Mmd + aneurysms ebs

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Presented by Dr Chris Davidoff

in collaboration with Dr Markus Wiedmannand Prof Marcus Stoodley

EBS Presentation 16/3/17Treatment of ruptured choroidal artery aneurysms in the setting of Moyamoya disease

Macquarie Neurosurgery 2

Case PresentationTREATMENT OF RUPTURED CHOROIDAL ARTERY ANEURYSMS IN THE SETTING OF MOYAMOYA DISEASE

• 34yr old female presents with sudden onset headache

• associated with nausea and vomitting

• 10 days post-partum










P – patients who have a ruptured choroidal artery aneurysm in the setting of Moyamoya disease

I – surgical treatment or interventional embolisation

C – patients conservatively managed

O – morbidity and mortality

Question: “What is the morbidity and mortality of treating a patient with a ruptured choroidal artery aneurysm in the setting of Moyamoya disease”

Searchable Question (PICO)TREATMENT OF RUPTURED CHOROIDAL ARTERY ANEURYSMS IN THE SETTING OF MOYAMOYA DISEASE


• Medline • Embase • Scopus

Search StrategyTREATMENT OF RUPTURED CHOROIDAL ARTERY ANEURYSMS IN THE SETTING OF MOYAMOYA DISEASE


Search ResultsTREATMENT OF RUPTURED CHOROIDAL ARTERY ANEURYSMS IN THE SETTING OF MOYAMOYA DISEASE

Initial Medline Search



Revised Medline Search



Revised Medline Search – Database Updated



Embase Search



Scopus Search



Markus’ Scopus Search



Medline 194 articles Embase 362 articles Scopus 362 articles

Total papers 918

Abstracts reviewed 397

Excluded 8

Articles retrieved 21

Excluded 376

Duplicates removed 521

Articles reviewed 13


ResultsTREATMENT OF RUPTURED CHOROIDAL ARTERY ANEURYSMS IN THE SETTING OF MOYAMOYA DISEASE

Authors Year No. of Patients

Aneurysm Location

Intervention Follow Up Morbidity& Mortality

Ali et al 2004 1 R PChoA + L thalamo perforator

clipping 6 month *re-haemorrhage prior to treatment

Chen et al 1988 1 L AChoA N/A lost to follow up

N/A

Chong et al 2007 1 R AChoA AChoA trapping + aneurysm excision

12 months reduced speech fluency, impaired fine motor, higher cognitive dysfunction

Choulakian et al 2010 1 L AChoA nBCA embolisation 6 months N/A

Hamada et al 1994 2 L PChoA

R AChoA

clipping

clipping + STA-MCA

6 months

3 weeks

hemiparesis – improved

hemiparesis – transient

He et al 2013 3 L PChoA

L PChoA

Bilateral AChoA

clipping + STA-MCA+ EDMS

clipping + STA-MCA + EDMS

N/A

34 months

21 months

4 months

N/A, GOS 5

N/A, GOS 5

re-haemorrhage




Aneurysm Location


Kawaguchi et al 1996 2 Basilar tip + PChoA

PChoA

clipping + STA-MCA

ventricular drainage + bilateral STA-MCA

3 months

3 months

GOS 5

GOS 4

Kawai et al 1997 1 R AChoA N/A 18 months re-haemorrhage

Kim et al 2009 7 R PChoA

L ACho A

R PChoA

R PChoA

L PChoA

R PChoA

R PChoA

nBCA embolisation

nBCA embolisation

nBCA embolisation

nBCA embolisation

nBCA embolisation

nBCA embolisation

nBCA embolisation

11-60 months, mean 4 months

“Stupor”

N/A

N/A

N/A

N/A

N/A

“Stupor”

Kodama et al 1978 3 L PChoA

R PChoA

L PChoA

N/A

N/A

N/A

6 weeks

11 months

3.5 months

not reported

not reported

not reported




Aneurysm Location


Liu et al 2016 5 PChoA

PChoA

PChoA

AChoA

PChoA

Onyx embolistion

N/A

N/A

Onyx embolistion

N/A

3-11 years, mean 6.4 years

all cases reported as mRS of 0 or 1 (but not individually specified)

Okawa et al 2013 1 R lateral PChoA - pseudoaneurysm

trapping + resection of pseudoaneurysm

3 months N/A

Yang et al 2010 2 L AChoA

L AChoA

Glubran 2 embolisation

coil embolisation

1 year

1 year

N/A

N/A


Results SummaryTREATMENT OF RUPTURED CHOROIDAL ARTERY ANEURYSMS IN THE SETTING OF MOYAMOYA DISEASE

Overall summary of patients• 30 patients that match criteria

- 10 AChoA, 20 PChoA

• most studies are case reports, few case series

• 9 patients treated conservatively – 2 re-haemorrhaged

• 12 patients underwent endovascular treatment - 2 patients had deficits post-op (?severe)

• 9 patients underwent surgical treatment- 3 patients had deficits post-op


• balance between keeping search broad and trying to focus in on area of interest

• multiple search terms needed for ruptured aneurysms

• had to keep search broad to avoid missing cases

• large number of papers to manually sort through

• large number of duplicates – Endnote X8 does not filter these well

Difficulties of SearchTREATMENT OF RUPTURED CHOROIDAL ARTERY ANEURYSMS IN THE SETTING OF MOYAMOYA DISEASE


• ruptured posterior choroidal artery aneurysms are twice as common as anterior choroidal artery aneurysms in the setting of Moyamoa disease

• in the setting of a ruptured aneurysm, the majority of patients are treated

• 2 of 9 reported conservatively treated cases re-haemorrhaged*

• majority of reported cases were treated endovascularly

• no significant difference in the morbidity and mortality between surgical and endovascular treatment reported

ConclusionsTREATMENT OF RUPTURED CHOROIDAL ARTERY ANEURYSMS IN THE SETTING OF MOYAMOYA DISEASE

Health & Medicine

Mmd + aneurysms ebs