ARISE I Consensus Review on the Management of Intracranial Aneurysms.

BACKGROUND: Intracranial aneurysms (IAs) remain a challenging neurological diagnosis associated with significant morbidity and mortality. There is a plethora of microsurgical and endovascular techniques for the treatment of both ruptured and unruptured aneurysms. There is no definitive consensus as to the best treatment option for this cerebrovascular pathology. The Aneurysm, Arteriovenous Malformation, and Chronic Subdural Hematoma Roundtable Discussion With Industry and Stroke Experts discussed best practices and the most promising approaches to improve the management of brain aneurysms. METHODS: A group of experts from academia, industry, and federal regulators convened to discuss updated clinical trials, scientific research on preclinical system models, management options, screening and monitoring, and promising novel device technologies, aiming to improve the outcomes of patients with IA. RESULTS: Aneurysm, Arteriovenous Malformation, and Chronic Subdural Hematoma Roundtable Discussion With Industry and Stroke Experts suggested the incorporation of artificial intelligence to capture sequential aneurysm growth, identify predictors of rupture, and predict the risk of rupture to guide treatment options. The consensus strongly recommended nationwide systemic data collection of unruptured IA radiographic images for the analysis and development of machine learning algorithms for rupture risk. The consensus supported centers of excellence for preclinical multicenter trials in areas such as genetics, cellular composition, and radiogenomics. Optical coherence tomography and magnetic resonance imaging contrast-enhanced 3T vessel wall imaging are promising technologies; however, more data are needed to define their role in IA management. Ruptured aneurysms are best managed at large volume centers, which should include comprehensive patient management with expertise in microsurgery, endovascular surgery, neurology, and neurocritical care. CONCLUSIONS: Clinical and preclinical studies and scientific research on IA should engage high-volume centers and be conducted in multicenter collaborative efforts. The future of IA diagnosis and monitoring could be enhanced by the incorporation of artificial intelligence and national radiographic and biologic registries. A collaborative effort between academic centers, government regulators, and the device industry is paramount for the adequate management of IA and the advancement of the field.

Safety and efficacy of stent-assisted coil embolization with periprocedural dual antiplatelet therapy for the treatment of acutely ruptured intracranial aneurysms.

PURPOSE: Despite growing evidence for the effectiveness of stent-assisted coil embolization (SAC) in treating acutely ruptured aneurysms, the safety of stent placement in acute phase remains controversial because of concerns for stent-induced thromboembolism and hemorrhagic events attributable to the necessity of antiplatelet therapy. Therefore, we investigated the safety and efficacy of SAC with periprocedural dual antiplatelet therapy (DAPT) compared with the coiling-only technique to determine whether it is a promising treatment strategy for ruptured aneurysms. METHODS: We retrospectively evaluated 203 enrolled patients with acutely ruptured aneurysms, categorizing them into two groups: SAC and coiling-only groups. Comparative analyses between the two groups regarding angiographic results, clinical outcomes, and procedure-related complications were performed. A subgroup analysis of procedural complications was conducted on patients who did not receive chronic antithrombotic medications to alleviate their influence before hospitalization. RESULTS: 130 (64.0%) patients were treated using the coiling-only technique, whereas 73 (36.0%) underwent SAC. There was a trend to a higher complete obliteration rate (p = 0.061) and significantly lower recanalization rate (p = 0.030) at angiographic follow-up in the SAC group compared to the coiling-only group. Postprocedural cerebral infarction occurred less frequently in the SAC group (8.2%) than in the coiling-only group (17.7%), showing a significant difference (p = 0.044). Although the ventriculostomy-related hemorrhage rate was significantly higher in the SAC group than in the coiling-only group (26.2% vs. 9.3%, p = 0.031), the incidence of symptomatic ventriculostomy-related hemorrhage was comparable. Subgroup analysis excluding patients receiving chronic antithrombotic medications showed similar results. CONCLUSION: SAC with periprocedural DAPT could be a safe and effective treatment strategy for acutely ruptured aneurysms. Moreover, it might have a protective effect on postprocedural cerebral infarction without increasing the risk of symptomatic hemorrhagic complications.

Clinical Outcomes of Clipping and Coil Embolization for Ruptured Intracranial Aneurysms Categorized by Region and Hospital Size: A Nationwide Cohort Study in Korea.

BACKGROUND: To analyze the outcomes of clipping and coiling for ruptured intracranial aneurysms (RIAs) based on data from the National Health Insurance Service in South Korea, with a focus on variations according to region and hospital size. METHODS: This study analyzed the one-year mortality rates for patients with RIAs who underwent clipping or coiling in 2018. Coiling was further categorized into non-stent assisted coiling (NSAC) and stent assisted coiling (SAC). Hospitals were classified as tertiary referral general hospitals (TRGHs), general hospitals (GHs), or semi-general hospitals (sGHs) based on size. South Korea's administrative districts were divided into 15 regions for analysis. RESULTS: In 2018, there were 2,194 (33.1%) clipping procedures (TRGH, 985; GH, 827; sGH, 382) and 4,431 (66.9%) coiling procedures (TRGH, 1,642; GH, 2076; sGH, 713) performed for RIAs treatment. Among hospitals performing more than 20 treatments, the one-year mortality rates following clipping or coiling were 11.2% and 16.0%, respectively, with no significant difference observed. However, there was a significant difference in one-year mortality between NSAC and SAC (14.3% vs. 19.5%, P = 0.034), with clipping also showing significantly lower mortality compared to SAC (P = 0.019). No significant differences in other treatment modalities were observed according to hospital size, but clipping at TRGHs had significantly lower mortality than at GHs (P = 0.042). While no significant correlation was found between the number of treatments and outcomes at GHs, at TRGHs, a higher volume of clipping procedures was significantly associated with lower total mortality (P = 0.023) and mortality after clipping (P = 0.022). CONCLUSION: Using Korea NHIS data, mortality rates for RIAs showed no significant variation by hospital size due to coiling's prevalence. However, differences in clipping outcomes by hospital size and volume in TRGH highlight the need for national efforts to improve clipping skills and standardization. Additionally, the higher mortality rate with SAC emphasizes the importance of precise indications for its application.

[Interpretation of Chinese guideline for the clinical management of patients with unruptured intracranial aneurysms (2024)].

With the popularization of cerebrovascular imaging technology, the clinical detection rate of unruptured intracranial aneurysm (UIA) is increasing. UIA has a low risk of rupture, but once ruptured, it can seriously affect human health. The treatment of UIA is highly controversial and has attracted widespread clinical attention. The Society of Neurosurgery of the Chinese Medical Association, the Society of Cerebrovascular Surgery of the Chinese Stroke Association, the National Center for Neurological Diseases, and the National Center for Clinical Research on Neurological Diseases jointly formulate "Chinese guideline for the clinical management of patients with unruptured intracranial aneurysm management (2024)", which adopts a modular format, highlighting management recommendations and indicating current research deficiencies and future research directions. It provides comprehensive clinical management recommendations on UIA epidemiology, population screening, clinical imaging and diagnosis, rupture risk assessment, treatment decisions and choices, postoperative follow-up, and long-term management. The evidence sources are divided into the Chinese population and other populations, which helps guide clinical practice in China.

[Chinese guideline for the clinical management of patients with unruptured intracranial aneurysms (2024)].

Unruptured intracranial aneurysm (UIA) has an estimated prevalence of about 7% among adults aged 35-75 in China. With the aging population trend, the detection rate of UIA is increasing. Most UIA are incidentally discovered and typically asymptomatic. There has been ongoing debate regarding the choice between aggressive treatment and conservative management. Although UIA has a low annual risk of rupture, once rupture occurs, the mortality and disability rates are high. Based on evidence-based medicine, this clinical management guideline provides 44 recommendations on population screening, clinical imaging diagnosis, risk assessment of growth and rupture, treatment strategies and selection, postoperative follow-up, and management of special populations with UIA. Aiming to provide clinical guidance for clinical doenrs and relevant professionals.

[Chinese guideline for the clinical management of patients with ruptured intracranial aneurysms (2024)].

Subarachnoid hemorrhage caused by intracranial aneurysm (aneurysmal subarachnoid hemorrhage,aSAH) poses a significant threat to the health of the Chinese people. The prognosis of aSAH patients is poor, with a mortality of up to 50%, which is a public health problem in China. The clinical evaluation, surgical ctrategies, and perioperative management are important parts of clinical management for aSAH patients. This clinical management guideline consists of 112 recommendations on epidemiology, clinical imaging diagnosis, prognosis evaluation, treatment strategies and selection, anesthesia management, perioperative care, and management of special populations with aSAH, aiming to provide clinical guidance for clinical doctors and related professionals.

[Interpretation of Chinese guideline for the clinical management of patients with ruptured intracranial aneurysms (2024)].

Aneurysmal subarachnoid hemorrhage (aSAH) is a life-threatening neurological emergency with high mortality, and even patients receiving optimal medical care may develop long-term disability, which seriously affects their quality of life and increases the heavy medical burden on society and families. To provide comprehensive clinical management advice, the Society of Neurosurgery of the Chinese Medical Association, the Society of the Chinese Stroke Association of the National Medical Center for Neurological Diseases, and the National Clinical Research Center for Neurological Diseases jointly formulate "Chinese Guidelines for the Clinical Management of Patients With Ruptured Intracranial Aneurysms in 2024". The evidence sources are divided into the Chinese population and other populations, using a modular format to provide recommendations, summaries of relevant opinions, and future research directions on epidemiology, clinical imaging diagnosis, prognosis evaluation, treatment strategies and choices, anesthesia management, perioperative care, and recommendations for the management of aSAH in special populations. It provides practical clinical guidance and recommendations for doctors and related professionals.

Management of neurological complications related to aneurysmal subarachnoid hemorrhage: A comparison of the bedside therapeutic algorithms.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (aSAH) is of the most serious emergencies in neurosurgical practice and continues to be associated with high morbidity and mortality. Beyond securing the ruptured aneurysm to prevent a rebleed, physicians continue to be concerned about potential complications such as cerebral vasospasm-delayed cerebral ischemia (DCI), an area where management remains highly variable. This study aimed at reviewing the most recent literature and assessing any up-to-date schemes for treating the most common aSAH neurological complications in adults that can be applied in daily clinical practice towards optimising outcomes. METHODS: A systematic review was performed according to PRISMA guidelines on the management of aSAH neurological complications in adults. The literature surveyed was between 2016 and 2022 inclusive, using the Pubmed search engine. Comparisons between the methods suggested by existing therapeutic algorithms were discussed. RESULTS: Six stepwise algorithms assisting the decision-making for treating cerebral vasospasm-DCI were recognised and compared. No algorithm was found for the management of any other neurological complications of aSAH. Despite differences in the algorithms, induced hypertension and endovascular therapy were common treatments in all approaches. Controversy in the therapeutic process of these complications surrounds not only the variability of methods but also their optimal application towards clinical outcome optimisation. CONCLUSIONS: A universal approach to managing aSAH complications is lacking. Despite advances in the techniques to secure a ruptured aneurysm, there persist a high rate of neurological deficit and mortality, and several unanswered questions. More research is required towards stratification of current treatment algorithms as per the quality of their evidence.

Migration of lipiodol into lateral ventricles after embolization of cerebral arteriovenous malformation: a case report.

N-butyl cyanoacrylate (NBCA) has been used to embolise brain arteriovenous malformations (AVMs) for over 30 years. It is a mixed with lipiodol in varying proportions. We report a 22-year-old male with intraventricular hemorrhage from a ruptured intranidal AVM aneurysm in the left temporal lobe. The intranidal aneurysm and the nidus were successfully embolized using a 20% NBCA and lipiodol mixture without any complications according to computed tomography (CT) immediately after treatment. Scattered high-density spots were observed in both lateral ventricles on CT 5 days after embolization, suggesting migration of lipiodol. We speculated that the aneurysm was a pseudoaneurysm whose wall protruded into the inferior horn of the left lateral ventricle, and the lipiodol in the NBCA migrated into the ventricles after the thin part of the wall ruptured. The patient developed pyrexia due to chemical meningitis, which responded to steroid treatment for one month.

Fly and treat: Endovascular treatment of ruptured aneurysms at an insular tertiary center.

(Objectives) Aneurysmal subarachnoid hemorrhage (aSAH) is a life-threatening condition associated with poor outcomes. Early intervention is critical, particularly in low-volume hospitals, which are advised to transfer aSAH patients to high-volume centers. This study examines a novel protocol implemented in 2016 at Região Autónoma da Madeira, a Portuguese island. It involves the mobilization of experienced neurointerventionalists from high-volume hospitals to provide aSAH treatment. (Methods) We conducted a retrospective analysis on 30 aSAH patients who underwent endovascular treatment at the island center between November 2016 and April 2022. Additionally, we included a comparison group of 74 aSAH patients, treated with the endovascular approach at Hospital de Braga (high volume center at Portugal mainland). (Results) There was no statistical difference in patients' clinical severity between both hospitals (median WFNS score of 1). Although 90 % of patients in the novel protocol group received treatment within 3 days, we observed a significant delay compared to Hospital de Braga. Rates of aneurysm occlusion and intra-procedure complications between the two groups were similar. At the 3-months follow-up, there were no statistically significant differences between groups regarding patients that achieved a modified Rankin score of 2 or less. However, the island center exhibited a significantly higher mortality rate. (Conclusions) Overall, our results suggest that making the neurointerventionalist fly to an insular center is feasible and allows most patients to be treated within the first 72 h, as recommended. We highlight some potential recommendations for implementing this model and discuss possible causes that might justify the high mortality rate.

Role of endovascular treatment for ruptured aneurysms involving the anterior spinal artery at the craniocervical junction.

Ruptured aneurysms at the craniocervical junction (CCJ) involving the anterior spinal artery (ASA) are rare and consist of heterogenous lesions with variable clinical entities. However, the standard therapeutic strategy for the lesions has not been well-established. Moreover, despite advances in modern neurointervention, reports describing endovascular treatment for this specific lesion have been few. Here, we report three cases of ruptured aneurysms on the pial tributary of the ASA at the CCJ, which were subsequently treated by transarterial glue injection or coil embolization. Endovascular treatment can be a therapeutic option, particularly for these ruptured aneurysms. Either transarterial glue injection or coil embolization can be effective depending on the type of etiology and the surrounding vasculature anatomy.

How a decade of aneurysms embolization with the Woven EndoBridge has changed our understanding and practices?

BACKGROUND: Safety and efficacy of the WEB (Woven EndoBridge) device have been extensively evaluated in several good clinical practice studies. Nonetheless, the WEB had several structural evolutions overtime up to the fifth generation WEB device (WEB17). Here, we tried to understand how this may have modified our practices and enlarged our indications for its use. METHODS: We retrospectively analyzed data from all patients with aneurysms treated (or intended to be treated) with a WEB at our institution between July 2012 and February 2022. The time frame was split in two periods: before and after the arrival of the WEB17 in our center (February 2017). RESULTS: 252 patients with 276 wide-necked aneurysms were included; 78 aneurysms (28.2%) were ruptured. Successful embolization with a WEB device was achieved in 263/276 aneurysms (95.3%). With the availability of WEB17, treated aneurysms were significantly smaller (8.2 mm versus 5.9 mm, p<0.001) and off-label location significantly increased (4.4% versus 17.3%, p = 0.02) with an increase of sidewall aneurysm (4.4% versus 11.6%, p = 0.06). Also, WEB were more significantly oversized (1.05 versus 1.11, p<0.01). Adequate and complete occlusion rates increased constantly during the two periods (54.8% versus 67.5%, p = 0.08 and 74.2% versus 83.7%, p = 0.10, respectively). The proportion of ruptured aneurysms slightly increased between the two periods (24.6% versus 29.5%, p = 0.44). CONCLUSIONS: Over the first decade of its availability, the WEB device usage shifted towards smaller aneurysms and broader indications, including ruptured aneurysms. The oversizing strategy also became the standard of practice for WEB deployment in our institution.

Ruptured Ovarian Artery Aneurysm Complicating a Term Vaginal Delivery in the Early Puerperium Period: A Case Study.

Spontaneous rupture of a gonadal artery aneurysm is an extremely rare occurrence and can lead to a rapidly lifethreatening retroperitoneal hemorrhage. We report a case of a pregnancy-related spontaneous rupture of a right ovarian artery aneurysm in a multiparous woman. A 37-year-old woman, gravida 4, para 4, presented to an outside facility with right flank pain roughly six hours following spontaneous vaginal delivery of full-term baby with complication of advanced maternal age (AMA). Computerized tomography at our facility revealed contrast extravasation from a right ovarian artery aneurysm and retroperitoneal hematoma. Successful management was achieved via selective angiography and embolization using both micro-coils and gel-foam. Diagnostic angiography followed by transcatheter arterial embolization is an effective and minimally invasive technique for management of ovarian artery aneurysm.

[Current State of the Flow Diverter in Endovascular Treatment].

Since Pipeline Flex(Covidien/Medtronic)was approved in April 2015, flow diverter(FD)treatment has started in Japan. Three kinds of FDs(Pipeline, FRED and Surpass)are available now, and we have been able to treat a variety of aneurysms, including those that are giant-sized and located posterior circulation, which had been difficult to treat safely before the appearance of the FD. In addition, indications for FDs have been expanding with increasing evidence. However, there are some challenges that need to be overcome. First, thromboembolic complications due to high metallic amounts in FD must be considered. The long duration of antiplatelet therapy must be continued to reduce thromboembolic complications, but the precise required-duration of this therapy has not yet been determined. Second, FD treatment requires a few months before an aneurysmal cure is achieved. Therefore, there is a possibility of an aneurysmal rupture after FD deployment. In addition, there are some kinds of aneurysms for which FD treatment is less effective, such as aneurysms with a large branch vessel. In this review, I describe the details of each FD and the current state of FD, based on the evidence.

Multicenter Study for the Treatment of Sidewall versus Bifurcation Intracranial Aneurysms with Use of Woven EndoBridge (WEB).

Background The Woven EndoBridge (WEB) device was explicitly designed for wide-neck intracranial bifurcation aneurysms. Small-scale reports have evaluated the off-label use of WEB devices for the treatment of sidewall aneurysms, with promising outcomes. Purpose To compare the angiographic and clinical outcomes of the WEB device for the treatment of sidewall aneurysms compared with the treatment of bifurcation aneurysms. Materials and Methods A retrospective review of the WorldWideWEB Consortium, a synthesis of retrospective databases spanning from January 2011 to June 2021 at 22 academic institutions in North America, South America, and Europe, was performed to identify patients with intracranial aneurysms treated with the WEB device. Characteristics and outcomes were compared between bifurcation and sidewall aneurysms. Propensity score matching (PSM) was used to match by age, pretreatment ordinal modified Rankin Scale score, ruptured aneurysms, location of aneurysm, multiple aneurysms, prior treatment, neck, height, dome width, daughter sac, and incorporated branch. Results A total of 683 intracranial aneurysms were treated using the WEB device in 671 patients (median age, 61 years [IQR, 53-68 years]; male-to-female ratio, 1:2.5). Of those, 572 were bifurcation aneurysms and 111 were sidewall aneurysms. PSM was performed, resulting in 91 bifurcation and sidewall aneurysms pairs. No significant difference was observed in occlusion status at last follow-up, deployment success, or complication rates between the two groups. Conclusion No significantly different outcomes were observed following the off-label use of the Woven EndoBridge, or WEB, device for treatment of sidewall aneurysms compared with bifurcation aneurysms. The correct characterization of the sidewall aneurysm location, neck angle, and size is crucial for successful treatment and lower retreatment rate. © RSNA, 2022 See also the editorial by Hetts in this issue.

Effects of the Cerebral Aneurysm Treatment Method on Coil Packing Density and Its Relationship with the Ostium Area.

PURPOSE: To test the following hypotheses: (a) balloon or stent assistance increases coil packing density (CPD) in the endovascular treatment of intracranial aneurysms, and (b) CPD correlates to ostium area (OA) and aneurysm volume (AV). MATERIALS AND METHODS: This retrospective study included 60 aneurysms (54 ruptured and 6 unruptured) treated with simple coiling (SC) (n = 18), balloon-assisted coiling (BAC) (n = 7), or stent-assisted coiling (SAC) (n = 35) at the authors' institution between August 2017 and December 2019. AV and OA measurements were obtained from 3-dimensional digital subtraction angiography images using commercial software. Coil sizes were retrieved from patient files, and coil volume (CV) measurements were obtained from https://www.angiocalc.com/. Analysis of covariance, multivariate covariance analysis, and Pearson correlation analyses were performed. RESULTS: The median value for AV, CV, CPD, and OA was 63.4 mm3 (range, 5.5-1,771.4 mm3), 23.13 mm3 (range, 2.03-296.95 mm3), 33.29% (range, 13.41%-81.02%), and 10.7 mm2 (range, 2.7-49.9 mm2), respectively. Multivariate analysis showed that the CPD values were not significantly different among the treatment groups, although OA significantly differed between the SC and SAC groups (P < .05). Pearson correlations showed that similar to AV, OA was negatively correlated with CPD (r = -0.321, P < .05). CONCLUSIONS: The CPD value in cerebral aneurysms treated with BAC or SAC did not differ from that in aneurysms treated with SC.

Ruptured peripheral superior cerebellar artery dissecting aneurysms associated with primitive trigeminal artery: a case report.

BACKGROUND: Persistent primitive trigeminal artery (PPTA) is a remnant of the carotid-vertebrobasilar anastomoses in the embryo. Although PPTAs are discovered incidentally in most cases, altered hemodynamics may lead to increased risk of stroke. To the best of our knowledge, no reports of PPTA associated with superior cerebellar artery (SCA) dissecting aneurysms have been published in the English language. We describe the case of a patient who presented with subarachnoid hemorrhage (SAH) due to ruptured peripheral SCA dissecting aneurysms in association with PPTA. Additionally, we discuss the relationship between PPTA and peripheral SCA aneurysms and the treatment of peripheral SCA aneurysms. CASE PRESENTATION: A 43-year-old woman presented with acute onset of headache and nausea and admitted to our hospital. She was diagnosed with SAH due to ruptured left SCA dissecting aneurysm(s) and had undergone digital subtraction angiography. The left vertebral angiography showed aneurysmal dilatations of the left S2 segment (lateral pontomesencephalic segment) along with dissection through the segments of S2 and S3 (cerebellomesencephalic segment). It also showed ipsilateral PPTA. The left vertebral artery (VA) had normal caliber and the basilar artery segment proximal to the orifice of the left PPTA was not hypoplastic. The patient underwent proximal parent artery occlusion at the S2 segment via the left VA and was successfully treated with no neurological deficits having lasted 5 months. CONCLUSIONS: The flow alteration with PPTA may have influenced the formation of SCA dissection in this patient. Further studies are needed to understand the etiology and treatment outcomes of peripheral SCA aneurysms better.

Imaging Intracranial Aneurysms in the Endovascular Era: Surveillance and Posttreatment Follow-up.

While most intracranial aneurysms (IAs) remain asymptomatic over a patient's lifetime, those that rupture can cause devastating outcomes. The increased usage and quality of neuroimaging has increased detection of unruptured IAs and driven an increase in surveillance and treatment of these lesions. Standard practice is to treat incidentally discovered unruptured IAs that confer high rupture risk as well as ruptured IAs to prevent rehemorrhage. IAs are increasingly treated with coil embolization instead of microsurgical clipping; more recently, flow diversion and intrasaccular flow disruption have further expanded the versatility and utility of endovascular IA treatment. Imaging is increasingly used for posttreatment IA follow-up in the endovascular era. While cerebral angiography remains the standard for IA characterization and treatment planning, advances in CT and CT angiography and MR angiography have improved the diagnostic accuracy of noninvasive imaging for initial diagnosis and surveillance. IA features including size, dome-to-neck ratio, location, and orientation allow rupture risk stratification and determination of optimal treatment strategy and timing. The radiologist should be familiar with the imaging appearance of common IA treatment devices and the expected imaging findings following treatment. In distinction to clipping and coil embolization, flow diversion and intrasaccular flow disruption induce progressive aneurysm obliteration over months to years. Careful assessment of the device; the treated IA; adjacent brain, bone, meninges; and involved extracranial and intracranial vasculature is crucial at posttreatment follow-up imaging to confirm aneurysm obliteration and identify short-term and long-term posttreatment complications. An invited commentary by Chatterjee is available online. Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. ©RSNA, 2022.

Alien hand syndrome in ruptured aneurysms: case report and review of the literature.

Alien hand syndrome is a rare condition associated with lesions of the corpus callosum and of the supplementary motor area, which can be caused by ruptured cerebral aneurysms. We present a novel case of a patient with a subarachnoid haemorrhage from an aneurysm of the anterior communicating artery who developed alien hand syndrome and intermanual conflict. In addition, we performed a systematic literature search and evaluated data on clinical presentation, treatment and radiological findings from relevant papers. To date, 17 cases of alien hand syndrome in aneurysmatic subarachnoid haemorrhage have been reported. Aneurysms of the anterior communicating artery were the most common origin of subarachnoid haemorrhage (10/17), followed by pericallosal artery aneurysms (7/10). The prognosis appears to be favourable; however, damage to the supplementary motor area during treatment should be avoided to keep symptoms minimal.