Safety of cerebral angiography and neuroendovascular therapy in patients with chronic kidney disease.

PURPOSE: Contrast-induced nephropathy is a common clinical concern in patients undergoing neuroendovascular procedures, especially in those with pre-existent kidney disease. We aimed to define the incidence of contrast-induced nephropathy in these high-risk patients in our practice. METHODS: We analyzed data retrospectively from patients undergoing neuroendovascular procedures at two academic medical centers over a 4-year period. Contrast-induced nephropathy was determined by an absolute increase in serum creatinine of 0.5 mg/dL or a rise from its baseline value by ≥ 25%, at 48-72 h after exposure to contrast agent after excluding other causes of renal impairment. High-risk patients were identified as those with pre-procedural estimated glomerular filtration rate < 60 mL/min irrespective of creatinine level, corresponding to stages 3-5 of chronic kidney disease. RESULTS: One hundred eighty-five high-risk patients undergoing conventional cerebral angiography and neuroendovascular interventions were identified. Only 1 out of 184 (0.54%) high-risk patients developed contrast-induced nephropathy. That one patient had stage 5 chronic kidney disease and multiple other risk factors. CONCLUSION: We have observed a very low rate of renal injury in patients with chronic kidney disease, traditionally considered high risk for neuroendovascular procedures. Multiple factors may be responsible in the risk reduction of contrast-induced nephropathy in this patient population.

Determinants of neurologic deterioration and stroke-free survival after spontaneous cervicocranial dissections: a multicenter study.

Patients with spontaneous cervicocranial dissection (SCCD) may experience new or recurrent ischemic events despite antiplatelet or anticoagulant therapy. Treatment with stent placement is an available option; however, the literature on patient selection is limited. Thus, identifying patients at high risk for neurologic deterioration after SCCD is of critical importance. The present study examined the rate of neurologic deterioration in medically treated patients with SCCD and evaluated demographic, clinical, and radiologic factors affecting this deterioration. We retrospectively identified consecutive patients with SCCD over a 7-year period from 3 medical institutions, and evaluated the relationships between demographic data, clinical characteristics, and angiographical findings and subsequent neurologic outcomes. Neurologic deterioration was defined as transient ischemic attack (TIA), ischemic stroke, or death occurring during hospitalization or within 1 year of diagnosis. Kaplan-Meier curves were used to determine neurologic event-free survival up to 12 months. A total of 69 patients (mean age, 47.8 ± 14 years; 45 males) with SCCD were included in the study. Eleven patients (16%) experienced in-hospital neurologic deterioration (TIA in 9, ischemic stroke in 1) or death (1 patient). An additional 8 patients developed neurologic deterioration within 1 year after discharge (TIA in 5, ischemic stroke in 2, and death in 1). The overall 1-year event-free survival rate was 72%. Women (P = .046), patients with involvement of both vertebral arteries (P = .02), and those with intracranial arterial involvement (P = .018) had significantly higher rates of neurologic deterioration. Our findings indicate that neurologic deterioration is relatively common after SCCD despite medical treatment in women, patients with bilateral vertebral artery involvement, and those with intracranial vessel involvement.

The ABCs of accurate volumetric measurement of cerebral hematoma.

BACKGROUND AND PURPOSE: Both initial hematoma volume and hematoma growth are independent predictors of clinical outcomes and mortality among intracerebral hemorrhage patients. The purpose of this study was to evaluate the accuracy of different computed tomography image acquisition protocols and hematoma volume measurement techniques. METHODS: We used plastic and cadaveric phantoms to determine the accuracy of different volumetric measurement techniques. We performed both axial and spiral computed tomography scans with 0.75-, 1.5-, 3.0-, and 4.5-mm-thick transverse sections (with no gap). Different measurement techniques (planimetry, ABC/2, and 3D rendering) and different window width/level settings (I, 150/50 versus II, 587/-321) were used to assess generated errors in volumetric calculations. RESULTS: Both axial and spiral computed tomography scans yielded similar percent errors for different slice thicknesses and different measurement techniques. Comparison of different measurement techniques revealed a significant difference in measurement error only from the ABC/2 method as compared with 3D-rendering measurements (P<0.0001). The overall measurement error according to the ABC/2 method was further increased by approximately 8% for irregularly shaped hematomas (P=0.0004). A significant percent difference in measurement error was observed between window width/levels I and II for both planimetry (mean difference across all thicknesses, 1.91 ± 3.78, P=0.004) and Analyze software (mean difference across all thicknesses, 6.92 ± 7.29, P<0.0001) methods. CONCLUSIONS: A better understanding of the limitations that may affect measurement of hematoma volume is crucial in the assessment of hematoma volume, which is considered an independent marker of clinical outcome.

Impact of percutaneous transluminal angioplasty for treatment of cerebral vasospasm on subarachnoid hemorrhage patient outcomes.

BACKGROUND: Percutaneous transluminal angioplasty (PTA) has been introduced for treatment of symptomatic cerebral vasospasm in patients with subarachnoid hemorrhage (SAH). While angiographic improvement is consistently reported, clinical improvement following the procedure varies, and limited data is available regarding overall impact on outcome. METHODS: The authors performed a retrospective analysis of all hospital admissions with aneurysmal SAH over a 6 year period. The length of stay, discharge outcomes (measured by modified Rankin scale [mRS] at discharge), and 1-year mortality among patients with SAH before (4 year period) and after (2 year period) institution of PTA for cerebral vasospasm were compared. Embolization for intracranial aneurysm was used as a therapeutic option throughout the study duration. The effect of institution of PTA for vasospasm after adjusting for age, clinical severity, and use of aneurysm embolization on both discharge outcomes and 1-year mortality in multivariate analysis was evaluated. RESULTS: A total of 146 patients with aneurysmal SAH were admitted during the study duration. There was no difference between the 89 patients admitted in pre-angioplasty period and 57 patients admitted in post-angioplasty period in regards to age, medical co-morbidities, and admission clinical severity of patients (measured by Hunt and Hess grade and Glasgow coma scale). A total of 18 (32%) patients underwent PTA with or without intra-arterial vasodilator treatment in the second period of the study. There was a non significant decrease in rates of severe disability and death (mRS 5-6) at discharge (45 vs. 33%, P = 0.09) and 1-year mortality (32 vs. 22%, P = 0.26) after introduction of PTA for cerebral vasospasm after adjusting for potential confounders. There was no significant difference between the two time periods in regards to length of stay. CONCLUSION: A non significant trend was noted with reduced rate of severe disability and mortality at discharge and 1-year mortality after the introduction of PTA for cerebral vasospasm associated with SAH without increasing the length of hospital stay.

A comparison of Computed Tomography perfusion-guided and time-guided endovascular treatments for patients with acute ischemic stroke.

BACKGROUND AND PURPOSE: The role of CT perfusion (CT-P) imaging for the selection of patients with acute ischemic stroke who may benefit from endovascular treatment is not defined. The objective of this study was to determine whether CT-P-guided endovascular treatment improves clinical outcomes compared with standard endovascular treatment based on the time interval between symptom onset and presentation and noncontrast cranial CT imaging. METHODS: A retrospective study was performed comparing the clinical characteristics, complications, and clinical outcomes of patients with acute ischemic stroke who were treated using endovascular modalities based on either CT-P imaging (CT-P-guided) or time interval between symptom onset and presentation and absence of intracerebral hemorrhage or extensive ischemic changes on noncontrast cranial CT scan (time-guided). RESULTS: The rates of partial and complete recanalization were similar between the CT-P- and time-guided treatment groups (n=61 [88%] versus n=103 [81%]; P=0.52) regardless of whether they received intravenous recombinant tissue plasminogen activator before endovascular treatment. Comparing the CT-P-guided with the time-guided patients, favorable discharge outcome (modified Rankin Scale 0 to 2) was observed in 23 (32%) versus 41 (33%) of the patients, respectively (P=0.9). In-hospital mortality was observed in 15 (21%) of CT-P- and 29 (23%) of time-guided patients (P=0.74). CONCLUSIONS: CT-P-guided endovascular treatment did not increase the rate of short-term favorable outcomes among patients with acute ischemic stroke. Prospective studies are required to validate the CT-P criteria and protocols currently in use before incorporating CT-P as a routine modality for patient selection for endovascular treatment.

Intracranial angioplasty and/or stent placement in octogenarians is associated with a threefold greater risk of periprocedural stroke or death.

PURPOSE: To compare the clinical and angiographic outcomes of endovascular treatment of symptomatic intracranial stenosis between octogenarian and younger patients. METHODS: Data for 244 consecutive patients (173 men; mean age 61.6 years) who underwent angioplasty and/or stenting for intracranial atherosclerotic disease at 5 specialized centers were pooled. Baseline, 30-day, and follow-up clinical and angiographic information were collected. Rates of clinical and angiographic endpoints were compared between patients >or=80 years old versus those <80 years. RESULTS: Patients >or=80 years (n = 15) were more likely to be hypertensive (87% versus 69%) and have underlying coronary artery disease (73% versus 36%, p<0.05) compared to younger patients (n = 229). The rate of periprocedural stroke and/or death was 3-fold higher among patients aged >or=80 years compared with those <80 years (20% versus 7%, p = 0.11). No recurrent stroke or death (excluding periprocedural events) was observed during follow-up in the octogenarian group. In patients who had follow-up angiography, a similar rate of >or=50% restenosis was observed among patients aged >or=80 years and those aged <80 years (25% versus 29%, p>0.1). CONCLUSION: The 3-fold higher periprocedural death and/or stroke rate suggests cautious use of intracranial angioplasty and/or stent placement in octogenarians.

Neurosurgeons performing tracheostomies- maintaining proficiency in the modern era.

OBJECTIVES: Tracheostomy is a basic surgical procedure that most surgeons, regardless of specialty, learn early in their training. With improvements in intensive care medicine, the number of neurosurgical patients requiring tracheostomy has declined. As neurosurgeons advance in their training, familiarity with airway management declines and falls under the domain of other specialties. Because neurosurgeons still manage critically ill patients, they often defer the airway management to other specialists. In many institutions, neurosurgeons no longer perform tracheostomies. The purpose of this study was to evaluate complications and outcomes following tracheostomies performed by neurosurgeons. PATIENTS AND METHODS: We reviewed a database of all neurosurgical procedures performed at a single institution from 9/2007 to 2/2017. We reviewed the operative and medical records of patients whose tracheostomies were performed by a neurosurgeon. RESULTS: Neurosurgeons performed 72 tracheostomies over the study period. All the procedures were done in an operating room using traditional open technique. Four patients had previous tracheostomy. Five patients were on dual antiplatelet therapy. The procedure was successful in all patients. There were no immediate complications in any patient. One patient required revision for development of tracheo-cutaneous fistula. CONCLUSION: Tracheostomies can be performed safely by neurosurgeons in this era of sub-specialization. There is a renewed interest in maintaining critical care proficiency in neurosurgery. Airway management is an important part of this skill-set. Neurosurgeons manage patients with brain injuries, cranial nerve deficits, and cervical spine injuries, Consequently, learning how to establish a surgical airway remains necessary in neurosurgical training.

Inadvertent subclavian artery catheter placement complicated by stroke: endovascular management and review.

BACKGROUND: Removal of large-bore venous catheters misplaced within the subclavian artery risks significant hemorrhage due to the noncompressible entry site. Comorbidities in these patients often make traditional surgical approaches prohibitive. CASE DESCRIPTION: We present a case of inadvertent subclavian artery placement of a central venous catheter complicated by thromboembolic stroke, illustrate treatment with a combination of percutaneous closure and temporary balloon tamponade, and review the endovascular management of this unusual problem. CONCLUSION: Endovascular treatment of inadvertent subclavian artery catheterization appears to be a reasonable option, and its less-invasive nature may be beneficial for patients in whom the underlying disease initially required central venous access.

Combined surgical and endovascular approach to treat symptomatic in-stent occlusion of the left common carotid artery origin.

Symptomatic occlusive lesions at the origins of the supra-aortic vessels pose challenges for treatment. Endovascular angioplasty and stent placement via the transfemoral approach is possible, but obtaining a stable position for the guide catheter via this approach is technically difficult. The authors describe the case of a 56-year-old man presenting with symptomatic occlusion of a previously placed stent at the origin of the left common carotid artery (CCA). An endovascular revascularization of the left CCA was planned. However, the absence of a lumen proximal to the stent prevented stable placement of a guide catheter via the transfemoral route. Consequently, the authors used a combined surgical and endovascular approach to gain access to the lesion. The left CCA was exposed surgically distal to the occlusion and clamped just proximal to its bifurcation to preserve flow from the external to the internal carotid artery (ICA) and to prevent embolism into the ICA. A wire was passed retrograde through the occlusive lesion and then was subsequently advanced proximally into the femoral sheath. This allowed transfemoral advancement of the appropriate endovascular devices to perform an angioplasty and placement of a stent. The patient remained neurologically stable, and postoperative studies showed improvement in cerebral perfusion. This case demonstrates the feasibility of distal-to-proximal stent delivery with a combined endovascular and surgical approach.

Use of the 8 French Simmons-2 guide catheter for carotid artery stent placement in patients with difficult aortic arch anatomy.

Inability to achieve vascular access is a common reason for failure to perform carotid artery angioplasty and stent placement. The authors report their experience with the use of an 8 Fr Simmons-2 catheter to gain carotid artery access in the setting of complex aortic arch anatomy. This guide catheter was used successfully to perform carotid artery angioplasty and stent placement in 10 patients with markedly tortuous aortic arches or supra-aortic branches. As the authors gained experience with this catheter, they used it as a first option in patients with the appropriate aortic arch anatomy.

Stent-Assisted Woven EndoBridge Implantation for Treatment of Wide-Necked Aneurysm Residual: Angiographic Video.

Woven EndoBridge (WEB) is an intrasaccular flow-disrupting device that has recently been approved by the U.S. Food and Drug Administration (FDA) for treatment of wide-neck ruptured and unruptured aneurysms at arterial bifurcations. Successful and effective treatment of aneurysms with the WEB device requires accurate sizing. For optimal positioning of the WEB device within the aneurysm sac, the diameter of the device has to exceed by the mean diameter of the aneurysm by 1.0 mm. However, this predictably results in an increase in the height of the device. In shallow, wide-necked aneurysms, this increase in height of the WEB device could result in encroachment of the device on the parent artery or branch vessel origins. In these circumstances, the placement of an intracranial stent can prevent such encroachment. In this video, we demonstrate the operative technique of stent-assisted WEB device placement that was performed at our institution for the treatment of a recurrent basilar apex aneurysm (Video 1). This previously ruptured aneurysm had been treated initially with primary coil embolization, and the patient consented to endovascular treatment of her aneurysm recurrence. The video illustrates this procedure using a combination of fluoroscopic images, fluoroscopic cines, and digital subtraction angiograms.

Gadolinium to the rescue for mechanical thrombectomy in acute ischemic stroke.

INTRODUCTION: Mechanical thrombectomy in the setting of acute ischemic stroke (AIS) requires cerebral digital subtraction angiography (DSA), typically performed with iodinated contrast medium. We present a case of emergent cerebral DSA and mechanical thrombectomy using gadolinium-based contrast for cerebral DSA in a patient with a history of anaphylaxis to iodinated contrast agents (ICs). CASE REPORT: A 72-year-old man developed left ventricle assist device thrombus while on anticoagulation. During hospitalization he suffered right middle cerebral artery occlusion with a National Institutes of Health stroke scale score of 10. He had a history of anaphylaxis and the advanced directives revealed do not resuscitate/do not intubate status. We performed an emergent DSA as part of thrombectomy procedure using gadolinium-based contrast mixed in 1:1 proportion with normal saline. The images obtained were of adequate quality and the patient underwent successful thrombectomy with modified thrombolysis in cerebral infarction 2B recanalization. CONCLUSION: Gadolinium-based contrast agents could be effective alternatives for cerebral DSA in patients undergoing mechanical thrombectomy for AIS who have a history of anaphylactic reaction to ICs.

MRI assessment followed by successful mechanical recanalization of a complete tandem (internal carotid/middle cerebral artery) occlusion and reversal of a 10-hour fixed deficit.

BACKGROUND: Mechanical clot extraction up to 8 hours after stroke onset is an alternative strategy for opening large vessels, especially for patients ineligible for intravenous thrombolysis. Safety beyond this therapeutic window is untested. METHODS: An 81-year-old woman presented 8 hours after she developed left-sided weakness and dysarthria with a National Institutes of Health Stroke Scale (NIHSS) score fluctuating between 6 and 13. Neuroimaging revealed a large perfusion deficit with no diffusion abnormalities. An emergent cerebral angiogram revealed a complete internal carotid artery terminus occlusion. RESULTS: Successful mechanical thrombectomy was performed without complication and resulted in almost complete reversal of the patient's deficit to an NIHSS score of 1, 10 hours after stroke onset. CONCLUSION: Patients with large hypoperfused areas and minimal diffusion abnormalities on the MRI may benefit from mechanical thrombectomy beyond an 8-hour window.

Safety and Feasibility of Balloon-Assisted Embolization with Onyx of Brain Arteriovenous Malformations Revisited: Personal Experience with the Scepter XC Balloon Microcatheter.

BACKGROUND/OBJECTIVE: Compliant dual-lumen balloon microcatheters have been used to perform balloon-assisted embolization (BAE) of brain arteriovenous malformations (AVMs) with ethylene vinyl alcohol copolymer (Onyx). However, vessel rupture and microcatheter retention have been reported from BAE using these microcatheters. Using an extra-compliant balloon microcatheter (Scepter XC; Microvention, Tustin, CA, USA) could help avoid pial vessel rupture during BAE. We herein report our experience using this balloon microcatheter for BAE. METHODS: This retrospective study included patients who underwent BAE of brain AVMs at our institution between June 2012 and March 2017. RESULTS: The extra-compliant Scepter XC balloon microcatheter was used for BAE of brain AVMs in 23 patients aged 44.3 ± 16.7 years (range 0-65 years). A total of 40 intracranial vessels (39 pial arteries and 1 pial vein) were catheterized and embolized during 30 separate sessions. In all instances, the balloon microcatheter could be successfully advanced to the AVM nidus. A mean volume of 2.4 ± 1.7 mL (range 0.65-4.6 mL) of Onyx was injected per session. There were no instances of vessel rupture, microcatheter retention, or stroke. CONCLUSION: Utilization of the extra-compliant balloon microcatheter results in safe and effective BAE, which adds to the growing experience with BAE for AVM treatment.

"Internal cross-clamping" for symptomatic internal carotid artery thrombus. Report of two cases.

Both carotid endarterectomy and carotid artery stent placement with filter embolic protection present a higher risk for patients with internal carotid artery (ICA) lesions containing intraluminal thrombus. Despite the risk associated with intervention, patients with symptomatic intraluminal thrombus who were enrolled in the North American Symptomatic Endarterectomy Trial did better with surgical than medical treatment. We describe the novel use of an endovascular "internal cross-clamping" technique in two patients with symptomatic intraluminal thrombus in the ICA. A 57-year-old woman presented with a history of multiple episodes of left upper-extremity numbness, mild dysarthria, and agraphia occurring over the previous 24 hours. Cranial magnetic resonance imaging revealed a scattered watershed infarction of the right hemisphere and a critical stenosis of the right ICA. An 81-year-old man awoke with hemiplegia and inability to follow commands after undergoing a complicated carotid endarterectomy. Computed tomographic perfusion imaging demonstrated an increased time to peak in the left middle cerebral territory, and emergent angiography demonstrated both intimal flaps and thrombus in the endarterectomy bed. The lesions in both patients were treated with endovascular stent placement using both proximal and distal flow occlusion--a functional "internal cross-clamping"--for embolic protection. To our knowledge, this is the first report of internal trapping and stent placement for symptomatic carotid stenosis containing intraluminal thrombus. This treatment strategy should be added to the armamentarium of endovascular surgeons in selected patients with symptomatic carotid intraluminal thrombus.

Risk factors for hemorrhage associated with external ventricular drain placement and removal.

OBJECTIVE External ventricular drains (EVDs) have an important role in the management of neurological disease, and their placement is a frequently performed neurosurgical procedure. Hemorrhage is a common complication of EVD placement and occurs more frequently than originally believed. There is also risk of hemorrhage with removal of an EVD, which has not been well described. The authors investigated the risk factors associated with placement and removal of EVDs at their institution. METHODS A database was created including patients who required EVD placement from March 2008 to June 2014 at the University of Minnesota. A retrospective chart review was completed, and data were collected for each patient. All cranial imaging studies during the index hospitalization were reviewed to identify hemorrhages associated with either EVD placement or removal. The study was performed using a research protocol approved by the University of Minnesota's institutional review board. RESULTS Four hundred eighty-two EVDs were placed during the designated time period. Among the cases in which patients underwent imaging after the placement procedure, hemorrhage was found in 94 (21.6%). The hemorrhage volume ranged from 0.003 cm3 to 45.9 cm3 (mean [± SD] 1.96 ± 6.48 cm3). Two of these hemorrhages resulted in additional interventions: 1 surgical evacuation and 1 contralateral EVD. In 55 (22.5%) of the 244 cases in which imaging was performed after EVD removal, hemorrhage associated with removal was identified. The mean volume of these hemorrhages was 8.25 ± 20.34 cm3 (range 0.012-82.08 cm3). Two EVDs were replaced, and 1 patient died as a result of a large hemorrhage. Large hemorrhages (> 30 cm3) occurred in 2 patients on placement (0.46%) and in 5 patients on removal (2.0%). In this series, decreased platelet levels on admission and an increasing number of EVD placement attempts correlated with an increased risk of hemorrhage on placement. Only those with an EVD placed at bedside were more likely to have hemorrhage on EVD removal. CONCLUSIONS Multiple studies have reported varying EVD hemorrhage rates while very few studies have described hemorrhage secondary to EVD removal. This is the first reported analysis of risk factors associated with hemorrhage on EVD removal. Hemorrhages occur relatively frequently following EVD placement and removal, though clinical significance of these events seems to be low.

Salvage of Herniated Flow Diverters Using Stent and Balloon Anchoring Techniques: A Technical Note.

BACKGROUND: The pipeline embolization device (PED; Medtronic, MN, USA) can sometimes herniate into the aneurysmal sac in an unexpected manner during or shortly after its deployment due to device foreshortening. In this report, we describe 2 endovascular techniques, which can be used to reposition a herniated PED construct into a more favorable alignment. SUMMARY: In a 67-year-old patient who had an intraprocedural herniation of a PED device into a giant cavernous aneurysm, a stent anchor technique was used to reverse the herniation, reorient the PED construct, and achieve successful flow diversion. In a different patient with a giant superior hypophyseal aneurysm, a balloon anchor technique followed by deployment of an LVIS Jr (Microvention, Tustin, CA, USA) stent was used to reverse the herniation into the aneurysmal sac. KEY MESSAGES: Stent anchor and balloon anchor techniques as described here can be used to reposition PED constructs, which have unexpectedly herniated into the aneurysm sac during attempted flow diversion for the treatment of giant aneurysms.

Endovascular management of a vein of Galen aneurysmal malformation in an infant with challenging femoral arterial access.

A 5-month-old infant was to be treated with elective transarterial embolization for a vein of Galen aneurysmal malformation (VGAM). A team of endovascular surgical neuroradiologists, pediatric interventional radiologists, and pediatric cardiologists attempted conventional femoral arterial access, which was unsuccessful given the small caliber of the femoral arteries and superimposed severe vasospasm. Thereafter, eventual arterial access was achieved by navigating from the venous to the arterial system across the patent foramen ovale following a right femoral venous access. Embolization was then successfully performed. At a later date, the child underwent successful transvenous balloon-assisted embolization and eventual arterial embolization with cure of the VGAM.

Transpetrosal approaches to the posterior fossa.

Resection of the petrous temporal bone to various degrees provides different levels of access to lesions of the posterior fossa. Although their nomenclature can be confusing, the numerous variants of the transpetrosal approaches can be classified broadly into anterior and posterior groups. The posterior transpetrosal approaches include the retrolabyrinthine, translabyrinthine, and transcochlear, whereas the ones in the anterior group are extensions of the basic middle fossa approach. Both the anterior and posterior approaches have the potential of exposing the cerebellopontine angle and the petroclival region. The posterior approaches are based on the standard mastoidectomy and involve resection of the petrous bone to various degrees. This results in progressively increased exposure anteriorly, but comes at the expense of hearing in the translabyrinthine approach and of hearing and facial strength in the transcochlear approach. In contrast, the middle fossa approaches spare the lateral petrous bone and involve resection of the medial petrous bone to various degrees. All of the middle fossa approaches are designed to preserve hearing. Extensions of the middle fossa approaches involve resection of bone within the Kawase rhomboid and division of the tentorium to provide exposure of the posterior fossa.

Contemporary management of incidental intracranial aneurysms.

The management of unruptured intracranial aneurysms has changed significantly in recent years and continues to evolve. The three main factors that have affected the management of unruptured intracranial aneurysms are as follows: 1) increased availability of noninvasive imaging technology, resulting in increased detection of incidental aneurysms; 2) improved understanding of the natural history of unruptured aneurysms; and 3) the advent of neuroendovascular therapy. In this report, the authors discuss the implications of these factors in the diagnosis and management of truly incidental, asymptomatic aneurysms and review the current practice patterns at their institution. Historical and current articles regarding noninvasive neuroimaging, aneurysm screening, endovascular and surgical therapy, and the natural history of unruptured aneurysms were reviewed. Current practices used for diagnosis and management of incidental aneurysms at the authors' institution were also reviewed. The management of incidental intracranial aneurysms has become an increasingly controversial subject in recent years. Improvements in noninvasive imaging resulting in detection of an increasing number of incidental aneurysms, the establishment of endovascular therapy as an attractive alternative to surgery, and studies indicating a more benign natural history for unruptured aneurysms than previously thought have led to significant changes in neurosurgical practice. Safety and long-term efficacy are the goals of treatment for unruptured aneurysms. Until conclusive studies are completed, the experience of the neurovascular team at each institution and the art of patient selection for treatment will continue to play a fundamental role in the management of these lesions.