Fusiform aneurysms of anterior cerebral artery: center experience and systematic literature review.

Fusiform aneurysms of the anterior cerebral artery (ACA) are uncommon, and the natural history of this entity is poorly characterized. Along with our center experience, we conducted a systematic literature review to help shed light on the clinical course of ACA fusiform aneurysms. We queried our institutional database to identify cases with fusiform aneurysms of ACA. In addition, following the PRISMA algorithm, we identified all reported cases published in the English literature from the inception of PubMed until December 2022. We categorized clinical presentations into three categories: (i) traumatic/iatrogenic, (ii) spontaneous symptomatic ruptured/unruptured, and (iii) spontaneous asymptomatic aneurysms. We utilized descriptive statistics. We identified seven cases from our center along with 235 patients from published literature. Blunt trauma was responsible for the development of 19 aneurysms. Sixty-three percent of these aneurysms tend to rupture within 2 weeks from the initial trauma, and despite treatment, only 74% of these patients had good clinical outcomes. Spontaneous symptomatic presentation occurred in 207 patients and was often associated with previous/concomitant ACA dissection. Subarachnoid hemorrhage from ruptured aneurysms was the most common presentation. Spontaneous symptomatic fusiform aneurysm is rapidly evolving lesions, and treatment is necessary. Three of our own cases were treated with an endovascular flow diverter (pipeline) stenting with good outcomes. Spontaneous asymptomatic aneurysms were reported in nine patients. These lesions are often associated with other vascular abnormalities. Treatment included surgical clipping with good clinical outcomes. Instead, four patients from our center database were managed conservatively with equally good outcomes. Our study demonstrates good clinical outcomes when fusiform aneurysms of ACA, especially when symptomatic, are treated promptly with either reconstructive or deconstructive therapies.

Fatal Spontaneous Subarachnoid Haemorrhage- A Report of Three Unusual Causes.

PURPOSE: To report three rare causes of fatal spontaneous subarachnoid haemorrhage (SAH) and to discuss the clinical presentations, neuroimaging findings of the patients, and a brief review of the literature on these unusual causes of SAH. CASE REPORTS: Anomalous branches of the internal carotid artery (ICA) are remarkably rare and multiple aneurysms associated with these aberrant arteries a rarer phenomenon still. A case of multiple proximal and distal aneurysms of the main trunk of an aberrant ICA branch, which resulted in a World Federation of Neurosurgical Societies (WFNS) grade V SAH, was presented. This abnormal vessel had an arterial fenestration, another rare occurrence. The second patient had a craniocervical junction (CCJ) arteriovenous fistula, which was associated with a distal aneurysm extending to the upper cervical spinal canal. The patient presented with recurrent SAH which had been misdiagnosed multiple times in the past. The third case presentation is that of a WFNS grade IV SAH, which occurred secondary to a ruptured giant fusiform aneurysm of the supraclinoid segment of the left ICA. The first two cases manifested with multiple episodes of Fisher grade IV SAH, and all cases proved fatal. CONCLUSION: It is crucial for clinicians to ensure prompt angiographic studies in patients presenting with spontaneous subarachnoid haemorrrhage, as delay in the definitive diagnosis/intervention can be lethal. In particular, a high index of suspicion for a vascular brain lesion should be entertained in cases of repetitive SAH.

BUT: Pour signaler trois causes rares d'hémorragies sousarachnoïdiennes spontanées mortelles (HSA) et discuter des présentations cliniques, les résultats de la neuro-imagerie des patients et une évaluation de la littérature concernant des causes inhabituelles de HSA. ETUDES DE CAS: Les vaisseaux anormaux de l'artère carotide interne (ACI) sont remarquablement rares et multiples anévrismes associés à ces vaisseaux aberrants est encore phénomène rare. Un cas de multiples anévrismes proximaux et distaux du tronc principal d'un navire ACI aberrant, à l'issue de WFNS grade V HSA a été présenté. Ce vaisseau anormal a eu une fenestration artérielle, qui est une autre occurrence rare. Le deuxième patient avait une charnière craniorachidienne (CCR), les fistules artério-veineuse, qui était associée à un anévrisme distal qui s'étend à la partie supérieure du col canal rachidien. Le patient avec une HSA récurrente qui avait été diagnostiquée plusieurs fois dans le passé. La troisième présentation de cas c'est celle d'un WFNS de grade IV du HSA, qui est le secondaire à un anévrisme fusiforme géant rompu du segment supra-clinoïde de l'ACI du gauche. Le les premiers deux cas se sont manifestés par de multiples épisodes d'HSA de niveau IV de Fisher, et tous les cas c'était avéré fatal. CONCLUSION: Il est cruciale que les cliniciens garantissent des examens angiographiques rapides chez les patients présentant une hémorragie sous-arachnoïdienne spontanée, car un retard dans le diagnostic définitif/l'intervention peut être mortel. En particulier, un indice élevé de suspicion d'une lésion cérébrale vasculaire doit être envisagé en cas d'HSA répétitive. MOTS CLÉS: Anomalie vaisseaux, Fistules artérioveineuse, Anévrismes fusiforme, Fenestration artérielle, Hémorragie subarachnoïde.

Treatment of an Intracranial Fusiform Vertebral Aneurysm Using the MVP® Micro Vascular Plug System as an Adjunct to Pipeline(TM) Embolization: Technical Case Instruction.

Fusiform and dolichoectatic aneurysms pose unique challenges in treatment, often requiring alternative approaches compared to saccular aneurysms. Microsurgical options like clipping or a bypass can be difficult, leading to the advancement of endovascular techniques. Flow-diverting stents and vessel sacrifice with detachable coils have shown efficacy in reconstruction. The MVP® Micro Vascular Plug System (Medtronic, Minneapolis, Minnesota, USA) offers a resheathable plug for vessel occlusion through electrolytic detachment. This case report illustrates the supplementary application of MVP® subsequent to flow diverter (FD) stenting, resulting in the effective endovascular management of a fusiform aneurysm affecting both vertebral arteries (VA), following unsuccessful coil vessel sacrifice treatment. A 61-year-old female presented with an unruptured fusiform aneurysm in the bilateral vertebral arteries (VAs). Treatment included a flow diverter in the right VA and vessel sacrifice in the left VA using Onyx-18 and coils. Despite initial success, left V4 segment recanalization occurred. Endovascular treatment, deploying two devices and additional coils using the MVP®, halted the flow. Follow-up showed left VA occlusion and reconstruction of the treated right VA, with the patient being discharged without deficits. This case demonstrates a unique approach using MVP® alongside a flow diverter (a PipelineTM Embolization Device (PED), Medtronic) for the treatment of a V4 segment fusiform aneurysm. This innovative technique is an alternative when conventional coil embolization for vessel sacrifice fails. The MVP®'s ease of use and precise delivery render it a feasible and efficacious alternative for treating complex aneurysms.

Coronary Artery Aneurysms and Acute Coronary Syndrome: An Interventionalist's Dilemma.

We report three cases of coronary artery aneurysm (CAA) in adults who presented with acute coronary syndrome. Two of these patients did not have traditional coronary artery disease risk factors. Management of CAA poses a significant challenge to interventionalists. We discuss the etiologic mechanisms, risk factors, pathophysiology, and diagnosis using angiography, intravascular ultrasound, and coronary computed tomography. We also highlight management options, including medical therapy and catheter-based interventions such as stenting, coil embolization, stent-assisted coil embolization, and surgical exclusion.

Asymptomatic Fusiform Aortic Aneurysms in a 37-Year-Old Male: A Case Report.

Abdominal aortic aneurysm (AAA) is mostly present in patients aged ≥65 years. Here, we present an unusual case of a 37-year-old male with a pair of asymptomatic, fusiform abdominal aortic aneurysms above and below the origin of the renal arteries. The patient was diagnosed with AAA in 2016 and had undergone yearly follow-ups since then. He had no major risk factors for AAA other than hypertension, which was managed with medication, and had only a brief history of smoking. He was also negative for all genetic and connective tissue defects. His aneurysms progressed slowly, with proximal and distal aneurysms currently measuring 3.9 cm and 4.5 cm, respectively. The patient was asymptomatic and was closely examined for further management.

Super-giant fusiform basilar artery aneurysm.

Intracranial aneurysms are focal pathological dilatation of the arteries with a prevalence of 3.2%. Fusiform aneurysms are rare and mainly due to dissection or atherosclerosis. They may manifestas as stroke, cranial nerve palsies, brainstem compression and Sub-arachnoid hemorrhage. A diameter greater than 10 mm is a risk factor for rupture and warrants early intervention.

Stent-alone treatment of unruptured vertebral artery fusiform aneurysms: A comparison of flow diverter and conventional stents.

Background: Treatment of vertebral artery fusiform aneurysms (VAFAs) is complex and controversial. This study aimed to compare the safety and efficacy between flow diverter and conventional stents in patients with VAFAs undergoing endovascular stent-alone treatment (SAT). Methods: Thirty-six patients with 36 VAFAs who underwent SAT between January 2014 and December 2018 were retrospectively analyzed. Patient and aneurysm characteristics, procedural details, complications, and angiographic and clinical outcomes were compared between flow diverter stent patients (n = 22) and conventional stent patients (n = 14). Results: More branches covered with stent were found in the conventional stent group (88.9 vs. 33.3%; p = 0.008). The number of stents placed was significantly higher in the conventional stent group (1.57 ± 0.76 vs. 1.09 ± 0.29; p = 0.016). The proportion of patients with significant or moderate stasis within the aneurysm immediately after stent placement was higher in the flow diverter stent group (95.5 vs. 57.1%; p = 0.004). The proportion of patients with complete obliteration or only a residual neck on follow-up angiography was significantly higher in the flow diverter stent group (86.3 vs 50.0%; p = 0.047). However, the incidence of parent artery stenosis or occlusion was also higher in the flow diverter stent group (27.3% vs. zero; p = 0.032). The rate of complications did not significantly differ between the groups. Conclusions: SAT was safe and effective in patients with VAFAs. Flow diverter stents are associated with a significantly better complete occlusion rate than conventional stents; however, they are also associated with an increased risk of parent artery stenosis.

Repeated Retching and Vomiting in the Pathophysiology of Isolated Spinal Aneurysms.

BACKGROUND: Rupture of spinal aneurysms is a rare cause of subarachnoid hemorrhage. These aneurysms are often associated with a variety of vascular malformations that increase blood flow in the spinal circulation or with disorders that compromise the vessel wall. However, spinal aneurysms may be isolated, not associated with any known predisposing condition. The objective of this study is to explore the possible mechanisms associated with the formation and rupture of isolated spinal aneurysms (ISAs). METHODS: We conducted a retrospective review of a series of consecutive patients admitted for a ruptured ISA. In all cases, spinal angiography confirmed the presence of a spinal aneurysm responsible for the bleeding. Particular attention was paid to medical history and symptoms before bleeding, for potential factors predisposing to their formation and rupture. RESULTS: Between 2008 and 2020, ten cases of spinal aneurysms were seen at our institution including 4 cases of ISA. All patients with ISA were female, and in 3 cases the aneurysm involved the territory of the posterior spinal artery. In 3 of these 4 (75%) ISA cases, there was a strikingly similar history of retching and vomiting preceding the thunderclap headache. In 1 patient, the aneurysm was surgically resected; pathologic analysis revealed a fusiform dissecting aneurysm. All 4 patients had a favorable outcome. CONCLUSIONS: We suggest that the straining during prolonged retching and vomiting plays a role in the formation and rupture of some ISAs, possibly because of pressure spikes, increased transmural arterial pressure, and increased wall shear stress during straining.

Giant Fusiform and Dolichoectatic Aneurysms of the Basilar Trunk and Vertebrobasilar Junction-Clinicopathological and Surgical Outcome.

BACKGROUND: Giant fusiform and dolichoectatic aneurysms of the basilar trunk and vertebrobasilar junction (BTVBJ-GFDA) are extremely difficult to treat. OBJECTIVE: To evaluate factors influencing survival and outcome of BTVBJ-GFDA by performing a retrospective multicenter cohort study. METHODS: A total of 32 patients with BTVBJ-GFDA were included in this study. Clinicopathological characteristics, treatment measures, and outcomes were collected from medical records and imaging studies. Autopsy and histological findings of the aneurysm and adjacent brain tissue were also obtained in 9 cases. RESULTS: A total of 11 patients did not undergo surgery, of whom 10 died; 3 from progressive brainstem compression, 4 from subarachnoid hemorrhage, 2 from brainstem infarction, and 1 from associated atherosclerotic disease. The remaining 21 patients underwent a surgical treatment, consisting of immediately proximal parent artery occlusion, remotely proximal parent artery occlusion, clip reconstruction, and distal bypass and achieved significantly longer overall survival compared with those who received conservative therapy (adjusted hazard ratio 1.508, 95% CI 1.058-2.148, P = .02). Histological examination of the aneurysms demonstrated staged clots, open lumen, and intrathrombotic channels with endothelial lining. The patients younger than 45 yr of age showed statistically longer survival than those equal and older than 45 yr (P = .03). CONCLUSION: Surgical intervention achieved greater survival than conservative management in BTVBJ-GFDA. Narrow ideal treatment window of the blood flow within the aneurysm to maintain sufficient but not excess supply should be targeted based on the hemodynamics of both the posterior communicating arteries and perforating vessel collaterals.

Flow Diversion and Outcomes of Vertebral Fusiform Aneurysms After Stent-Only Treatment: A Hemodynamic Study.

BACKGROUND: The aim of this study was to determine the effectiveness of treating vertebral fusiform aneurysms (VFAs) only with stents. Using computational fluid dynamics, we evaluated the hemodynamic patterns of VFAs after stent-only treatment (SOT) and monitored hemodynamic changes in the side branches. METHODS: Between September 2014 and December 2015, we enrolled 10 consecutive patients with VFAs who underwent SOT. Successful aneurysm reconstruction is defined as perfect reconstruction of the parent artery and complete or nearly complete occlusion of the aneurysm. Otherwise, the reconstruction was considered unsuccessful. After SOT, we used computational fluid dynamics to assess hemodynamic changes in aneurysmal velocity, wall shear stress, and relative residual time (RRT) as well as velocity in side branches. RESULTS: Ten patients were studied. At follow-up after initial treatment, 7 of the 10 reconstructions were successful. Compared with the 3 unsuccessful reconstructions, successful reconstructions showed a significantly greater increase in the mean RRT (1185.1% vs. 204.8%; P = 0.030) and a greater reduction in mean velocity (44.5% vs. 34.7%; P = 0.053) and wall shear stress (49.2% vs. 27.9%; P = 0.087). The average velocity in the branches decreased by 10.0% after SOT. There was also a significant difference between the mean reduction in the rate of flow velocity in the aneurysm and the side branches (42.1% vs. 10.0%; P < 0.001). CONCLUSIONS: We found a significant increase in RRT of successful reconstruction of aneurysms. There may be less effect on the flow in branches arising from VFAs after SOT, whether the aneurysms showed complete occlusion or not.

Fusiform superior cerebellar artery aneurysm treated with STA-SCA bypass and trapping.

BACKGROUND: Fusiform aneurysms of cerebellar arteries are rare. Different surgical techniques to address these challenging lesions have been described, and their application depends on whether the goal is to maintain the flow in the parent vessel or to occlude it. CASE DESCRIPTION: The authors reported a case of a fusiform aneurysm located in the lateral pontomesencephalic segment of the superior cerebellar artery (SCA) in a 32-year-old man who presented with subarachnoid hemorrhage. The patient was subjected to aneurysm trapping followed by a bypass between the superficial temporal artery (STA) and SCA and had an uneventful recovery. CONCLUSIONS: Although only a few cases of fusiform aneurysms in the supracerebellar artery have been reported in the literature, the treatment strategies adopted were diverse. In selected cases of patients in good neurological condition with ruptured fusiform aneurysms at the proximal segments of SCA and who have poor evidence of collateral supply, the possibility of a STA-SCA bypass with aneurysm trapping must be considered. A review of the current treatment modalities of this pathology is also presented.