms were not included in this review.
Category 1: a. Conception and design: J. A. Micieli, V. Biousse, N. J. Newman, and D. L. Barrow; b. Acquisition of data: J. A. Micieli, V. Biousse, and N. J. Newman; c. Analysis and interpretation of data: J. A. Micieli, V. Biousse, N. J. Newman, and D. L. Barrow. Category 2: a. Drafting the manuscript: J. A. Micieli; b. Revising it for intellectual content: V. Biousse, N. J. Newman, and D. L. Barrow. Category 3: a. Final approval of the completed manuscript: V. Biousse, N. J. Newman, and D. L. Barrow.
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