Misdiagnosis of a Dissecting Aneurysm as a Cerebral Aneurysm: A Preoperative Case Report.

Background: Intracranial Aneurysm (IA) is characterized by abnormal dilation of intracranial arterial walls, a tumor-like protrusion, often occurring in the anterior communicating artery. Intracranial Dissecting Aneurysm (IDA) refers to hemodynamic changes within intracranial arteries, leading to ruptures between blood vessel walls, disrupting normal arterial blood flow within the arterial lumen. IDA is relatively uncommon in the anterior circulation. To date, there have been no reported cases of dissecting aneurysms misdiagnosed as cerebral aneurysms before surgical intervention. This case report presents a patient's detailed clinical diagnosis, treatment, and imaging data. Case Presentation: A 56-year-old female patient experienced post-work headaches. Cranial Computed Tomography (CT), Magnetic Resonance Imaging (MRI), and Digital Subtraction Angiography (DSA) examinations revealed a small hemorrhage following infarction and aneurysms in the initial part of the right A2 segment. Initially, the patient was diagnosed with a ruptured cerebral aneurysm, accompanied by hemorrhage and cerebral vasospasm (cerebral infarction in the right frontal lobe). Subsequently, cerebral aneurysm clipping was performed. During surgery, it was observed that the aneurysm originated from the ipsilateral A2 starting site and displayed dissecting-like changes extending towards the distal end. The final diagnosis confirmed an aneurysm evolving from intracranial artery dissection. Artificial meninges were employed to encase and clip the aneurysm. Post-surgery, the patient was transferred to a superior hospital for A3 bypass. Follow-up assessments indicated a successful recovery. Conclusion: Cerebral aneurysms typically involve larger arteries with rare possibilities of stenosis. Moreover, the cerebral artery is relatively small, making it challenging for Brain Computed Tomography Angiography (CTA) to distinguish true and false lumen within blood vessels. The diagnosis of dissecting aneurysms is difficult and often susceptible to clinical misdiagnosis.

The markers and risk stratification model of intracranial aneurysm instability in a large Chinese cohort.

Intracranial aneurysm is the leading cause of nontraumatic subarachnoid hemorrhage. Evaluating the unstable (rupture and growth) risk of aneurysms is helpful to guild decision-making for unruptured intracranial aneurysms (UIA). This study aimed to develop a model for risk stratification of UIA instability. The UIA patients from two prospective, longitudinal multicenter Chinese cohorts recruited from January 2017 to January 2022 were set as the derivation cohort and validation cohort. The primary endpoint was UIA instability, comprising aneurysm rupture, growth, or morphology change, during a 2-year follow-up. Intracranial aneurysm samples and corresponding serums from 20 patients were also collected. Metabolomics and cytokine profiling analysis were performed on the derivation cohort (758 single-UIA patients harboring 676 stable UIAs and 82 unstable UIAs). Oleic acid (OA), arachidonic acid (AA), interleukin 1ß (IL-1ß), and tumor necrosis factor-α (TNF-α) were significantly dysregulated between stable and unstable UIAs. OA and AA exhibited the same dysregulated trends in serums and aneurysm tissues. The feature selection process demonstrated size ratio, irregular shape, OA, AA, IL-1ß, and TNF-α as features of UIA instability. A machine-learning stratification model (instability classifier) was constructed based on radiological features and biomarkers, with high accuracy to evaluate UIA instability risk (area under curve (AUC), 0.94). Within the validation cohort (492 single-UIA patients harboring 414 stable UIAs and 78 unstable UIAs), the instability classifier performed well to evaluate the risk of UIA instability (AUC, 0.89). Supplementation of OA and pharmacological inhibition of IL-1ß and TNF-α could prevent intracranial aneurysms from rupturing in rat models. This study revealed the markers of UIA instability and provided a risk stratification model, which may guide treatment decision-making for UIAs.

Treatment of refractory headache secondary to intracranial endovascular procedure by transcutaneous electrical nerve stimulation of the occipital nerve.

This pilot study aimed at assessing the effect of transcutaneous electrical nerve stimulation (TENS) of the occipital nerve (ON) to treat chronic refractory headache secondary to intracranial endovascular procedures (iEVP) in 4 patients. The duration of ON-TENS therapy was only 1 month (n=2) or longer than 4 months (n=2). Overall, pain intensity decreased from 7.8 (on a 0-10 scale) at baseline to 0.8 at 6 months after ON-TENS therapy initiation (-90%), while drug treatment was reduced from 34.3 to 0.8 (-98%) on the medication quantification scale. ON-TENS is a simple technique that may benefit patients with post-iEVP refractory headache.

Impact of Early Versus Late Intravenous Followed by Oral Nimodipine Treatment on the Occurrence of Delayed Cerebral Ischemia Among Patients With Aneurysm Subarachnoid Hemorrhage.

BACKGROUND: Guidelines for aneurysm subarachnoid hemorrhage (aSAH) management recommend treatment with nimodipine to all patients to reduce delayed cerebral ischemia (DCI) and poor clinical outcome. However, it did not give the most beneficial time to start therapy and route of administration. OBJECTIVES: To compare the DCI occurrence and clinical outcome among aSAH patients who received nimodipine treatment at different times. METHODS: A retrospective cohort study was conducted by collecting data from medical chart reviews between August 30, 2010, and October 31, 2015, at Prasart Neurological Institute, Thailand. Patients were classified into 2 groups by time to receive nimodipine: early group and late group (<96 and >96 hours, respectively). All patients received intravenous (IV) followed by oral nimodipine to complete treatment course. Clinical outcome was graded using the Glasgow Outcome Scale at 21 days. The factors related to DCI were analyzed using multivariate logistic regression. RESULTS: A total of 149 patients were recruited: early (n = 97) and late (n = 52). No difference in baseline characteristics between groups was observed. The occurrence of DCI was not statistically significantly different between groups (early group, 18.60%, vs late group, 20.80%; P = 0.74). The World Federation of Neurosurgical Societies IV to V was associated with DCI occurrence. The proportion of patients with good outcome, poor outcome, or death did not show any difference between groups. CONCLUSIONS AND RELEVANCE: Receiving IV nimodipine 3 to 7 days following oral therapy after bleeding can be the alternative regimen in patients who did not start nimodipine within 96 hours.

[Subarachnoid Hemorrhage and Isolated Brainstem Death]. / Aneurysmatische Subarachnoidalblutung und Entwicklung eines "isolierten Hirnstammtods".

BACKGROUND: Worldwide there are differences in the procedure of determining brain death. An irreversible loss of all brain functions, including cerebrum, cerebellum and brainstem is mandatory for the diagnosis of brain death in Germany. On the basis of a case report some important aspects of the new recommendations of the German guidelines are discussed. CASE REPORT: We present the case of a 41-year old patient who was admitted to our clinic due to acute subarachnoid hemorrhage (SAH). Angiography revealed an aneurysm of the posterior inferior cerebellar artery. The patient was comatose without any brainstem reflexes and showed apnoea. However, on day 3, EEG showed alpha activity as a sign of residual cortical function. We diagnosed an isolated brainstem death. The next day EEG was isoelectric and brain death was confirmed. DISCUSSION: The diagnosis of isolated brainstem death does not allow a confirmation of death in Germany. Our case presents a primary infratentorial brain damage mandating additional confirmatory tests.

False-negative Interpretations of Cranial Computed Tomography in Aneurysmal Subarachnoid Hemorrhage.

OBJECTIVES: Prior studies examining the sensitivity of cranial computed tomography (CT) for the detection of subarachnoid hemorrhage (SAH) have used the final radiology report as the reference standard. However, optimal sensitivity may have been underestimated due to misinterpretation of reportedly normal cranial CTs. This study aims to estimate the incidence of missed CT evidence of SAH among a cohort of patients with aneurysmal SAH (aSAH). METHODS: We performed a retrospective chart review of emergency department (ED) encounters within an integrated health delivery system between January 2007 and June 2013 to identify patients diagnosed with aSAH. All initial noncontrast CTs from aSAH cases diagnosed by lumbar puncture (LP) and angiography following a reportedly normal noncontrast cranial CT (CT-negative aSAH) were then reviewed in a blinded, independent fashion by two board-certified neuroradiologists to assess for missed evidence of SAH. Reviewers rated the CT studies as having definite evidence of SAH, probable evidence of SAH, or no evidence of SAH. Control patients who underwent a negative evaluation for aSAH based on cranial CT and LP results were also included at random in the imaging review cohort. RESULTS: A total of 452 cases of aSAH were identified; 18 (4%) were cases of CT-negative aSAH. Of these, seven (39%) underwent cranial CT within 6 hours of headache onset, and two (11%) had their initial CTs formally interpreted by board-certified neuroradiologists. Blinded independent CT review revealed concordant agreement for either definite or probable evidence of SAH in nine of 18 (50%) cases overall and in five of the seven (71%) CTs performed within 6 hours of headache onset. Inter-rater agreement was 83% for definite SAH and 72% for either probable or definite SAH. CONCLUSIONS: CT evidence of SAH was frequently present but unrecognized according to the final radiology report in cases of presumed CT-negative aSAH. This finding may help explain some of the discordance between prior studies examining the sensitivity of cranial CT for SAH.

Sensitivity of a Clinical Decision Rule and Early Computed Tomography in Aneurysmal Subarachnoid Hemorrhage.

INTRODUCTION: Application of a clinical decision rule for subarachnoid hemorrhage, in combination with cranial computed tomography (CT) performed within six hours of ictus (early cranial CT), may be able to reasonably exclude a diagnosis of aneurysmal subarachnoid hemorrhage (aSAH). This study's objective was to examine the sensitivity of both early cranial CT and a previously validated clinical decision rule among emergency department (ED) patients with aSAH and a normal mental status. METHODS: Patients were evaluated in the 21 EDs of an integrated health delivery system between January 2007 and June 2013. We identified by chart review a retrospective cohort of patients diagnosed with aSAH in the setting of a normal mental status and performance of early cranial CT. Variables comprising the SAH clinical decision rule (age≥40, presence of neck pain or stiffness, headache onset with exertion, loss of consciousness at headache onset) were abstracted from the chart and assessed for inter-rater reliability. RESULTS: One hundred fifty-five patients with aSAH met study inclusion criteria. The sensitivity of early cranial CT was 95.5% (95% CI [90.9-98.2]). The sensitivity of the SAH clinical decision rule was also 95.5% (95% CI [90.9-98.2]). Since all false negative cases for each diagnostic modality were mutually independent, the combined use of both early cranial CT and the clinical decision rule improved sensitivity to 100% (95% CI [97.6-100.0]). CONCLUSION: Neither early cranial CT nor the SAH clinical decision rule demonstrated ideal sensitivity for aSAH in this retrospective cohort. However, the combination of both strategies might optimize sensitivity for this life-threatening disease.

Validation of cerebrospinal fluid findings in aneurysmal subarachnoid hemorrhage.

BACKGROUND: Recently proposed cutoff criteria for cerebrospinal fluid (CSF) analyses might safely exclude a diagnosis of aneurysmal subarachnoid hemorrhage (aSAH). OBJECTIVE: The objective of this study was to examine the sensitivity of a CSF red blood cell (RBC) count greater than 2000 × 10(6)/L (ie, 2000 RBCs per microliter) or the presence of visible CSF xanthochromia in identifying patients with aSAH. METHODS: We identified a retrospective case series of patients diagnosed with aSAH after lumbar puncture (LP) in an integrated health delivery system between January 2000 and June 2013 by chart review. All identified patients had at least 1 cerebral aneurysm that was treated with a neurosurgical or endovascular intervention during the index hospitalization. The lowest CSF RBC count was used for validation analysis. Cerebrospinal fluid color was determined by visual inspection. Xanthochromia was defined as pink, orange, or yellow pigmentation of CSF supernatant. RESULTS: Sixty-four patients met study inclusion criteria. Of these, 17 (33%) of 52 underwent LP within 12 hours of headache onset, and 49 (84%) of 58 exhibited CSF xanthochromia. The median CSF RBC count was 63250 × 10(6)/L. The sensitivity of a CSF RBC count of greater than 2000 × 10(6)/L in identifying aSAH was 96.9% (95% confidence interval, 89.3%-99.1%). Additional consideration of CSF xanthochromia resulted in a sensitivity of 100% (95% confidence interval, 94.3%-100%). CONCLUSIONS: All patients in this case series of patients with aSAH had either a CSF RBC count greater than 2000 × 10(6)/L or visible CSF xanthochromia, increasing the likelihood that this proposed cutoff strategy may safely identify patients who warrant further investigation for an aneurysmal cause of subarachnoid hemorrhage.

Development of image segmentation methods for intracranial aneurysms.

Though providing vital means for the visualization, diagnosis, and quantification of decision-making processes for the treatment of vascular pathologies, vascular segmentation remains a process that continues to be marred by numerous challenges. In this study, we validate eight aneurysms via the use of two existing segmentation methods; the Region Growing Threshold and Chan-Vese model. These methods were evaluated by comparison of the results obtained with a manual segmentation performed. Based upon this validation study, we propose a new Threshold-Based Level Set (TLS) method in order to overcome the existing problems. With divergent methods of segmentation, we discovered that the volumes of the aneurysm models reached a maximum difference of 24%. The local artery anatomical shapes of the aneurysms were likewise found to significantly influence the results of these simulations. In contrast, however, the volume differences calculated via use of the TLS method remained at a relatively low figure, at only around 5%, thereby revealing the existence of inherent limitations in the application of cerebrovascular segmentation. The proposed TLS method holds the potential for utilisation in automatic aneurysm segmentation without the setting of a seed point or intensity threshold. This technique will further enable the segmentation of anatomically complex cerebrovascular shapes, thereby allowing for more accurate and efficient simulations of medical imagery.

Impact of integrated cerebrovascular program on outcomes in patients with intracranial aneurysms.

BACKGROUND: Recent evidence indicates that multidisciplinary care improves patient outcomes in cerebrovascular (CV) disease. A multidisciplinary integrated CV program was recently instituted at a high-volume tertiary referral center, providing the opportunity to evaluate patient outcomes before and after its introduction. OBJECTIVE: To evaluate outcomes after treatment of patients with intracranial aneurysm in relation to the introduction of a CV program at our institution. METHODOLOGY: A retrospective chart review was performed on all new patient encounters for a 6-month period each before and immediately after the introduction of the CV program, as well as at a more recent 6-month period to evaluate long-term results. Data were collected on demographic variables, rupture status, medical comorbidities, hospital complications, in-hospital procedures, hospital course and modified Rankin score at discharge and follow up. RESULTS: The total number of patients treated increased from 55 in the 6-month period before the introduction of the CV program to 112 in the most recent time period (p<0.05). Both the surgical clipping and endovascular coiling procedures increased (p<0.05). A significant increase occurred in patients with multiple comorbidities (30.5% vs 34.7%, p=0.035). The mean length of stay decreased from 12.22 ± 13.26 days before the program to 9.23 ± 12.04 days in the most current data (p<0.05). CONCLUSIONS: Creation of an integrated CV program at a large-volume tertiary referral center resulted in better outcomes for an increased number of more medically complicated patients with intracranial aneurysms. This study provides preliminary data for developing an integrated model of multidisciplinary care for the management of CV disease.

Incidental findings on brain Magnetic Resonance Imaging in long-term survivors of breast cancer treated with adjuvant chemotherapy.

PURPOSE: Incidental brain findings defined as previously undetected abnormalities of potential clinical relevance that are unexpectedly discovered at brain imaging and are unrelated to the purpose of the examination are common in the general population. Because it is unclear whether the prevalence of incidental findings in breast cancer patients treated with chemotherapy is different to that in the general population, we compared the prevalence in breast cancer survivors treated with chemotherapy to that in a population-based sample of women without a history of any cancer. PATIENTS AND METHODS: Structural brain MRI (1.5T) was performed in 191 female CMF (Cyclophosphamide, Methotrexate, 5-Fluorouracil) chemotherapy-exposed breast cancer survivors. A reference group of 1590 women without a history of cancer was sampled from a population-based cohort study. All participants were aged 50 to 80 years. Five trained reviewers recorded the brain abnormalities. Two experienced neuro-radiologists reviewed the incidental findings. RESULTS: The cancer survivors had completed chemotherapy on average 21 years before. Of the 191 subjects, 2.6% had an aneurysm and 3.7% had a meningioma. The prevalence of meningiomas and aneurysms was not different between the groups. The prevalence of pituitary macro adenomas in the breast cancer survivors (1.6%) was higher than that in the reference group (0.1%) (OR=23.7; 95% CI 2.3-245.8). CONCLUSION: Contrary to commonly held opinions, we did not observe an increased prevalence of meningiomas in cancer survivors. Breast cancer survivors previously treated with chemotherapy are more likely to develop pituitary adenomas than persons without a history of cancer and chemotherapy treatment.

Minimally conscious state after ruptured giant basilar aneurysm.

OBJECTIVE: To report the clinical and radiologic findings in a case of transient minimally conscious state after rupture and coiling of a giant basilar aneurysm. DESIGN: Case report. SETTING: Neuroscience intensive care unit. PATIENT: A 44-year-old man who developed a transient minimally conscious state in association with perianeurysmal edema in the rostral brainstem and thalamus after rupture and coiling of a giant basilar artery aneurysm. MAIN OUTCOME MEASURE: Correlation of clinical and magnetic resonance imaging findings. RESULTS: A minimally conscious state and bilaterally symmetric vasogenic edema of the rostral brainstem and thalamus developed 2 days after endovascular aneurysm coiling. The clinical and radiologic abnormalities improved significantly and in parallel during the following 4 weeks. CONCLUSIONS: Perianeurysmal vasogenic edema in the brainstem and thalamus can develop after rupture and coiling of a giant basilar artery aneurysm. This process can be transient and can produce dramatic alterations in consciousness that later resolve.

Dissection of the posterior inferior cerebellar artery in a young adult with cerebellar infarct.

The posterior inferior cerebellar artery (PICA) is frequently involved in dissection of the vertebral artery (VA); however, isolated PICA dissection has rarely been reported. A 37-year-old man experienced acute and progressive drowsiness, vertigo, occipital headache, vomiting, and ataxia. There was no precedent trauma or chiropractic manipulation. Neurologically, he had dysmetria of the left extremities. His NIHSS score was 3. Brain magnetic resonance imaging showed an acute cerebellar infarct in the left PICA territory. Magnetic resonance angiography showed a faint signal adjacent to the junction of the left VA and PICA, suggesting a vascular shadow. Catheter angiography showed focal stenosis with a post-stenotic fusiform aneurysmal dilatation of the left proximal PICA that was highly suggestive of dissection with pseudoaneurysm formation. He was treated with clopidogrel and was free of neurological symptoms 3 months after the stroke event. Isolated PICA dissection may be considered in patients with PICA territory infarct or subarachnoid hemorrhage. Treatment depends on the manifestations; ruptured dissecting aneurysms are often treated with surgery or embolization, and infarcts are usually treated with antithrombotic agents.

Three-dimensional visualization of vertebrobasilar system aneurysms in a vertigo patient.

Cerebral artery fenestration refers to a division in the lumen of an artery leading to two distinct endothelium-lined channels. At the site of turbulent flow, fenestration may predispose to an aneurysm formation. In this study, a 45-year-old woman suffered an acute vertiginous attack after cervical manipulation. The MRI scan demonstrated basilar artery duplication and tortuous left distal vertebral artery impinging on the cisternal segment of the cochleovestibular nerve. Subsequent three-dimensional (3D) reconstruction by MR imaging showed vertebrobasilar artery fenestrations with aneurysms. Unfortunately, subarachnoid hemorrhage occurred 6 days later, and the patient became comatose one year after presentation. In summary, subarachnoid hemorrhage caused by vertebrobasilar system aneurysms is a life-threatening event. Delineating the configuration by 3D-reconstruction of MR images allows more accurate diagnosis and more effective management.

Chiropractic manipulation: reasons for concern?

Chiropractic's popularity is rising among the general population. Moreover, few studies have been conducted to properly evaluate its safety. We report three cases of serious neurological adverse events in patients treated with chiropractic manipulation. The first case is a 41 years old woman who developed a vertebro-basilar stroke 48 h after cervical manipulation. The second case represents a 68 years old woman who presented a neuropraxic injury of both radial nerves after three sessions of spinal manipulation. The last case is a 34 years old man who developed a cervical epidural haematoma after a chiropractic treatment for neck pain. In all three cases there were criteria to consider a causality relation between the neurological adverse events and the chiropractic manipulation. The described serious adverse events promptly recommend the implementation of a risk alert system.

Evaluación comparativa de efectividad y costo/efectividad en terapias alternativas para algunas lesiones vasculares encefálicas: experiencia del autor y revisión de la literatura / Comparative assessment of effectiveness and cost/effectiveness in alternative therapies to vascular encephalic lesions: author experience and review

Las patologías vasculares encefálicas quirúrgicas (aneurismas, malformaciones arterio venosas) han experimentado uno de los avances más importantes dentro de la medicina en las últimas décadas en materias de diagnóstico y tratamiento. Técnicas de introducción relativamente reciente y contemporánea, como la micro neurocirugía, la terapia endovascular encefálica y la radiocirugía, lograron mejorar en magnitudes las posibilidades de diagnóstico y los resultados de los tratamiento en estas lesiones. En este contexto parece de suma importancia definir el rol que juega cada uno de estos tratamientos en el manejo de la patología; así como la participación de los profesionales involucrados en la toma de decisiones muchas veces complejas y no exentas de controversia. El análisis de los resultados clínicos, la efectividad y la relación costo/efectividad son fundamentales para tener claridad en nuestro enfrentamiento como neurocirujanos tratantes. Este análisis debe interpretar la experiencia internacional en estas materias y a la vez revisar la experiencia local, hecho de suma importancia, que muchas veces dejamos rezagado en nuestro medio. Este estudio revisa los tópicos mencionados, incluyendo la experiencia del autor y un análisis exhaustivo de la bibliografía universal. Los resultados y las conclusiones podrán servir como herramienta a la hora de buscar referentes locales y foráneos que avalen con solidez nuestras conductas diagnósticas y terapéuticas.

Surgical vascular brain diseases (aneurysms, arterio venous malformations) have experienced one of the most important advances in medicine in the last decades related, to diagnosis and treatment. Recently and contemporary developed techniques, like micro neurosurgery, endovascular therapy and radiosurgery, have remarkably improved the diagnostic possibilities and the treatment outcomes in this lesions. In this context, it seems to be of the most importance to define the part that each treatment plays in the management of these diseases; and the participation of the professionals linked to the decision making in issues frequently complex and controversial. The analysis of clinical outcomes, the effectiveness and the cost/effectiveness ratio are basic to be clear in our approaches like neurosurgeons. This article reviews the international literature in these topics and, at the same time, the local experience, a fact of enormous importance that we use to left behind. The previously mentioned issues are reviewed, including the author's own experience and an exhaustive bibliographic analysis. Some of the results and conclusions included article should be useful tools when searching for local and foreign references to endorse with strength our diagnostic and therapeutic behaviour.

Headache caused by an intracranial aneurysm in a 32-year-old woman.

OBJECTIVES: We describe the case of a woman with a headache later found to be a result of an intracranial aneurysm. Through this article, we aim to raise awareness regarding the red flags that should lead doctors of chiropractic to suspect the presence of this condition to facilitate appropriate patient management that increases the likelihood of patients' recovery. CLINICAL PRESENTATION: A 32-year-old woman sought care for a constant headache of 4 days' duration. She described the headache as severe throughout her entire head, centralized at the base of the occiput, and unlike any headache she had experienced. She had concomitant neck pain. Her left eye deviated toward the midline and had excessive tearing 12 hours after the onset of the headache. INTERVENTION AND OUTCOME: No chiropractic adjustment was administered; immediate transfer for emergency treatment was arranged instead. The diagnosis of a bleeding intracranial aneurysm was confirmed by magnetic resonance imaging. The patient was transferred to a local university hospital for surgical intervention. Unfortunately, she died of vasospastic complications. CONCLUSIONS: The red flags to be considered in evaluating patients with such headache as that described for our case patient include a history of hypertension, cigarette smoking, oral contraceptive use, alcohol consumption, pregnancy, and cocaine use. Practitioners need to be aware of the signs and symptoms that indicate whether a headache may be a result of serious problems such as an aneurysm.

In vitro evaluation of 2D-digital subtraction angiography versus 3D-time-of-flight in assessment of intracranial cerebral aneurysm filling after endovascular therapy.

BACKGROUND AND PURPOSE: The aim of this study was to evaluate 2D-digital subtraction angiographic (DSA) and 3D-time-of-flight (TOF) MR imaging in assessment of aneurysmal residue by using a pulsating silicon aneurysm model. For each imaging system, we studied intra- and interobserver reproducibility and the agreement between interpretations and reference measurements. We also examined how each imaging technique affected the operator's therapeutic decision. METHODS: Two silicon aneurysm models depicting subarachnoidal aneurysms were used, one with a wide neck and one with a narrow neck. Each aneurysm model was placed in series on a pulsed flow circuit and was filled with Guglielmi detachable coils to simulate a clinical case. Each aneurysm was then gradually filled with silicon gel in increments of 10%, up to 100% to simulate different levels of occlusion (residual neck or dog ear, partial, complete) at each filling level. For each level of filling, we performed conventional 2D-DSA and 3D-TOF MR imaging. We submitted the images for examination by 2 senior medical staff with 2 readings per image. A combined reading of the 2 images was submitted to each expert to determine whether the 2 examinations were complementary. RESULTS: The 2D-DSA analysis showed good reproducibility (k = 0.8 and k = 0.57) and agreement (k = 0.71) in describing "complete" treatments. The distinction between a "residual neck" and "partial treatment," however, was not reliable. The 2D-DSA provided a good description of the coil and silicon protrusion into the parent artery. The 3D-TOF analysis of the residual aneurysm, however, was not reproducible, though it was more effective than the 2D-DSA in evaluation of partially wide-necked aneurysms (k = 0.68 MR imaging vs k = 0.041 2D-DSA; P = .018). At the same filling level, the 2D-DSA analysis indicated repeat treatment more often than 3D-TOF analysis (P = .059). CONCLUSION: The 2D-DSA remains the gold standard, but MR imaging is more effective in evaluating a "partial treatment." The 2D-DSA analysis indicated repeat treatment more often than the 3D-TOF for the same occlusion level. The distinction between "partial treatment" and a "residual neck" was not reliable with either method of evaluation.

Complementary management of partially occluded aneurysms by using surgical or endovascular therapy.

OBJECT: The authors present a series of patients in whom partially occluded aneurysms were retreated using complementary surgical or endovascular therapy. METHODS: During a period of 18 months, 301 patients with intracranial aneurysms were treated using either clip application (171 patients) or endovascular embolization with Guglielmi Detachable Coils ([GDCs] 130 patients). Routine posttreatment angiography studies revealed residual aneurysms in 21 of these patients, nine of whom were retreated using an endovascular or surgical method, with a mean treatment latency of 1.2 months. Four patients underwent primary surgical clip application, whereas five patients experienced GDC packing first. Among patients in the surgical group, the residual aneurysm neck was small and total elimination of the aneurysm was achieved by packing in GDCs. In patients in the endovascular group the authors incompletely packed the aneurysm because of its wide neck or fusiform component in two patients, perforation of a very small aneurysm in one patient, and coil dislocation in another patient. Typical coil compaction occurred in one case. Complete clip application was achieved in all patients. There was no complication in any patient due to the second treatment modality. Final outcome was excellent or good in six and fair in three. CONCLUSIONS: Following clip application or endovascular embolization of intracranial aneurysms, the use of complementary surgical or endovascular management is successful and associated with low morbidity.

Risk factors for aneurysmal subarachnoid haemorrhage: the Tromsø study.

OBJECTIVES: To conduct a population based case-control study with premorbid registration of potential risk factors to address the difficulty in identifying risk factors for aneurysmal subarachnoid haemorrhage (SAH). SAH is rare in prospective studies, and retrospective studies may have a selection bias. METHODS: The Tromsø health study is a population based survey of risk factors for cardiovascular disease in 27 161 subjects. 26 cases of aneurysmal SAH were identified in which risk factors were registered before the bleeding. Four age and sex matched controls were selected for each case. A backward logistic regression analysis was conducted and odds ratios (ORs) for significant risk factors were calculated. Systolic and diastolic blood pressure, cigarette smoking habits, serum concentrations of lipoproteins, body mass index, and coffee consumption were analysed. RESULTS: The crude annual incidence rate of aneurysmal SAH was 8.84/100 000 population. The proportion of current smokers was significantly (p = 0.003) higher in patients with SAH (73.1%) than in controls (41.3%). Drinking more than five cups of coffee per day was more common among patients (85%) than controls (59%) (p = 0.004). Mean (SD) systolic blood pressure was higher (p = 0.017) in patients (154.0 (32.5)) than in controls (136.3 (23.3)). Regression analysis showed that cigarette smoking (p = 0.04), systolic blood pressure (p < 0.0001), and coffee consumption (p = 0.004) were independent risk factors for SAH. The OR of current smokers versus never smokers was 4.55 (95% confidence interval (CI) 1.08 to 19.30) and the OR of drinking more than five cups of coffee a day was 3.86 (95% CI 1.01 to 14.73). The OR of an increase in systolic blood pressure of 20 mm Hg was 2.46 (95% CI 1.52 to 3.97). CONCLUSIONS: Cigarette smoking and hypertension are significant independent risk factors for aneurysmal SAH. A high coffee consumption may also predispose patients to aneurysmal SAH.