Changes and Innovations For The Surgical Management of Intracranial Aneurysms Leon Tat Lai, MBBS A thesis submitted to fulfill the requirements for the degree of Doctor of Philosophy in the Australian School of Advanced Medicine, Faculty of Human Sciences, Macquarie University January 2014 2 TABLE OF CONTENTS Abstract ................................................................................................................................ 15 Statement of Originality ....................................................................................................... 17 Acknowledgements ............................................................................................................. 19 Author‟s publications and book chapters written during the period of candidature ............ 21 Published/accepted manuscripts related to this thesis .................................................. 21 Published book chapters related to this thesis .............................................................. 24 Published/accepted manuscripts not related to this thesis ............................................ 24 Author‟s conference proceedings and presentations at scientific meetings during the period of candidature ....................................................................................................................... 25 Oral presentations at scientific meetings related to this thesis ..................................... 25 Invited lectures at scientific meetings and courses related to this thesis ...................... 27 Poster presentations at scientific meetings related to this thesis .................................. 27 List of tables and figures ...................................................................................................... 29 Abbreviations and definitions .............................................................................................. 35 CHAPTER 1. ................... 39 Preface to Chapter 1 ......................................................................................................... 39 Author‟s contribution ....................................................................................................... 39 Abstract ............................................................................................................................ 40 Introduction ...................................................................................................................... 41 The Hunterian principle of carotid artery ligation ............................................................. 41 Extending the Hunterian principle intracranially ............................................................. 42 The beginning of direct surgery on intracranial aneurysms ............................................. 43 The birth of Surgical clip ligation of intracranial aneurysms ........................................... 44 The microsurgical era of aneurysm treatment ................................................................... 45 The development of cranial base approaches to intracranial aneurysms ........................ 46 The refinement of aneurysm clip designs ......................................................................... 47 Continuing microsurgical innovations for intracranial aneurysm surgery ...................... 48 Endoscopic endonasal approach and surgical treatment of intracranial aneurysms ....... 48 Conclusion ........................................................................................................................ 50 3 Declaration of interest and acknowledgements ................................................................ 50 CHAPTER 2. ............................................................................... 53 Preface to Chapter 2 ......................................................................................................... 53 Author‟s contribution ....................................................................................................... 53 Abstract ............................................................................................................................ 54 Introduction ...................................................................................................................... 55 Methods ............................................................................................................................ 56 Data source ................................................................................................................... 56 Inclusion and exclusion criteria .................................................................................... 57 Statistical analysis ........................................................................................................ 58 Results .............................................................................................................................. 58 Discussion ........................................................................................................................ 59 Limitations of Study ......................................................................................................... 64 Conclusion ........................................................................................................................ 64 Declaration of interest and acknowledgements ................................................................ 64 CHAPTER 3. ............................................................................................. 65 Preface to Chapter 3 ......................................................................................................... 65 Author‟s contribution ....................................................................................................... 65 Abstract ............................................................................................................................ 66 Introduction ...................................................................................................................... 67 Methods ............................................................................................................................ 68 Data source ................................................................................................................... 68 Inclusion and exclusion criteria .................................................................................... 69 Statistical analysis ........................................................................................................ 69 Results .............................................................................................................................. 71 Overall incidences ........................................................................................................ 71 Gender .......................................................................................................................... 71 Age ............................................................................................................................... 71 Aneurysm location ....................................................................................................... 72 Discussion ........................................................................................................................ 77 4 Limitations of Study ......................................................................................................... 79 Conclusion ........................................................................................................................ 80 Declaration of interest and acknowledgements ................................................................ 80 CHAPTER 4. .................................................................................. 81 Preface to Chapter 4 ......................................................................................................... 81 Author‟s contribution ....................................................................................................... 81 Abstract ............................................................................................................................ 82 Introduction ...................................................................................................................... 83 Methods ............................................................................................................................ 83 Data source, selection criteria and definition of endpoints ........................................... 83 Admission status risk factors ......................................................................................... 84 Ruptured aneurysm locations ........................................................................................ 84 In-hospital related variables........................................................................................... 85 Statistical analysis ......................................................................................................... 85 Results .............................................................................................................................. 86 Admission status risk factors ........................................................................................ 86 Ruptured aneurysm locations ....................................................................................... 86 In-hospital related variables .......................................................................................... 87 Multivariate logistic regression Analysis ..................................................................... 87 Discussion ........................................................................................................................ 89 Limitations of Study ......................................................................................................... 91 Conclusion ........................................................................................................................ 92 Declaration of interest and acknowledgements ................................................................ 92 CHAPTER 5. ................................... 93 Preface to Chapter 5 ......................................................................................................... 93 Author‟s contribution ....................................................................................................... 93 Abstract ............................................................................................................................ 94 Introduction ...................................................................................................................... 95 Methods ............................................................................................................................ 95 5 Data source, selection criteria and definition of endpoints ........................................... 95 Defining the risk of seizures based on treatment modalities ........................................ 96 Defining predictive factors for seizures ........................................................................ 96 Establishing a difference in complication rates for clipping and coiling ...................... 97 Statistical analysis ......................................................................................................... 97 Results .............................................................................................................................. 97 Risk of seizures following surgical clipping or endovascular coiling of UIAs ............ 97 Predictors of in-hospital seizures ................................................................................. 98 Complications associated with surgical clipping and endovascular coiling of UIAs . 99 Discussion ........................................................................................................................ 99 Limitations of Study ....................................................................................................... 101 Conclusion ...................................................................................................................... 102 Declaration of interest and acknowledgements .............................................................. 102 CHAPTER 6. ............................................................................................................. 105 Preface to Chapter 6 ....................................................................................................... 105 Author‟s contribution ..................................................................................................... 105 Abstract .......................................................................................................................... 106 Introduction .................................................................................................................... 106 Methods .......................................................................................................................... 107 Clinical material .......................................................................................................... 107 Technical consideration .............................................................................................. 108 Outcome assessment .................................................................................................... 109 Statistical analysis ....................................................................................................... 109 Results ............................................................................................................................ 109 Surgical procedures ..................................................................................................... 111 Intraoperative complications ....................................................................................... 111 Transient morbidity ..................................................................................................... 111 Permanent morbidity and mortality ............................................................................. 113 Visual outcomes .......................................................................................................... 113 Angiographic and clinical outcomes ........................................................................... 114 Prognostic predictors of surgical outcomes ................................................................. 114 Age ............................................................................................................................. 114 6 Size ............................................................................................................................. 114 Calcification, thrombus and irregularities of the aneurysms on CT ........................... 116 Surgical procedures .................................................................................................... 117 Temporary clipping .................................................................................................... 117 Specific subgroup of patients with surgical complications ........................................ 117 Logistic regression analysis of prognostic factors ...................................................... 118 Discussion ...................................................................................................................... 118 Limitations of Study ....................................................................................................... 121 Conclusion ...................................................................................................................... 121 Declaration of interest and acknowledgements .............................................................. 122 CHAPTER 7. ............................................................................................................. 123 Preface to Chapter 7 ....................................................................................................... 123 Author‟s contribution ..................................................................................................... 123 Abstract .......................................................................................................................... 124 Introduction .................................................................................................................... 125 Methods .......................................................................................................................... 125 Clinical material .......................................................................................................... 125 Technical consideration .............................................................................................. 126 Outcome assessment .................................................................................................... 126 Statistical analysis ........................................................................................................... 127 Results ............................................................................................................................ 127 Surgical procedures ..................................................................................................... 127 Morbidity ..................................................................................................................... 128 Angiographic and clinical outcomes ........................................................................... 129 Specific subgroup of patients with surgical complications ........................................ 130 Prognostic predictors of surgical outcomes ................................................................ 131 Discussion ...................................................................................................................... 131 Limitations of Study ....................................................................................................... 132 Conclusion ...................................................................................................................... 133 Declaration of interest and acknowledgements .............................................................. 134 7 CHAPTER 8. ............................................................................................................................................ 139 Preface to Chapter 8 ....................................................................................................... 139 Author‟s contribution ..................................................................................................... 139 Abstract .......................................................................................................................... 140 Introduction .................................................................................................................... 141 Methods .......................................................................................................................... 141 Clinical material ......................................................................................................... 141 Technical consideration .............................................................................................. 142 Outcome assessment ................................................................................................... 142 Statistical analysis ...................................................................................................... 143 Results ............................................................................................................................ 143 Surgical procedures .................................................................................................... 144 Morbidity .................................................................................................................... 144 Oculomotor nerve palsy ............................................................................................. 145 Angiographic and long-term outcomes ...................................................................... 145 Specific subgroup of patients with surgical complications ........................................ 145 Discussion ...................................................................................................................... 146 Limitations of Study ....................................................................................................... 148 Conclusion ...................................................................................................................... 148 Declaration of interest and acknowledgements .............................................................. 149 CHAPTER 9. ............... 155 Preface to Chapter 9 ....................................................................................................... 155 Author‟s contribution ..................................................................................................... 155 Abstract .......................................................................................................................... 156 Introduction .................................................................................................................... 157 Methods .......................................................................................................................... 157 Literature review ........................................................................................................ 157 Patient population ....................................................................................................... 158 Statistical analysis ...................................................................................................... 159 Results ............................................................................................................................ 160 Literature review of de novo aneurysm detection ....................................................... 160 8 Clinical case series....................................................................................................... 160 Discussion ...................................................................................................................... 161 Limitations of Study ....................................................................................................... 163 Conclusion ...................................................................................................................... 163 Declaration of interest and acknowledgements .............................................................. 163 CHAPTER 10. ..................................... 169 Preface to Chapter 10 ..................................................................................................... 169 Author‟s contribution ..................................................................................................... 169 Abstract .......................................................................................................................... 170 Introduction .................................................................................................................... 171 Methods .......................................................................................................................... 171 Clinical material .......................................................................................................... 171 Outcome assessment ................................................................................................... 172 Surgical management .................................................................................................. 172 Principles of ICG videoangiography .......................................................................... 173 Statistical analysis ....................................................................................................... 173 Results ............................................................................................................................ 174 Discussion ...................................................................................................................... 177 Limitations of Study ....................................................................................................... 179 Conclusion ...................................................................................................................... 180 Declaration of interest and acknowledgements .............................................................. 180 CHAPTER 11. .............................................................................................................. 185 Preface to Chapter 11 ..................................................................................................... 185 Author‟s contribution ..................................................................................................... 185 Abstract .......................................................................................................................... 186 Introduction .................................................................................................................... 187 Methods .......................................................................................................................... 187 Specimens .................................................................................................................. 188 Surgical dissection ..................................................................................................... 188 9 Dimensions of the surgical field and craniotomy ...................................................... 189 Exposure of the posterior circulation arteries ............................................................. 189 Instrument access and clip application ...................................................................... 189 Statistical analysis ...................................................................................................... 190 Results ............................................................................................................................ 190 Dimensions of the surgical field and craniotomy ...................................................... 190 Exposure of the posterior circulation arteries ............................................................ 190 Instrument access and clip application ...................................................................... 191 Discussion ...................................................................................................................... 192 Conclusion ...................................................................................................................... 197 Declaration of interest and acknowledgements .............................................................. 197 CHAPTER 12. .......................................................................... 199 Preface to Chapter 12 ..................................................................................................... 199 Author‟s contribution ..................................................................................................... 199 Abstract .......................................................................................................................... 200 Introduction .................................................................................................................... 201 Methods .......................................................................................................................... 201 Specimens .................................................................................................................. 202 Surgical dissection ..................................................................................................... 202 Dimensions of the surgical field, craniotomy, and the infra-chiasmal window ......... 202 Exposure of the clinoidal ICA segment and proximal vascular control .................... 203 Exposure of the paraclinoid region vasculature ......................................................... 204 Instrument access and clip application ...................................................................... 204 Predictors of surgical access and vascular clip placement ........................................ 204 Statistical analysis ...................................................................................................... 204 Results ............................................................................................................................ 205 Dimensions of the surgical field, craniotomy, and the infra-chiasmal window ........ 205 Exposure of the clinoid ICA segment for proximal vascular control ........................ 205 Exposure of the paraclinoid region vasculature ......................................................... 205 Instrument access and clip application ...................................................................... 206 Predictors of surgical access and vascular clip placement ........................................ 207 Discussion ...................................................................................................................... 207 10