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
Macquarie Neurosurgery 3
Case PresentationTREATMENT OF RUPTURED CHOROIDAL ARTERY ANEURYSMS IN THE SETTING OF MOYAMOYA DISEASE
Macquarie Neurosurgery 4
Case PresentationTREATMENT OF RUPTURED CHOROIDAL ARTERY ANEURYSMS IN THE SETTING OF MOYAMOYA DISEASE
Macquarie Neurosurgery 5
Case PresentationTREATMENT OF RUPTURED CHOROIDAL ARTERY ANEURYSMS IN THE SETTING OF MOYAMOYA DISEASE
Macquarie Neurosurgery 6
Case PresentationTREATMENT OF RUPTURED CHOROIDAL ARTERY ANEURYSMS IN THE SETTING OF MOYAMOYA DISEASE
Macquarie Neurosurgery 7
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
Macquarie Neurosurgery 8
• Medline • Embase • Scopus
Search StrategyTREATMENT OF RUPTURED CHOROIDAL ARTERY ANEURYSMS IN THE SETTING OF MOYAMOYA DISEASE
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Search ResultsTREATMENT OF RUPTURED CHOROIDAL ARTERY ANEURYSMS IN THE SETTING OF MOYAMOYA DISEASE
Initial Medline Search
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Search ResultsTREATMENT OF RUPTURED CHOROIDAL ARTERY ANEURYSMS IN THE SETTING OF MOYAMOYA DISEASE
Revised Medline Search
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Search ResultsTREATMENT OF RUPTURED CHOROIDAL ARTERY ANEURYSMS IN THE SETTING OF MOYAMOYA DISEASE
Revised Medline Search – Database Updated
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Search ResultsTREATMENT OF RUPTURED CHOROIDAL ARTERY ANEURYSMS IN THE SETTING OF MOYAMOYA DISEASE
Embase Search
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Search ResultsTREATMENT OF RUPTURED CHOROIDAL ARTERY ANEURYSMS IN THE SETTING OF MOYAMOYA DISEASE
Scopus Search
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Search ResultsTREATMENT OF RUPTURED CHOROIDAL ARTERY ANEURYSMS IN THE SETTING OF MOYAMOYA DISEASE
Markus’ Scopus Search
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Search ResultsTREATMENT OF RUPTURED CHOROIDAL ARTERY ANEURYSMS IN THE SETTING OF MOYAMOYA DISEASE
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
Macquarie Neurosurgery 16
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
Macquarie Neurosurgery 17
ResultsTREATMENT OF RUPTURED CHOROIDAL ARTERY ANEURYSMS IN THE SETTING OF MOYAMOYA DISEASE
Authors Year No. of Patients
Aneurysm Location
Intervention Follow Up Morbidity& Mortality
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
Macquarie Neurosurgery 18
ResultsTREATMENT OF RUPTURED CHOROIDAL ARTERY ANEURYSMS IN THE SETTING OF MOYAMOYA DISEASE
Authors Year No. of Patients
Aneurysm Location
Intervention Follow Up Morbidity& Mortality
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
Macquarie Neurosurgery 19
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
Macquarie Neurosurgery 20
• 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
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• 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
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