Challenges in identifying ruptured aneurysms in cases of multiple aneurysms: Utilizing MRI with contrast for surgical planning-A case report.

Key Clinical Message: Accurately identifying the ruptured aneurysm in patients with subarachnoid hemorrhage and multiple aneurysms is critical to prevent rebleeding and optimize outcomes. Vessel wall MRI with contrast can aid in pinpointing the culprit aneurysm, informing a tailored surgical or endovascular management strategy for these complex cases. In patients with subarachnoid hemorrhage (SAH) and multiple intracranial aneurysms, MRI with contrast and DSA are crucial for identifying the ruptured aneurysm, guiding a shift from endovascular to microsurgical clipping. Successful single-session treatment and absence of postsurgical deficits highlight the effectiveness of a multidisciplinary approach. Further research on optimal strategies is needed. Abstract: Multiple intracranial aneurysms make up approximately 20% of cases of aneurysmal SAH. In patients with aneurysmal SAH and multiple intracranial aneurysms, definite treatment of the ruptured aneurysm causing SAH is of the highest priority. However, identifying the bleeding source can be challenging, and it may not be recognizable by the hemorrhage pattern. Misdiagnosis and mistreatment of a ruptured aneurysm in a patient with multiple aneurysms can lead to bleeding recurrence and an undesirable outcome. We report a 65-year-old woman who presented with severe sudden onset headache. Neuroimaging studies revealed diffuse SAH and concurrent PICA and ACom aneurysm with triplicate A2. However, the ruptured aneurysm responsible for the patient's symptoms was not obvious based on routine neuroimaging studies. Magnetic resonance imaging with contrast was performed, revealing circumferential enhancement of the PICA aneurysm. In this report, we demonstrate the real-world effect of vessel wall MRI with contrast on decision-making regarding identifying the ruptured aneurysm and surgical planning in cases of multiple aneurysms. Furthermore, we show that MRI and aneurysm wall enhancement could be a promising option in detecting ruptured aneurysms in cases of multiple aneurysms.

Radiotherapeutic outcomes of Rosai-Dorfman disease with falx cerebri and superior sagittal sinus involvement: A rare case report with long-term follow-up.

Key Clinical Message: Intracranial RDD is rare medical event mimicking different diagnoses. Although the surgical resection is the best treatment option, but radiation therapy can also achieves long-term suboptimal outcomes. Abstract: An 83-year-old male with a history of tension-type headaches was evaluated. He was conscious with no focal neurological deficits. His brain MRI revealed an enhancable bifrontal tumor originating from falx cerebri and superior sagittal sinus dura. Due to the patient's preference and decline for gross total resection, she underwent a stereotactic biopsy. The pathology was positive for Rosai-Dorfman diseases. He received definitive targeted radiation with a total dose of 4500 cGy administered in 200 cGy daily fractions. His 4-year follow-up showed regional tumor control with excellent neurological outcome.

Endoluminal flow diversion as a primary treatment strategy for pediatric traumatic intracranial aneurysms: a case-based review of literature.

BACKGROUND: Traumatic intracranial aneurysms (TICAs) constitute a notable portion of pediatric intracranial aneurysms. Their unstable structure dictates a high incidence of rupture or mass effect from enlarging unruptured aneurysms, necessitating prompt diagnosis and treatment. TICAs often lack a true neck or are wide-necked, making them unsuitable for coil embolization and surgical clipping, and their fragile nature poses a risk of rupture during surgical and intrasaccular interventions. Endoluminal flow diverters (FD), deployed without requiring direct access to the aneurysmal sac, have emerged as an appealing sole treatment modality for TICAs. However, the clinical experience with this technique remains limited in the pediatric population. METHOD: We describe the successful treatment of a paraclinoid TICA in a 4-year-old female using an endoluminal FD alone. Additionally, we conducted a literature review to assess the safety and effectiveness of this treatment modality in pediatric TICAs. RESULTS: Endoluminal flow diversion led to complete aneurysm obliteration in our case, with no observed complication, at the 9-month follow-up. Our review of the previously reported pediatric TICAs managed by standalone flow diversion highlights this technique as safe, efficient, and promising as a sole treatment modality, particularly in the anterior circulation, with a high rate of persistent total obliteration and a low rate of complications. However, the requirement for long-term antiplatelet therapy with the possibility of frequent dose monitoring and adjustments warrants special attention when using endoluminal FDs. Until guidelines specifically addressing optimal antiplatelet therapy in children with intracranial FDs are formulated, adherence to existing protocols is imperative to avoid in-stent thrombosis. CONCLUSION: Our literature review and personal experience indicate that endoluminal flow diversion can be a viable treatment approach for pediatric TICAs. However, prospective studies with extensive follow-ups are required to assess the durability of endoluminal FDs in treating pediatric TICAs, considering the long life expectancy of this demographic.

Evaluation of Serum Interleukin-1ß (IL-1ß) Levels in Patients with Intracranial Aneurysms Compared to a Control Group.

AIM: To examine the screening value of the serum level of interleukin-1ß (IL-1ß) in aneurysmal subarachnoid hemorrhage (SAH), and to evaluate its association with the severity of initial bleeding. MATERIAL AND METHODS: This case-control study was performed in Namazi Hospital, affiliated to Shiraz University of Medical Sciences, Shiraz, Iran. The study population included patients referred to Namazi Hospital with a diagnosis of SAH, whose symptoms had emerged within less than 48 hours. The case group consisted of patients with cerebral aneurysms, who were divided into two groups of raptured and un-raptured brain aneurysms. This study examined the relationship between the serum IL-1ß levels and brain aneurysms. The number of samples was 43 per group and 86 in total. Forty-eight hours before the onset of symptoms and before surgery, a blood sample was collected to measure the IL-1Β antibody (anti-IL-1ß) level; in less than three hours, the serum was isolated and placed in a -80ºC freezer. RESULTS: In patients with unruptured aneurysms, the Fisher's grade was 0, while most ruptured aneurysms were grade 3. The middle cerebral artery (MCA) (n=10, 23%) was the most common site of aneurysm, followed by the anterior communicating artery (ACom) (n=9, 20%). There was a significant correlation between ruptured aneurysms and the Glasgow Comma Scale (GCS) score (p=0.01) and also Fisher's classification (p=0.04). Patients with ruptured and unruptured aneurysms showed no significant differences regarding the serum IL-1ß levels. A significant difference was found in the serum level of IL-1ß between the case and control groups (p=0.04). CONCLUSION: Generally, knowledge of the association between aneurysm development and inflammatory response can have significant clinical implications in the future. The present findings suggested a significant correlation between the IL-1ß levels and the outcomes of aneurysmal SAH, independent of initial hemorrhage.

Bifrontal Epidermoid Cyst.

In this paper, we will present a case of a 63-year-old female with bifrontal epidermoid tumor who has gone under bilateral craniotomy. In a case report study, a 63-year-old female with a chief complaint of progressive headache that has been admitted to Department of Neurosurgery was studied. Magnetic resonance imaging was performed for better evaluation. After detection of bifrontal epidermoid cyst, the patient underwent surgery, and following the surgery, a cut of the tumor has been excised, sent for pathology sampling and reviewed for detection of cyst. Microscopic review of the resected part reported normal brain tissue along with sections containing parts of cyst wall covered by squamous epithelium and huge amount of irregularly stratified keratin within its lumen, which clearly emphasizes on diagnosis of a typical epidermoid tumor. Bifrontal epidermoid cyst is rare, and according to our study, the clinical symptoms and patients imaging were consistent with other studies.