Effective and organ doses in patient undergoing interventional neuroradiology procedures: A multicentre study.

PURPOSE: Radiation doses to adult patients submitted to cerebral angiography and intracranial aneurysms treatments were assessed by using DICOM Radiation Dose Structured Reports (RDSR) and Monte Carlo simulations. Conversion factors to estimate effective and organ doses from Kerma-Area Product (PKA) values were determined. METHODS: 77 cerebral procedures performed with five angiographic equipment installed in three Italian centres were analyzed. Local settings and acquisition protocols were considered. The geometrical, technical and dosimetric data of 16,244 irradiation events (13305 fluoroscopy, 2811 digital subtraction angiography, 128 cone-beam CT) were extracted from RDSRs by local dose monitoring systems and were input in MonteCarlo PCXMC software to calculate effective and organ doses. Finally, conversion factors to determine effective and organ doses from PKA were determined. Differences between centres were assessed through statistical analysis and accuracy of dose calculation method based on conversion factors was assessed through Bland-Altman analysis. RESULTS: Large variations in PKA (14-561 Gycm2) and effective dose (1.2-73.5 mSv) were observed due to different degrees of complexity in the procedures and angiographic system technology. The most exposed organs were brain, salivary glands, oral mucosa, thyroid and skeleton. The study highlights the importance of recent technology in reducing patient exposure (about fourfold, even more in DSA). No statistically significant difference was observed in conversion factors between centres, except for some organs. A conversion factor of 0.09 ± 0.02 mSv/Gycm2 was obtained for effective dose. CONCLUSIONS: Organ and effective doses were assessed for neuro-interventional procedures. Conversion factors for calculating effective and organ doses from PKA were provided.

MR Imaging of the Cerebral Aneurysmal Wall for Assessment of Rupture Risk.

The evaluation of unruptured intracranial aneurysms requires a comprehensive and multifaceted approach. The comprehensive analysis of aneurysm wall enhancement through high-resolution MRI, in tandem with advanced processing techniques like finite element analysis, quantitative susceptibility mapping, and computational fluid dynamics, has begun to unveil insights into the intricate biology of aneurysms. This enhanced understanding of the etiology, progression, and eventual rupture of aneurysms holds the potential to be used as a tool to triage patients to intervention versus observation. Emerging tools such as radiomics and machine learning are poised to contribute significantly to this evolving landscape of diagnostic refinement.

Prototype of Low-Cost Microvascular Clips for Laboratory Use.

BACKGROUND: Vascular neurosurgical procedures require temporary or permanent surgical clips to treat cerebral aneurysms, arteriovenous malformations, or bypass surgery. In this scenario, surgical clips should have specific characteristics such as high-quality material, proper design, closing force, and biocompatibility. Due to these characteristics, the price of these clips does not allow their availability at the experimental surgery laboratory worldwide. METHODS: We describe here the technique for manufacturing handcrafted clips of low cost, using dental stainless steel or titanium wire of 0.18 mm, 0.20 mm, or 0.22 mm in diameter. We must complete six steps to obtain the clip using our hands and small electrician needle nose pliers for wire molding. RESULTS: These clips have a closing force of 30-60 gr/cm2 (depending on the wire diameter). They can be used in the experimental surgery laboratory to clip arteries or veins during vascular microsurgery procedures. Also, they can be used as temporary clips with confidence in low-flow bypass (v.gr. superficial temporal artery to middle cerebral artery or occipital artery to posterior inferior cerebellar artery anastomoses). CONCLUSIONS: Making practical low-cost clips for use in laboratory procedures or during low-flow anastomosis as temporary clips is possible. The main advantages are the low cost and the worldwide availability of the basic materials. The main disadvantage is the learning curve to get the ability to master the manufacturing of these clips.

Exploring the Landscape of Intracranial Aneurysms in South America: A Comprehensive Narrative Review Intracranial Aneurysms in South America.

Exploring the landscape of intracranial aneurysms in South America unravels a complex interplay of epidemiological factors, clinical manifestations, and therapeutic challenges. The study methodically conducts a comprehensive literature review spanning the years 2003 to 2023, focusing on English-language articles obtained from diverse databases to elucidate the multifaceted nature of intracranial aneurysms in the region. Results and discussions categorize outcomes into positive domains, emphasizing successful treatments, favorable recoveries, and high survival rates, while also shedding light on negative aspects such as residual aneurysms and complications. The research illuminates significant gaps in pathological typing of intracranial aneurysms and exposes challenges in healthcare accessibility, notably the disparities in neurosurgical resources. Management challenges, including constrained infrastructure access, a neurosurgeon shortage, and gender disparities, are underscored. Transitioning to future prospects, the study advocates for strategic interventions, proposing expanded neurosurgical training, multidisciplinary approaches, improved funding, enhanced access to care, and fostering international collaborations. The study concludes by emphasizing the pivotal role of collaborative efforts, intensified training programs, and global partnerships in propelling intracranial aneurysm management forward in South America, ultimately contributing to enhanced patient outcomes across the region.

Virtual diluted cone beam CT for device apposition assessment during endovascular treatment of intracranial aneurysm: A technical note.

The increasing use of embolization devices with suboptimal radio-opacity to treat intracranial aneurysm underscores the need for advanced imaging techniques to characterize device-vessel interactions more accurately. Contrast-diluted cone-beam CT is commonly used in neurointervention but requires additional technical refinements to improve endovascular treatment assessment. In this technical note, we describe the virtual dilution cone beam CT (VDCBCT), a technique that synthetizes non-contrast and contrast-enhanced CBCT images to virtually dilute iodinated contrast agents, thereby facilitating a more accurate assessment of embolization device apposition. Through a set of intracranial aneurysms treated with different embolization devices, we describe the VDCBCT protocol and its usefulness for device apposition confidence. VDCBCT may enhance the global understanding of neurovascular embolization treatments by providing improved visualization of target vessels and low-radio-opacity embolization devices, obviating the need for contrast dilution.

Thromboembolic Events With the Woven Endobridge Device: Incidence, Predictive Factors, and Management.

BACKGROUND AND OBJECTIVES: The Woven EndoBridge (WEB) device has been increasingly used to treat wide-neck aneurysms showing a safe and effective profile, but a relatively high number of thromboembolic events (TEEs) have been reported with such treatment. We aimed to evaluate the incidence and management of TEEs and possible predictive factors related to WEB embolization of ruptured and unruptured intracranial aneurysms. METHODS: A single-center database with consecutive aneurysms treated with a WEB device between July 2012 and May 2022 was reviewed for intraoperative and delayed TEEs. Univariate and multivariable analyses were used to determine factors associated with TEEs. RESULTS: A total of 266 independent aneurysms were treated with WEB devices in 245 patients (mean age 55.78 ± 11.64 years, 169 (63.5%) females, 80 (30%) ruptured). The overall rate of TEEs is 13% (35/266), including 8.7% intraoperative. Symptomatic TEEs with clinical sequelae at a 3-month follow-up are reported to be 2.6% (7/266) with no TEE-related mortality. Both the replacement of a WEB device during the procedure (adjusted odds ratio = 2.61, 95% CI 1.24-5.49; P = .01) and ruptured aneurysms (adjusted odds ratio = 2.74, 95% CI 1.31-5.7; P = .007) were independent predictors of TEEs. A case-by-case management of intraprocedural TEE is also presented; tirofiban was successfully used in most cases of this cohort. CONCLUSION: In this study, we demonstrated that ruptured aneurysms and WEB device replacement during the procedure were independent predictive factors for TEEs. As a result, making the correct choice of WEB is crucial for improving treatment outcomes. Moreover, with proper medical management of TEEs, minimal morbidity and no mortality could be achieved, which reinforces the safety of the technique.

Pipeline embolization device versus Atlas stent assisted coiling for intracranial aneurysm treatment: a retrospective, propensity score matched study with a focus on midterm outcomes and hospital costs.

BACKGROUND: Stent assisted coiling (SAC) and flow diverters (FDs) are common endovascular treatments for wide necked cerebral aneurysms, but studies comparing the new generation Atlas SAC and FDs are scarce. We performed a propensity score matched (PSM) cohort study to compare the Atlas SAC and the pipeline embolization device (PED) for proximal internal carotid artery (ICA) aneurysms. METHODS: Consecutive ICA aneurysms treated at our institution with either the Atlas SAC or PED were studied. PSM was used to control for age, sex, smoking, hypertension, and hyperlipidemia, and the rupture status, maximal diameter, and neck size of the aneurysm (aneurysms >15 mm and non-saccular aneurysms were excluded). Midterm outcomes and hospital costs were compared between these two devices. RESULTS: A total of 309 patients with 316 ICA aneurysms were included. Following PSM, 178 aneurysms treated with the Atlas SAC and PED were matched (n=89 in each group). Aneurysms treated with the Atlas SAC required a slightly longer procedure time, but had lower hospital costs than those treated with the PED (115.2±24.6 vs 102.4±40.8 min, P=0.012; $27 650.2±$6961.4 vs $34 107.0±$3707.2, P<0.001). Atlas SAC and PED treatments showed equivalent aneurysm occlusion rates (89.9% vs 86.5%, P=0.486), complication rates (5.6% vs 11.2%, P=0.177), and a favorable functional outcome (96.6% vs 97.8%, P=1.0) at follow-up (8.2±3.0 vs 8.4±4.2 months, P=0.652). CONCLUSION: In this PSM study, midterm outcomes of the PED and Atlas SAC in the treatment of ICA aneurysms were similar. However, SAC required a longer operation time, and the PED may increase the economic cost of inpatients in Beijing, China.

Predicting the formation of mixed pattern hemorrhages in ruptured middle cerebral artery aneurysms based on a decision tree model: A multicenter study.

OBJECTIVE: Mixed-pattern hemorrhages (MPH) commonly occur in ruptured middle cerebral artery (MCA) aneurysms and are associated with poor clinical outcomes. This study aimed to predict the formation of MPH in a multicenter database of MCA aneurysms using a decision tree model. METHODS: We retrospectively reviewed patients with ruptured MCA aneurysms between January 2009 and June 2020. The MPH was defined as subarachnoid hemorrhages with intracranial hematomas and/or intraventricular hemorrhages and/or subdural hematomas. Univariate and multivariate logistic regression analyses were used to explore the prediction factors of the formation of MPH. Based on these prediction factors, a decision tree model was developed to predict the formation of MPH. Additional independent datasets were used for external validation. RESULTS: We enrolled 436 patients with ruptured MCA aneurysms detected by computed tomography angiography; 285 patients had MPH (65.4%). A multivariate logistic regression analysis showed that age, aneurysm size, multiple aneurysms, and the presence of a daughter dome were the independent prediction factors of the formation of MPH. The areas under receiver operating characteristic curves of the decision tree model in the training, internal, and external validation cohorts were 0.951, 0.927, and 0.901, respectively. CONCLUSION: Age, aneurysm size, the presence of a daughter dome, and multiple aneurysms were the independent prediction factors of the formation of MPH. The decision tree model is a useful visual triage tool to predict the formation of MPH that could facilitate the management of unruptured aneurysms in routine clinical work.

Subdural Hygroma After Management of Ruptured Intracranial Aneurysms: Incidence, Associated Factors, Clinical Course, and Management Options.

OBJECTIVE: To evaluate the incidence, associated factors, clinical course, and management options of subdural hygroma in patients treated for aneurysmal subarachnoid hemorrhage (aSAH). METHODS: From January 2013 until June 2022, 336 consecutive patients with aSAH underwent treatment in our center. No one patient was excluded from the study cohort. Computed tomography (CT) examinations were performed at admission, immediately after surgery and on the first postoperative day, and subsequently in case of any neurologic deterioration or, at least, once per week until discharge from the hospital. Thereafter, CT examinations were at the discretion of specialists in the rehabilitation facility, referring physicians, or neurosurgeons at the outpatient clinic. RESULTS: The length of radiologic follow-up starting from CT at admission ranged from 1 to 3286 days (mean, 673 ± 895 days; median, 150 days). Subdural hygromas developed in 84 patients (25%). An average interval until this imaging finding from the initial CT examination was 25 ± 55 days (median, 8 days; range, 0-362 days). Evaluation in the multivariate model showed that patient age ≥72 years (P < 0.0001), cerebrospinal fluid (CSF) shunting (P < 0.0001), and microsurgical clipping of ruptured intracranial aneurysm (RIA; P < 0.0001) are independently associated with the development of subdural hygroma. In 54 of 84 cases (64%), subdural hygromas required observation only. Increase of the lesion size with (5 cases) or without (10 cases) appearance of midline shift was associated with patient age <72 years (P = 0.0398), decompressive craniotomy (P = 0.0192), and CSF shunting (P = 0.0009), whereas evaluation of these factors in the multivariate model confirmed independent association of only CSF shunting (P = 0.0003). Active management of subdural hygromas included adjustment of the shunt programmable valve opening pressure, cranioplasty, external subdural drainage, or their combination. Overall, during follow-up (mean, 531 ± 824 days; median, 119 days; range, 2-3285 days) after the start of observation or applied treatment, subdural hygromas showed either decrease (50 cases) or stabilization (34 cases) of their sizes, and no one lesion showed progression again. CONCLUSIONS: The clinical course of subdural hygromas in patients treated for aSAH is generally favorable, but occasionally these lesions show progressive enlargement with or without the appearance of midline shift, which requires active management.

Intraluminal assessment of inflammatory factors in patients with intracranial aneurysms.

BACKGROUND: The formation, growth, and rupture of intracranial aneurysms (IA) are due to several pathophysiological mechanisms, including focal hemodynamic injury and inflammation of the arterial wall. We investigated the differences between venous, parent artery, and intra-aneurysmal blood by measuring inflammatory factors and antibodies in patients with ruptured (rIA) or unruptured intracranial aneurysms (uIA). METHOD: A prospective study was performed in patients who presented with IA and required endovascular treatment. Blood was drawn from the lumen of the aneurysm sac, the parent artery, and the peripheral veins, to determine the serum concentrations of complement factors C3, C4, IgG, IgM, IgA antibodies, and C-reactive protein (CRP). RESULTS: Thirty-six patients (15 with uIA and 21 with rIA) were enrolled in the study. In both groups, C3, C4, IgM, IgG, and IgA showed a gradual decrease from venous to intra-aneurysmal samples, but only IgG in the parent artery and intra-aneurysmal samples reached a significant decrease in uIA compared with venous samples. Accordingly, C3 and IgG concentrations in the intra-aneurysmal samples showed a significant decrease in rIA compared with venous samples. A significant increase in CRP concentrations was observed in parent artery and intra-aneurysmal samples from patients with rIA compared with patients with uIA; a significant increase in C3 concentrations was observed in parent artery samples from patients with rIA compared with patients with uIA, and a significant decrease in IgM concentrations was observed in venous, parent artery, and intra-aneurysmal samples from patients with rIA compared with patients with uIA. CONCLUSIONS: A decrease in C3 and IgG in the aneurysm sac indicates activation of the complement system in the arterial wall. CRP in the aneurysm sac and lumen of the parent artery was significantly increased in ruptured compared with unruptured aneurysms, whereas venous, parent artery, and intra-aneurysmal IgM were decreased in ruptured compared with unruptured aneurysms. These results argue for the role of an ongoing inflammatory process in aneurysms leading to their growth and rupture.

Assessment of magnetic field interactions and heating for cerebral aneurysm flow diverters during 7T MRI.

Flow diverters (FDs) are utilized for a wide range of aneurysms, but show safety issues such as adverse interactions with static magnetic fields (displacement force and torque) and radiofrequency-induced heating during magnetic resonance imaging (MRI). The present study aimed to assess these adverse interactions in a 7-tesla (7T) static magnetic field and radiofrequency-induced heating during a 7T MRI for two types of FD. Displacement force and magnetically induced torque were assessed using the deflection angle method and low friction surface method, respectively. To assess heating, each FD was set in a phantom filled with gelled-saline mixed with polyacrylic acid and underwent a 7T MRI using a three-dimensional fast spin echo method. Displacement force and magnetically induced torque in the 7T static magnetic field were undetectable, and radiofrequency-induced heating during 7T MRI remained ≤ 0.6 °C for both types of FD, suggesting that magnetic field interactions and heating on FDs during a 7T MRI are acceptable from a safety perspective.

SAD score of intracranial aneurysms for rupture risk assessment based on high-resolution vessel wall imaging.

OBJECTIVE: We aimed to develop a comprehensive model that integrates the radiological, morphological, and clinical factors to assess rupture risk for intracranial aneurysms. METHODS: We prospectively enrolled patients with intracranial saccular aneurysms who underwent high-resolution vessel wall imaging (HR-VWI) preoperatively. Clinical characteristics, aneurysm features and aneurysm wall enhancement scale (AWES) were recorded. AWES was categorized into three grades (no/faint/strong enhancement) by comparing AWE to enhancement of the pituitary infundibulum or choroid plexus on HR-VWI. Univariate and multivariate logistic regression analyses were performed to determine risk factors associated with aneurysmal rupture. RESULTS: A total of 25 ruptured and 116 unruptured aneurysms were included. Multivariate logistic regression analysis revealed that non-ICA site (OR 6.25, 95% CI 1.35-28.30, P = 0.019), AWES (OR 5.99, 95% CI 2.51-14.29, P < 0.001) and daughter sac or lobulated shape (OR 6.22, 95% CI 1.68-23.16, P = 0.006) were independent factors associated with ruptured aneurysms. The "SAD" model was generated and named after the first letters of each of these factors. SAD scores of 0-4 predicted 0, 2%, 12%, 42% and 100% ruptured aneurysms, respectively. The area under the receiver operating characteristic curve for the SAD model was 0.8822. CONCLUSION: The SAD model aids in distinguishing aneurysm rupture status and in managing unruptured aneurysms. Larger cohort studies are needed to confirm its applicability in predicting the rupture risk of unruptured aneurysms.

Ultra-High-Resolution Time-of-Flight MR-Angiography for the Noninvasive Assessment of Intracranial Aneurysms, Alternative to Preinterventional DSA?

PURPOSE: The 3D time-of-flight (TOF) magnetic resonance angiography (MRA) at 3T shows high sensitivity for intracranial aneurysms but is inferior to three-dimensional digital subtraction angiography (3D-DSA) regarding aneurysm characteristics. We applied an ultra-high-resolution (UHR) TOF-MRA using compressed sensing reconstruction to investigate the diagnostic performance in preinterventional evaluation of intracranial aneurysms compared to conventional TOF-MRA and 3D-DSA. METHODS: In this study 17 patients with unruptured intracranial aneurysms were included. Aneurysm dimensions, configuration, image quality and sizing of endovascular devices were compared between conventional TOF-MRA at 3T and UHR-TOF with 3D-DSA as gold standard. Quantitatively, contrast-to-noise ratios (CNR) were compared between TOF-MRAs. RESULTS: On 3D-DSA, 25 aneurysms in 17 patients were detected. On conventional TOF, 23 aneurysms were detected (sensitivity: 92.6%). On UHR-TOF, 25 aneurysms were detected (sensitivity: 100%). Image quality was not significantly different between TOF and UHR-TOF (p = 0.17). Aneurysm dimension measurements were significantly different between conventional TOF (3.89 mm) and 3D-DSA (4.2 mm, p = 0.08) but not between UHR-TOF (4.12 mm) and 3D-DSA (p = 0.19). Irregularities and small vessels at the aneurysm neck were more frequently correctly depicted on UHR-TOF compared to conventional TOF. Comparison of the planned framing coil diameter and flow-diverter (FD) diameter revealed neither a statistically significant difference between TOF and 3D-DSA (coil p = 0.19, FD p = 0.45) nor between UHR-TOF and 3D-DSA (coil: p = 0.53, FD 0.33). The CNR was significantly higher in conventional TOF (p = 0.009). CONCLUSION: In this pilot study, ultra-high-resolution TOF-MRA visualized all aneurysms and accurately depicted aneurysm irregularities and vessels at the base of the aneurysm comparably to DSA, outperforming conventional TOF. UHR-TOF with compressed sensing reconstruction seems to represent a non-invasive alternative to pre-interventional DSA for intracranial aneurysms.

Cost-effectiveness of WEB Embolization, Coiling and Stent-assisted Coiling for the Treatment of Unruptured Intracranial Aneurysms.

PURPOSE: Information about the cost-effectiveness of a certain treatment is relevant for decision-making and healthcare providers. This study compares the cost-effectiveness of the novel Woven Endobridge (WEB) for intracranial aneurysm treatment with conventional coiling and stent-assisted coiling (SAC) from the perspective of the German Statutory Health Insurance. METHODS: A patient-level simulation was constructed to simulate 55-year-old patients with an unruptured middle cerebral artery aneurysm (size: 3-11 mm) considering WEB treatment, coiling or SAC in terms of morbidity, angiographic outcome, retreatment, procedural and rehabilitation costs and rupture rates. Incremental cost-effectiveness ratios (ICERs) were calculated as costs per quality-adjusted life years (QALYs) and costs per year with neurologic morbidity avoided. Uncertainty was explored with deterministic and probabilistic sensitivity analyses. The majority of data were obtained from prospective multi-center studies and meta-analyses of non-randomized studies. RESULTS: In the base case, lifetime QALYs were 13.24 for the WEB, 12.92 for SAC and 12.68 for coiling. Lifetime costs were 20,440 € for the WEB, 23,167 € for SAC, and 8200 € for coiling. Compared to coiling, the ICER for the WEB was 21,826 €/QALY, while SAC was absolutely dominated by WEB. Probabilistic sensitivity analysis revealed that at a willingness-to-pay of ≥ 30,000 €/QALY, WEB was the preferred treatment. Deterministic sampling showed that the discount rate, material costs and retreatment rates had the largest impact on the ICERs. CONCLUSION: The novel WEB showed at least comparable cost-effectiveness to SAC for treatment of broad-based unruptured aneurysms. Considering all three modalities, coiling had the least costs; however this modality is often not appropriate for the treatment of wide-necked aneurysms.

Assessment of morphometric parameters of middle cerebral artery using CT angiography in a tertiary care hospital.

PURPOSE: Middle cerebral artery (MCA) favors secondaries and emboli deposition. Also, with an increase in incidence of MCA aneurysms, majorly at the M1 division point, actual standardized measurement of MCA is necessary. Thus, main aim of the study is assessment of the MCA morphometry using CT Angiography in Indian population. METHODS: CT cerebral Angiography datasets of 289 patients (180 males and 109 females) were assessed for the MCA morphometry (Average age - 49.29 ± 16.16 years, Range- 11 to 85 years). The cases involving aneurysms and infarcts were excluded. The total length of MCA, length of M1 segment and diameter were measured and the results were statistically analysed. RESULTS: The mean total length of MCA, length of M1 segment and diameter were 24.02 ± 1.22 mm, 14.32 ± 1.27 mm, 3.33 ± 0.62 mm, respectively. The mean length of M1 segment on the right and left sides was 14.19 ± 1.39 mm and 14.44 ± 1.12 mm, respectively and the difference was statistically significant (p ≤ 0.05). The mean diameter on the right and left sides was 3.32 ± 0.62 mm and 3.33 ± 0.62 mm, respectively and the difference was not statistically significant (p = 0.832). The M1 segment length was maximum in patients over 60 years and diameter was maximum in young patients (20-40 years). The mean length of M1 segment in early bifurcation (4.4 ± 0.65 mm), bifurcation (14.32 ± 1.27 mm) and trifurcation (14.15 ± 1.43 mm) was also noted. CONCLUSION: The MCA measurements will be useful for surgeons to minimize errors in handling cases of intracranial aneurysms or infarcts and provide the best possible outcome to the patients.

[Brain aneurysms treatment with pCONus2 device. Initial experience at IMSS]. / Aneurismas cerebrales tratados con dispositivo pCONus2. Experiencia inicial en el IMSS.

Background: pCONus2 device has been used in some countries as coadyuvant in the treatment of wide-neck bifurcation aneurysms with coils. Objective: To present the first series of brain aneurysms treated with pCONus2 in the Mexican Institute for Social Security (IMSS). Material and methods: We retrospectively present the first 13 aneurysms treated from October 2019 to February 2022 with pCONus2 device at a third level hospital. Results: 6 aneurysms located at anterior communicating artery, 3 at middle cerebral artery bifurcation, 2 at internal carotid artery bifurcatión, and 2 at the tip of basilar artery were treated. Device deployment was performed without complications and it was possible to embolize aneurysms with coils in 12 patients (92%), while on an internal carotid bifurcation aneurysm (8%) there was an incident of a pCONus2 petal migration toward vascular lumen caused by coils mesh pressure, situation that was solved by placing an nitinol self-expandable microstent. In 7 cases (54%) we performed coiling technique after microcatheter passage through pCONus2, while in 6 cases (46%) we used the jailing technique without complications. Conclusions: pCONus2 is a useful device for wide-neck bifurcation aneurysms embolization. In Mexico our experience is yet limited; however, the first cases have been successful. Furthermore, we showed the first cases treated using jailing technique. Much more cases are required in order to carry out a statistically conclusive analysis and to establish the effectiveness and safety of the device.

Introducción: el dispositivo pCONus2 ha sido usado en algunos países como coadyuvante en el tratamiento con coils de los aneurismas de cuello ancho localizados en las bifurcaciones. Objetivo: presentar los primeros aneurismas tratados con pCONus2 en el Instituto Mexicano del Seguro Social (IMSS). Material y métodos: se exponen retrospectivamente 13 casos de pacientes tratados con pCONus2 de octubre de 2019 a febrero de 2022 en un hospital de tercer nivel del IMSS. Resultados: se trataron 6 aneurismas de la arteria comunicante anterior, 2 de la bifurcación de la arteria carótida interna, 3 en la bifurcación de la arteria cerebral media y 2 del tope de la arteria basilar. El uso del pCONus2 se hizo sin complicaciones ni incidentes en 12 pacientes (92%), mientras que en un aneurisma de la bifurcación de carótida interna (8%) ocurrió la migración de un pétalo del dispositivo hacia la luz vascular, motivado por la presión de la malla de coils, que se solucionó con un microstent. Siete aneurismas (54%) fueron embolizados con coils después del paso del microcatéter a través del pCONus2, mientras que en 6 (46%) se utilizó la técnica jailing, sin complicaciones ni incidentes. Conclusiones: el pCONus2 es un dispositivo útil en la embolización de aneurismas localizados en bifurcaciones arteriales. En México la experiencia todavía es poca, pero los primeros casos han sido exitosos. Mostramos, además, los primeros casos tratados con la técnica de jailing. Se requieren más casos en nuestro país para hacer un análisis estadísticamente concluyente y determinar la efectividad y seguridad del dispositivo.

Health inequities and socioeconomic factors predicting the access to treatment for unruptured intracranial aneurysms in the USA in the last 20 years: interaction effect of race, gender, and insurance.

BACKGROUND: The literature suggests that minority racial and ethnic groups have lower treatment rates for unruptured intracranial aneurysms (UIA). It is uncertain how these disparities have changed over time. METHODS: A cross-sectional study using the National Inpatient Sample database covering 97% of the USA population was carried out. RESULTS: A total of 213 350 treated patients with UIA were included in the final analysis and compared with 173 375 treated patients with aneurysmal subarachnoid hemorrhage (aSAH) over the years 2000-2019. The mean (SD) age of the UIA and aSAH groups was 56.8 (12.6) years and 54.3 (14.1) years, respectively. In the UIA group, 60.7% were white patients, 10.2% were black patients, 8.6% were Hispanic, 2% were Asian or Pacific Islander, 0.5% were Native Americans, and 2.8% were others. The aSAH group comprised 48.5% white patients, 13.6% black patients, 11.2% Hispanics, 3.6% Asian or Pacific Islanders, 0.4% Native Americans, and 3.7% others. After adjusting for covariates, black patients (OR 0.637, 95% CI 0.625 to 0.648) and Hispanic patients (OR 0.654, 95% CI 0.641 to 0.667) had lower odds of treatment compared with white patients. Medicare patients had higher odds of treatment than private patients, while Medicaid and uninsured patients had lower odds. Interaction analysis showed that non-white/Hispanic patients with any insurance/no insurance had lower treatment odds than white patients. Multivariable regression analysis showed that the treatment odds of black patients has improved slightly over time, while the odds for Hispanic patients and other minorities have remained the same over time. CONCLUSION: This study from 2000 to 2019 shows that disparities in the treatment of UIA have persisted but have slightly improved over time for black patients while remaining constant for Hispanic patients and other minority groups.

An Analysis of the Incidence and Cost of Intracranial Aneurysm and Subarachnoid Haemorrhage Treatment between 2013 and 2021.

The incidence of unruptured intracranial aneurysms (UIAs) amounts to 3.2% among adults. The annual risk of aneurysm rupture is 2-10% and it results in subarachnoid haemorrhage (SAH). The aim of this study is to assess changes in the incidence of unruptured intracranial aneurysms and subarachnoid haemorrhages in Poland between 2013 and 2021 and the cost associated with their in-hospital treatment in the acute phase. The analysis was based on the National Health Fund database. Patients diagnosed with UIA and SAH and hospitalised between 2013 and 2021 were chosen. The statistical analysis was performed with an assumed significance level of α = 0.05. The ratio between the prevalence of SAH and UIA diagnoses was 4:6. The proportion of women in relation to men was higher in both diagnoses. The highest proportions of patients with diagnoses SAH and UIA were found in highly urbanised provinces. The value of medical services in 2021 compared to 2013 increased by 81.8%. The highest values in this period were recorded in Mazowieckie province, and the lowest were recorded in Opolskie province. The overall number of patients hospitalised with diagnosis of UIA or SAH did not decrease, but the risk of aneurysm rupture probably decreased, which resulted in lower incidence of SAH in subsequent years of observation. The recorded changes in the dynamics of the value of medical services per patient or per hospitalisation largely coincided. However, it is difficult to speculate on expected value levels as not all provinces showed linear changes in the value of services provided.

Assessment of the flow-diverter efficacy for intracranial aneurysm treatment considering pre- and post-interventional hemodynamics.

Endovascular treatment of intracranial aneurysms with flow diverters (FD) has become one of the most promising interventions. Due to its woven high-density structure they are particularly applicable for challenging lesions. Although several studies have already conducted realistic hemodynamic quantification of the FD efficacy, a comparison with morphologic post-interventional data is still missing. This study analyses the hemodynamics of ten intracranial aneurysm patients treated with a novel FD device. Based on pre- and post-interventional 3D digital subtraction angiography image data, patient-specific 3D models of both treatment states are generated applying open source threshold-based segmentation methods. Using a fast virtual stenting approach, the real stent positions available in the post-interventional data are virtually replicated and both treatment scenarios were characterized using image-based blood flow simulations. The results show FD-induced flow reductions at the ostium by a decrease in mean neck flow rate (51%), inflow concentration index (56%) and mean inflow velocity (53%). Intraluminal reductions in flow activity for time-averaged wall shear stress (47%) and kinetic energy (71%) are present as well. However, an intra-aneurysmal increase in flow pulsatility (16%) for the post-interventional cases can be observed. Patient-specific FD simulations demonstrate the desired flow redirection and activity reduction inside the aneurysm beneficial for thrombosis formation. Differences in the magnitude of hemodynamic reduction exist over the cardiac cycle which may be addressed in a clinical setting by anti-hypertensive treatment in selected cases.