failedflowdivertedaneurysm-241017233048-19b29da3.pptx

EBS 16.10.24

1. Evidence Based Neurosurgery Ursalan Khan 16/10/2024 Clipping of a Previously Flow Diverted PCOM Aneurysm: Evidence Based Surgery and Surgical Nuances

2. Clinical case A 41 year old woman who works as a university lecturer was investigated for headache and was found to have an incidental finding of a left sided 4.5mm PCOM aneurysm. She has no significant past medical history and is a non-smoker. Her family history is specific for her mother being treated for an unruptured intracranial aneurysm at the age of 50. Her grandmother suffered an intracerebral haemorrhage of unknown aetiology . She has expressed wishes to start a family. The aneurysm was treated at a different department after discussion at their cerebrovascular multidisciplinary team meeting with an endovascular pipeline shield flow diverting stent deployed to the distal ICA. Her post procedural course was complicated by a left retinal artery occlusion causing an inferior scotoma requiring a prolonged course of dual antiplatelets. In addition, she developed symptoms of amaurosis fugax and required re-commencement of Aspirin. On close follow up, by 3 years and 7 months the aneurysm demonstrated persistent filling via the PCOM artery.

3. Searchable question Surgical treatment after failed flow diversion. Important considerations including proximal control, placement of clip and risk of tearing the dome or the parent vessel. Anatomical and flow factors that predispose to flow diversion failure. Side points beyond the scope of this discussion and analysis – risk of aneurysm rupture following failure of flow diversion. Risk of aneurysm rupture during pregnancy.

4. PICO Framework P atient/Population I ntervention C omparison O utcomes Who is your patient? Failed flow diverted aneurysm. What do you plan on doing for the patient? Clipping. What alternative are you considering? Nil at present. What do wish to accomplish? Treatment of the aneurysm.

5. Search strategy Use 3 different databases Medline, Embase and Scopus Use of key words Words that describe an article chosen by the author. Words that come up on titles and abstracts (information available to the database) Use of subject headings These are assigned descriptors to research articles by indexers of a database. Eg medline calls these MeSH terms. Interesting fact – before 2022, 200 members of staff were expected to index 1 million studies per year. Now automated.

6. Search strategy Use 3 different databases Medline, Embase and Scopus Use of key words Words that describe an article chosen by the author. Words that come up on titles and abstracts (information available to the database) Use of subject headings These are assigned descriptors to research articles by indexers of a database. Eg medline calls these MeSH terms. Interesting fact – before 2022, 200 members of staff were expected to index 1 million studies per year. Now automated.

7. 9 OFFICE I FACULTY I DEPARTMENT

8. 10 OFFICE I FACULTY I DEPARTMENT

9. 11 OFFICE I FACULTY I DEPARTMENT

10. Summary of key papers Results Table Study Number of Patients Aneurysm Gressot et al 1 Opthalmic artery Aneurysm Mbabuike et al 12 PCOMM PCOMM PCOMM Communicating segment Ventral ICA Ophthalmic Ophthalmic Ophthalmic Supraclinoid ICA Posterior Cerebral Vertebrobasilar Fusiform basilar trunk Kalani et al 1 PICA Nakamura et al 1 CCA Nguyen et al 1 SCA Van Der Veken et al 1 MCA 17

11. Conclusions & recommendations for patient Most of the reported failed flow diverted aneurysms are ophthalmic and PCOM. None of the failed flow diverted aneurysms required proximal control. All patients had no complications post op. Reporter bias.