1naresh2naresh
Array
(
    [urn:ac.highwire.org:guest:identity] => Array
        (
            [runtime-id] => urn:ac.highwire.org:guest:identity
            [type] => guest
            [service-id] => ajnr-ac.highwire.org
            [access-type] => Controlled
            [privilege] => Array
                (
                    [urn:ac.highwire.org:guest:privilege] => Array
                        (
                            [runtime-id] => urn:ac.highwire.org:guest:privilege
                            [type] => privilege-set
                            [privilege-set] => GUEST
                        )

                )

            [credentials] => Array
                (
                    [method] => guest
                )

        )

    [06416304-fc36-4f67-923d-5f3d4a8f5fc9] => Array
        (
            [runtime-id] => 06416304-fc36-4f67-923d-5f3d4a8f5fc9
            [type] => toll-free-key
            [service-id] => ajnr-ac.highwire.org
            [access-type] => Controlled
            [privilege] => Array
                (
                    [c01b7922-f260-4d2b-beea-6c62704e8049] => Array
                        (
                            [runtime-id] => c01b7922-f260-4d2b-beea-6c62704e8049
                            [type] => toll-free-key
                        )

                )

            [credentials] => Array
                (
                    [method] => toll-free-key
                    [value] => tf_ipsecsha;b76be4e3d2947c009cbd17b6cbefea507c76a33f
                )

        )

)
1naresh2naresh
Array
(
    [urn:ac.highwire.org:guest:identity] => Array
        (
            [runtime-id] => urn:ac.highwire.org:guest:identity
            [type] => guest
            [service-id] => ajnr-ac.highwire.org
            [access-type] => FreeToRead
            [privilege] => Array
                (
                    [urn:ac.highwire.org:guest:privilege] => Array
                        (
                            [runtime-id] => urn:ac.highwire.org:guest:privilege
                            [type] => privilege-set
                            [privilege-set] => GUEST
                        )

                )

            [credentials] => Array
                (
                    [method] => guest
                )

        )

    [d210e041-b286-429d-87b7-d368005edb03] => Array
        (
            [runtime-id] => d210e041-b286-429d-87b7-d368005edb03
            [type] => toll-free-key
            [service-id] => ajnr-ac.highwire.org
            [access-type] => FreeToRead
            [privilege] => Array
                (
                    [8cc9dc57-8ef1-46cf-9434-c1b688a6ba42] => Array
                        (
                            [runtime-id] => 8cc9dc57-8ef1-46cf-9434-c1b688a6ba42
                            [type] => toll-free-key
                        )

                )

            [credentials] => Array
                (
                    [method] => toll-free-key
                    [value] => tf_ipsecsha;b76be4e3d2947c009cbd17b6cbefea507c76a33f
                )

        )

)
1naresh2naresh
Array
(
    [urn:ac.highwire.org:guest:identity] => Array
        (
            [runtime-id] => urn:ac.highwire.org:guest:identity
            [type] => guest
            [service-id] => ajnr-ac.highwire.org
            [access-type] => FreeToRead
            [privilege] => Array
                (
                    [urn:ac.highwire.org:guest:privilege] => Array
                        (
                            [runtime-id] => urn:ac.highwire.org:guest:privilege
                            [type] => privilege-set
                            [privilege-set] => GUEST
                        )

                )

            [credentials] => Array
                (
                    [method] => guest
                )

        )

    [6c2cf5ca-7a97-4163-a9c2-f95192cbbebe] => Array
        (
            [runtime-id] => 6c2cf5ca-7a97-4163-a9c2-f95192cbbebe
            [type] => toll-free-key
            [service-id] => ajnr-ac.highwire.org
            [access-type] => FreeToRead
            [privilege] => Array
                (
                    [c30601f5-9323-4397-92d2-dcff34e2e580] => Array
                        (
                            [runtime-id] => c30601f5-9323-4397-92d2-dcff34e2e580
                            [type] => toll-free-key
                        )

                )

            [credentials] => Array
                (
                    [method] => toll-free-key
                    [value] => tf_ipsecsha;b76be4e3d2947c009cbd17b6cbefea507c76a33f
                )

        )

)
1naresh2naresh
Array
(
    [urn:ac.highwire.org:guest:identity] => Array
        (
            [runtime-id] => urn:ac.highwire.org:guest:identity
            [type] => guest
            [service-id] => ajnr-ac.highwire.org
            [access-type] => Controlled
            [privilege] => Array
                (
                    [urn:ac.highwire.org:guest:privilege] => Array
                        (
                            [runtime-id] => urn:ac.highwire.org:guest:privilege
                            [type] => privilege-set
                            [privilege-set] => GUEST
                        )

                )

            [credentials] => Array
                (
                    [method] => guest
                )

        )

    [06416304-fc36-4f67-923d-5f3d4a8f5fc9] => Array
        (
            [runtime-id] => 06416304-fc36-4f67-923d-5f3d4a8f5fc9
            [type] => toll-free-key
            [service-id] => ajnr-ac.highwire.org
            [access-type] => Controlled
            [privilege] => Array
                (
                    [c01b7922-f260-4d2b-beea-6c62704e8049] => Array
                        (
                            [runtime-id] => c01b7922-f260-4d2b-beea-6c62704e8049
                            [type] => toll-free-key
                        )

                )

            [credentials] => Array
                (
                    [method] => toll-free-key
                    [value] => tf_ipsecsha;b76be4e3d2947c009cbd17b6cbefea507c76a33f
                )

        )

)
1naresh2naresh
Array
(
    [urn:ac.highwire.org:guest:identity] => Array
        (
            [runtime-id] => urn:ac.highwire.org:guest:identity
            [type] => guest
            [service-id] => ajnr-ac.highwire.org
            [access-type] => Controlled
            [privilege] => Array
                (
                    [urn:ac.highwire.org:guest:privilege] => Array
                        (
                            [runtime-id] => urn:ac.highwire.org:guest:privilege
                            [type] => privilege-set
                            [privilege-set] => GUEST
                        )

                )

            [credentials] => Array
                (
                    [method] => guest
                )

        )

    [06416304-fc36-4f67-923d-5f3d4a8f5fc9] => Array
        (
            [runtime-id] => 06416304-fc36-4f67-923d-5f3d4a8f5fc9
            [type] => toll-free-key
            [service-id] => ajnr-ac.highwire.org
            [access-type] => Controlled
            [privilege] => Array
                (
                    [c01b7922-f260-4d2b-beea-6c62704e8049] => Array
                        (
                            [runtime-id] => c01b7922-f260-4d2b-beea-6c62704e8049
                            [type] => toll-free-key
                        )

                )

            [credentials] => Array
                (
                    [method] => toll-free-key
                    [value] => tf_ipsecsha;b76be4e3d2947c009cbd17b6cbefea507c76a33f
                )

        )

)
1naresh2naresh
Array
(
    [urn:ac.highwire.org:guest:identity] => Array
        (
            [runtime-id] => urn:ac.highwire.org:guest:identity
            [type] => guest
            [service-id] => ajnr-ac.highwire.org
            [access-type] => Controlled
            [privilege] => Array
                (
                    [urn:ac.highwire.org:guest:privilege] => Array
                        (
                            [runtime-id] => urn:ac.highwire.org:guest:privilege
                            [type] => privilege-set
                            [privilege-set] => GUEST
                        )

                )

            [credentials] => Array
                (
                    [method] => guest
                )

        )

    [06416304-fc36-4f67-923d-5f3d4a8f5fc9] => Array
        (
            [runtime-id] => 06416304-fc36-4f67-923d-5f3d4a8f5fc9
            [type] => toll-free-key
            [service-id] => ajnr-ac.highwire.org
            [access-type] => Controlled
            [privilege] => Array
                (
                    [c01b7922-f260-4d2b-beea-6c62704e8049] => Array
                        (
                            [runtime-id] => c01b7922-f260-4d2b-beea-6c62704e8049
                            [type] => toll-free-key
                        )

                )

            [credentials] => Array
                (
                    [method] => toll-free-key
                    [value] => tf_ipsecsha;b76be4e3d2947c009cbd17b6cbefea507c76a33f
                )

        )

)
1naresh2naresh
Array
(
    [urn:ac.highwire.org:guest:identity] => Array
        (
            [runtime-id] => urn:ac.highwire.org:guest:identity
            [type] => guest
            [service-id] => ajnr-ac.highwire.org
            [access-type] => Controlled
            [privilege] => Array
                (
                    [urn:ac.highwire.org:guest:privilege] => Array
                        (
                            [runtime-id] => urn:ac.highwire.org:guest:privilege
                            [type] => privilege-set
                            [privilege-set] => GUEST
                        )

                )

            [credentials] => Array
                (
                    [method] => guest
                )

        )

    [06416304-fc36-4f67-923d-5f3d4a8f5fc9] => Array
        (
            [runtime-id] => 06416304-fc36-4f67-923d-5f3d4a8f5fc9
            [type] => toll-free-key
            [service-id] => ajnr-ac.highwire.org
            [access-type] => Controlled
            [privilege] => Array
                (
                    [c01b7922-f260-4d2b-beea-6c62704e8049] => Array
                        (
                            [runtime-id] => c01b7922-f260-4d2b-beea-6c62704e8049
                            [type] => toll-free-key
                        )

                )

            [credentials] => Array
                (
                    [method] => toll-free-key
                    [value] => tf_ipsecsha;b76be4e3d2947c009cbd17b6cbefea507c76a33f
                )

        )

)
1naresh2naresh
Array
(
    [urn:ac.highwire.org:guest:identity] => Array
        (
            [runtime-id] => urn:ac.highwire.org:guest:identity
            [type] => guest
            [service-id] => ajnr-ac.highwire.org
            [access-type] => FreeToRead
            [privilege] => Array
                (
                    [urn:ac.highwire.org:guest:privilege] => Array
                        (
                            [runtime-id] => urn:ac.highwire.org:guest:privilege
                            [type] => privilege-set
                            [privilege-set] => GUEST
                        )

                )

            [credentials] => Array
                (
                    [method] => guest
                )

        )

    [794b6cd9-9bf4-42cd-8a88-e656b7e301f4] => Array
        (
            [runtime-id] => 794b6cd9-9bf4-42cd-8a88-e656b7e301f4
            [type] => toll-free-key
            [service-id] => ajnr-ac.highwire.org
            [access-type] => FreeToRead
            [privilege] => Array
                (
                    [7c84b4fb-6ecb-4b8d-ad1f-cb98ed6953dc] => Array
                        (
                            [runtime-id] => 7c84b4fb-6ecb-4b8d-ad1f-cb98ed6953dc
                            [type] => toll-free-key
                        )

                )

            [credentials] => Array
                (
                    [method] => toll-free-key
                    [value] => tf_ipsecsha;b76be4e3d2947c009cbd17b6cbefea507c76a33f
                )

        )

)


  
    






































































    When Dealing with Unruptured Aneurysms, What Do Low Morbidity and Mortality Mean? | American Journal of Neuroradiology  
    



















    

































    
  
  




    
    

  

      


    

      

  
  
  

    

  

    

  

                
    

      

  

    

  
      
  
  

    


Advertisement



  



  


  
  



  



    

  


  


  


  
  
  
  
  
  

  	      


    
      

    
  
    
        
    

  

    
                        

  

                
    

      

	  

		
		

			

			  

  
      
  
  

    

  
  
      
LetterLETTER

  
      

  
      
When Dealing with Unruptured Aneurysms, What Do Low Morbidity and Mortality Mean?
  
    	
R.A. Pérez Falero and O.L. Piloto

  
    	
American Journal of Neuroradiology October 2012,  33 (9) E120; DOI: https://doi.org/10.3174/ajnr.A3314 

  
  
  



  


  
  



			

		

	
	
 	
	  
  

		
		

			

			  

  
      
  
  

    
  


  
  



  
      
  
  

    

  

    

  
      
  
  

    
After reading with interest “Endovascular Therapy of 500 Small Asymptomatic Unruptured Intracranial Aneurysms,”1 we have some remarks to share with the authors and readers.
Oishi et al1 included in their introduction the following comment, “Current evidence does not conclusively justify the conservative management of small asymptomatic UIA [unruptured intracranial aneurysms] ”; but is there any class I or II study that supports any particular treatment in patients with UIAs? Regardless of the fact that published series on this particular issue2 have increasing numbers of cases and even outstanding results compared with outcomes of patients with ruptured aneurysms, they lack the best available statistical design. Therefore and despite the intrinsic limitations of the International Study of Unruptured Intracranial Aneurysms,3 this study remains as a landmark article on the natural history of intracranial aneurysms and, thus, an obligated control group.
In the article of Oishi et al,1 most of the aneurysms (90%) were located in the anterior circulation. The authors have treated them with the following results: 20% residual aneurysms and 1% combined mortality and permanent morbidity. According to these numbers, almost 1 in 4 patients did not receive any benefit from the intervention or their conditions worsened. What would the outcome have been if observation was the chosen strategy instead? In agreement with the opinion of Molyneux4 on this issue and relying on the reported results, can we justify any kind of intervention for an asymptomatic lesion?
Concerning the learning curve of Oishi et al,1 the combined complete occlusion and residual neck were 67% of the first 100 treated lesions, while they were 68% in the final group. Even if there was no significant difference between these 2 variables, residual aneurysms increased from 22% to 31%, and they said, “The reasons for decreased failure seem to be related to the practitioners' technical advances and the development of the right devices. …” How can the authors explain this statement?
On the discussion related to the effectiveness of coiling in preventing aneurysmal SAH, the authors state, “These results suggest that endovascular therapy of UIAs, particularly that of small asymptomatic UIAs, provides sufficient protection from aneurysmal SAH in short-to-midterm periods.” However, how can we accept this suggestion if they have not included an observational group that truly reflects the incidence of SAH in UIAs? Again, the controversy about the natural history of UIAs shows up and dilutes the hidden benefits that any intervention can provide.
Regardless of the above-mentioned problems, Oishi et al1 have displayed high proficiency and remarkable technical skills in dealing with this complex group of aneurysms.
References
  1. 1.↵


    1. Oishi  H, 
    2. Yamamoto  M, 
    3. Shimizu  T, 
    4. et al
    . 
Endovascular therapy of 500 small asymptomatic unruptured intracranial aneurysms. 
AJNR Am J Neuroradiol 
2012;
33:
958–
64
    Abstract/FREE Full Text
  2. 2.↵


    1. Im  SH, 
    2. Han  MH, 
    3. Kwon  Ok, 
    4. et al
    . 
Endovascular coil embolization of 435 small asymptomatic unruptured intracranial aneurysms: procedural morbidity and patient outcome. 
AJNR Am J Neuroradiol 
2009;
30:
79–
84
    Abstract/FREE Full Text
  3. 3.↵


    1. Wiebers  DO, 
    2. Whisnant  JP, 
    3. Huston  J  3rd., 
    4. et al.
    , 
for the International Study of Unruptured Intracranial Aneurysms Investigators. 
Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. 
Lancet 
2003;
362:
103–
10
    CrossRefPubMed
  4. 4.↵


    1. Molyneux  AJ
    . 
The treatment of unruptured cerebral aneurysms: cause for concern? 
AJNR Am J Neuroradiol 
2011;
32:
1076–
77
    FREE Full Text
  


  
  



  
      
  
  

    
  


  
  



  




  


  
  



  
      
  
  

    
  


  
  



  
      
  
  

     Back to top  


  
  



			

		

		
		

			

			  

  
        
In this issue

    
  
  

    
  


  
  



  
      
  
  

    

  

    

  
      
  
  

    


Advertisement



  



  


  
  



  



  


  
  



  
      
  
  

    

	  
  

		

          

            

  
      
  
  

     Print  


  
  



  
      
  
  

     Download PDF  


  
  



  
      
  
  

    
 Email Article
  


  
  



  
      
  
  

    
 Citation Tools
  


  
  



          

        

        
        

          

            



  
      
  
  

    

  

    

  
      
  
  

    

  
  
  
  
      
When Dealing with Unruptured Aneurysms, What Do Low Morbidity and Mortality Mean?
  
    	
R.A. Pérez Falero, O.L. Piloto

  
    	
American Journal of Neuroradiology Oct 2012, 33 (9) E120; DOI: 10.3174/ajnr.A3314 

  
  
  



  


  
  



  
      
  
  

    

  
    
  
  
    
  
  
    
  


  


  
  



  
      
  
  

    
del.icio.us logo Twitter logo Facebook logo Mendeley logo
  


  
  



  



  


  
  



  
      
  
  

    
  


  
  



          

        

	
 	
	
	


  


  
  



  
      
  
  

    
              Purchase  


  
  



  
        
Jump to section

    
  
  

    
  


  
  



  
      
  
  

    

  

    
 Related Articles
  • No related articles found.
 Cited By...
  • No citing articles found.
 More in this TOC Section
 Similar Articles

  



  


  
  



			

		

	
	
 	
	
	


    

  



  

                
    

      

  

    

  
      
  
  

    


Advertisement