Spontaneous occlusion of ruptured microaneurysm formed on postoperative transosseous anastomosis after indirect revascularization in a patient with moyamoya disease.

A 40-year-old female with a history of ischemic moyamoya disease treated with indirect revascularization at ages 12 and 25 years presented with a sudden severe headache. Imaging studies revealed focal parenchymal hemorrhage and acute subdural hematoma, confirming a microaneurysm formed on the postoperative transosseous vascular network as the source of bleeding. Conservative management was performed, and no hemorrhage recurred during the 6-month follow-up period. Interestingly, follow-up imaging revealed spontaneous occlusion of the microaneurysm. However, due to the rarity of this presentation, the efficacy of conservative treatment remains unclear. Further research on similar cases is warranted.

Management of Incidental Carotid Cave Aneurysm.

BACKGROUND: Incidental diagnosis of saccular aneurysms is more common with the advent of imaging techniques. Because of the severe morbidity and mortality that they can cause, treatment is chased for them, either microsurgical treatment or endovascular, even when they are diagnosed incidentally. Carotid cave aneurysms are rare, and they seem to have a more benign course compared to other intracranial aneurysms, probably related to the physical enveloping effect of the surrounding structures. Yet, their microsurgical treatment is a serious challenge technically for the neurosurgeon, with its severe morbidity and mortality for the patient. Endovascular techniques have their risks, too. PURPOSE: In this paper, we analyzed and presented our series of incidentally diagnosed carotid cave aneurysms. MATERIALS AND METHODS: The age, gender of patients, the size, laterality, and MR angiographic follow-up of aneurysms were reported. Their clinical results were noted. RESULTS: Fifty-six patients who had incidentally been diagnosed with 59 carotid cave aneurysms were followed up. No patient was microsurgically treated, but 15 patients had endovascular treatment for 15 aneurysms. The mean size of 15 treated aneurysms was 4.6 ± 2.1 (range = 2-10) mm, and it was 3.0 ± 1.5 (range = 1.7-10) mm for the untreated aneurysms (n = 44). There was no significant difference between the follow-up times of the treated and untreated groups (P = 0.487). The median follow-up of 59 aneurysms in 56 patients was 52 (mean = 49.6 ± 27.9, range = 1-124) months, with a total follow-up of 244 aneurysm years. None of the patients had subarachnoid hemorrhage related to carotid cave aneurysms during follow-up, and none of the aneurysms had shown growth. Two patients who had endovascular treatment had ischemic complications with minor neurologic deficits. CONCLUSION: Follow-up can be a reasonable option for the incidental aneurysms that are located and confined to the carotid cave. Additionally, TOF might be a reliable method for follow-up imaging of carotid cave aneurysms.

Pearls & Oy-sters: What Came First, the Bleed or the Fall?: An Aneurysmal Subdural Hemorrhage.

Acute subdural hemorrhages are a common emergency presentation often associated with trauma. However, in the absence of significant trauma, it is important to consider alternative causes. In this case, a 58-year-old woman with trivial trauma after a sudden collapse had bilateral subdural hemorrhages on CT. CT-angiogram revealed anterior communicating artery aneurysm, which had ruptured. This case explores intracerebral aneurysms as a rare cause of subdural hemorrhage that is important to consider in the absence of significant trauma.

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.

Safety and efficacy of the novel Alpha stent for the treatment of intracranial wide-necked aneurysm.

The Alpha stent is an intracranial closed-cell stent with a unique mesh design to enhance wall apposition. It recently underwent structural modifications to facilitate easier stent deployment. This study aimed to evaluate the safety and efficacy of stent-assisted coil embolization for unruptured intracranial aneurysms using the Alpha stent. Between January 2021 and November 2021, 35 adult patients with 35 unruptured intracranial aneurysms in the distal internal carotid artery were prospectively enrolled. For efficacy outcomes, magnetic resonance angiography at the 6-month follow-up was evaluated using the Raymond-Roy occlusion classification (RROC). The safety outcome evaluated the occurrence of symptomatic procedure-related neurological complications up to 6 months postoperatively. Technical success was achieved in 34/35 (97.1%). Six months postoperatively, aneurysm occlusion showed RROC I in 32/35 (91.4%) and RROC II in 3/35 (8.6%) patients. Procedure-related neurologic complications occurred in one patient (2.9%) who experienced hemiparesis due to acute lacunar infarction, which resulted in a 6-month mRS score of 1. The Alpha stent demonstrated excellent efficacy and safety outcomes in stent-assisted coil embolization of unruptured distal ICA aneurysms. The recent structural modifications allowed for easier stent delivery and deployment.Clinical trial registration number: KCT0005841; registration date: 28/01/2021.

Coil Embolization of the Azygos Anterior Cerebral Artery Aneurysm: Three Case Reports.

The azygos anterior cerebral artery (ACA) is a rare anatomical anomaly. Clipping surgery has been conducted in approximately 30 reported cases because it is frequently associated with aneurysms. However, few cases in which coil embolization was performed have been reported. We report three cases of coil embolization for distal ACA aneurysms with distal azygos ACA at our institution in 7 years. All patients were over 65-year-old women with saccular aneurysms larger than 7 mm; two with subarachnoid hemorrhage and one with an unruptured aneurysm. No patient had surgical complications associated with coil embolization. Coil embolization is also useful for large aneurysms in the distal azygos ACA, and its indication for treatment could be broadened.

ARISE I Consensus Review on the Management of Intracranial Aneurysms.

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

Three-dimensional Images Fusion Method Useful for Preoperative Simulation of Clipping Surgery for Cerebral Aneurysms.

This study aimed to introduce a three-dimensional (3D) images fusion method for preoperative simulation of aneurysm clipping. Consecutive unruptured aneurysm cases treated with surgical clipping from March 2021 to October 2023 were included. In all cases, preoperative images of plain computed tomography (CT), CT angiography, magnetic resonance imaging (MRI) 3D fluid-attenuated inversion recovery, 3D heavily T2-weighted images, and 3D rotational angiography were acquired and transported into a commercial software (Ziostation2 Plus, Ziosoft, Inc. Tokyo, Japan). The software provided 3D images of skull, arteries including aneurysms, veins, and brain tissue that were freely rotated, magnified, trimmed, and superimposed. Using the 3D images fusion method, two operators predicted clips to be used in the following surgery. The predicted clips and actually used ones were compared to give agreement scores for the following factors: (1) type of clips (simple or fenestrated), (2) shape of clips (straight, curved, angled, or bayonet), and (3) clipping strategy (single or multiple). The agreement score ranged from 0 to 3 because a score of 1 or 0 was given for agreement or disagreement on each factor. Interoperator reproducibility was also evaluated. During the study period, 44 aneurysms from 37 patients were clipped. All procedures were successfully completed, thanks to the precisely reproduced surgical corridors with the 3D images fusion method. Agreement in clip prediction was good with mean agreement score of 2.4. Interobserver reproducibility was also high with the kappa value of 0.79. The 3D images fusion method was useful for preoperative simulation of aneurysm clipping.

Internal carotid artery bulb width: a novel potential parameter for the prediction of cerebral vascular diseases.

OBJECTIVE: To investigate the relationship between the width of the internal carotid artery (ICA) bulb and cerebral vascular diseases including stroke and intracranial aneurysms. MATERIAL AND METHODS: In total 300 patients who had supra-aortic computed tomography angiography (CTA) were enrolled in this study from 2015 to 2021. The study groups consisted of 100 ischemic stroke patients, 100 patients with intracranial aneurysms, and 100 control subjects. The intracranial aneurysm patient group was divided into two subgroups according to the presence of subarachnoid hemorrhage (SAH). The largest diameters of the ICA C1 (cervical) and C2 (petrous) segments in all individuals were measured bilaterally on CTA images. The ICA diameter ratios of the cases were measured using the formula C1-C2C1. The relationship between the age and ICA vessel analysis was evaluated as well. RESULTS: The mean ICA bulb width values in the ischemic stroke patient group and the intracranial aneurysm patient group were significantly higher than the control group (p < 0.001). The ICA C1 and C2 segment diameter values and ICA diameter ratio were smaller in the intracranial aneurysm patients with SAH than those who had not (p = 0.7). There was a statistically significant but weak relationship between the age and ICA diameter ratios in all study groups (R-squared value of 0.26, p = 0.03). CONCLUSION: ICA bulb width is a parameter that can be easily evaluated with neuroimaging modalities and is a successful method that may be used for predicting the risk of ischemic stroke or the presence of an intracranial aneurysm.

Ruptured aneurysm in collateral arteries with blood-flow impairment of posterior inferior cerebellar artery: a report of three cases.

Herein, we report three cases of cerebellar hemorrhage due to a ruptured small aneurysm located on a collateral artery compensating for one or more stenotic or occluded major cerebellar arteries. In each case, endovascular distant parent artery occlusion of both the collateral artery and aneurysm was performed to prevent rebleeding. A ruptured small aneurysm in a collateral artery may be observed in patients with hemorrhage in an atypical cerebellar region, especially in cases of stenosis or occlusion of the vertebral artery or posterior inferior cerebellar artery. Thus, cerebral angiography is recommended to rule out collateral artery aneurysm.

Shifts in Diagnostic Testing for Headache in the Emergency Department, 2015 to 2021.

Importance: Subarachnoid hemorrhage is typically diagnosed by noncontrast head computed tomography (CT); lumbar puncture is recommended if computed tomography is nondiagnostic, although CT cerebral angiography has been promoted as an alternative to lumbar puncture in this diagnostic pathway. The outcomes of this debate in practice have not been studied. Objective: To determine whether CT cerebral angiography use has increased in lieu of lumbar puncture among emergency department (ED) patients with headache, with an increase in unruptured intracranial aneurysm detection. Design, Setting, and Participants: This retrospective cohort study took place in 21 community EDs of an integrated health care system in Northern California between 2015 and 2021. Participants were adult (aged >17 years) health plan members with a chief concern of headache. Exclusions were prior diagnoses of subarachnoid hemorrhage, unruptured intracranial aneurysm, cerebral arteriovenous malformation, or cerebrospinal fluid shunt. Data were analyzed from October to November 2023. Exposures: CT cerebral angiography and/or lumbar puncture during the ED encounter. Main Outcomes and Measures: Primary and secondary outcomes were 14-day and 90-day unruptured intracranial aneurysm detection, respectively. Safety outcomes were missed diagnoses of subarachnoid hemorrhage or bacterial meningitis. The annual incidence of unruptured intracranial aneurysm detection was normalized to the incidence of subarachnoid hemorrhage (UIA:SAH ratio). Average annualized percentage changes were quantified using joinpoint regression analysis. Results: Among 198 109 included ED encounters, the mean (SD) age was 47.5 (18.4) years; 140 001 patients (70.7%) were female; 29 035 (14.7%) were Black or African American, 59 896 (30.2%) were Hispanic or Latino, and 75 602 (38.2%) were White. Per year, CT cerebral angiography use increased (18.8%; 95% CI, 17.7% to 20.3%) and lumbar punctures decreased (-11.1%; 95% CI, -12.0% to -10.4%), with a corresponding increase in the 14-day UIA:SAH ratio (3.5%; 95% CI, 0.9% to 7.4%). Overall, computed tomography cerebral angiography use increased 6-fold relative to lumbar puncture, with a 33% increase in the detection of UIA. Results were similar at 90 days and robust to sensitivity analyses. Subarachnoid hemorrhage (1004 cases) and bacterial meningitis (118 cases) were misdiagnosed in 5% and 18% of cases, respectively, with no annual trends (P = .34; z1003 = .95 and P = .74; z117 = -.34, respectively). Conclusions and Relevance: In this cohort study of ED patients with headache, increases in CT cerebral angiography use were associated with fewer lumbar punctures and higher detection of unruptured intracranial aneurysms, with no significant change in missed diagnoses of subarachnoid hemorrhage or bacterial meningitis. While this shift in diagnostic strategy appeared safe in the short-term, the long-term consequences remain unclear.

[Automatic detection method of intracranial aneurysms on maximum intensity projection images based on SE-CaraNet].

Conventional maximum intensity projection (MIP) images tend to ignore some morphological features in the detection of intracranial aneurysms, resulting in missed detection and misdetection. To solve this problem, a new method for intracranial aneurysm detection based on omni-directional MIP image is proposed in this paper. Firstly, the three-dimensional magnetic resonance angiography (MRA) images were projected with the maximum density in all directions to obtain the MIP images. Then, the region of intracranial aneurysm was prepositioned by matching filter. Finally, the Squeeze and Excitation (SE) module was used to improve the CaraNet model. Excitation and the improved model were used to detect the predetermined location in the omni-directional MIP image to determine whether there was intracranial aneurysm. In this paper, 245 cases of images were collected to test the proposed method. The results showed that the accuracy and specificity of the proposed method could reach 93.75% and 93.86%, respectively, significantly improved the detection performance of intracranial aneurysms in MIP images.

Ultrasonography monitoring with Superb Microvascular Imaging during cerebrovascular surgery.

INTRODUCTION: Ultrasonography (US) is used as a real-time dynamic imaging modality during neurosurgery. A novel Doppler US technique, Superb Microvascular Imaging (SMI), can be used to visualize low-velocity flow of small vessels at high resolution with high frame rates. We visualized vessel flow using this US SMI technique and contrast agent during cerebrovascular surgery. METHODS: Forty-three patients with an unruptured cerebral aneurysm (control), ischemic and hemorrhagic moyamoya disease, carotid artery stenosis, hemangioblastoma, severe stenosis of the middle cerebral artery, venous angioma, and intracerebral hemorrhage (ICH) underwent neurosurgery with US SMI monitoring using a contrast agent. The diameter, length, and number of penetrating vessels were analyzed in patients with an unruptured cerebral aneurysm (control), moyamoya disease, and ICH. RESULTS: Diameter and length of cerebral penetrating vessels were significantly increased in patients with moyamoya disease and ICH compared to control patients. The number of penetrating vessels was increased in moyamoya disease patients compared to control and ICH patients. In hemorrhagic moyamoya disease, flow in the penetrating vessels originated from a deep periventricular point and extended to the cerebral surface. Pulsatile cerebral aneurysms during clipping surgery and carotid artery stenosis during carotid endarterectomy were easily identified by SMI. Drastically increased vessel flow in patients with a hemangioblastoma or a venous angioma was observed. CONCLUSION: Using the US SMI technique and contrast agent, we obtained useful flow information of the vascular disease structure and intracerebral deep small vessels during cerebrovascular surgery. Further quantitative analysis will be informative and helpful for cerebrovascular surgery.

Initial Experiences with the Trenza Embolization Device for the Treatment of Wide-Neck Intracranial Aneurysms: A 12-Patient Case Series.

The Trenza embolization device is a frame coil implant with flow-disruption properties and is a new alternative to treat challenging mid-to-large-sized broad-neck bifurcation or sidewall aneurysms. We conducted an observational single-center retrospective study of 12 consecutive patients treated for 10 unruptured and 2 ruptured 6- to 12-mm broad-neck bifurcation or sidewall aneurysms with the Trenza device during 2022-2023. The median patient age was 64 years (interquartile range, 59-70 years), 58% were women, the median largest aneurysm diameter was 9.6 mm (interquartile range, 7.5-11.9 mm), the median dome-to-neck ratio was 1.8 (interquartile range, 1.6-1.9), the most common aneurysm locations were the anterior communicating artery (33%) and basilar artery tip (33%). After a median follow-up of 6.5 months, adequate aneurysm occlusion was achieved in 83%. There were 3 major ischemic complications (25%), leading to 2 permanent neurologic deficits (17%) and 1 transient neurologic deficit (8%). There was 1 fatal rupture of a treated aneurysm 1.6 months after the index treatment. Two patients were retreated (17%). Ischemic complications occurred in patients after a too-dense coil packing at the base of the aneurysm. No technical issues related to the device were encountered. In summary, an adequate aneurysm occlusion rate was achieved using the Trenza-assisted coiling technique for otherwise challenging mid-to-large-sized broad-neck aneurysms. Ischemic complications seemed to occur following overdense coiling at the base of the aneurysm.

Comparative analysis of supra-orbital keyhole approach and pterional approach for surgical clipping of intracranial anterior circulation aneurysms in patients with favorable Hunt and Hess grades.

INTRODUCTION: Traditional large craniotomies have been the standard for aneurysm surgery. However, minimally invasive "keyhole" approaches have gained popularity for aneurysm clipping in recent years. This study focuses on Supra-Orbital Keyhole Approach (SOKHA),its use in clipping of aneurysms of the anterior Circle of Willis. Here we share the experiences of a tertiary care center regarding aneurysm clipping using SOKHA. MATERIALS AND METHODS: We retrospectively reviewed 166 cases involving aneurysm clipping, with 62 patients undergoing SOKHA and 104 patients undergoing the pterional approach. Factors evaluated included patient demographics, aneurysm characteristics, incidence of intraoperative complications, temporary-clipping usage, and postoperative clinical outcomes. Glasgow Outcome Scale scores were utilized to assess clinical outcomes. RESULTS: The study found that both the SOKHA and pterional approaches were similar in terms of age distribution, Hunt and Hess grades, and the incidence of hydrocephalus. The majority of aneurysms in both groups were anterior communicating artery aneurysms.Hydrocephalus was observed in 14.5 % of SOKHA cases and 13.5 % of pterional cases. Intraoperative aneurysm rupture occurred in 8.1 % of SOKHA cases and 7.7 % of pterional cases. There were no mortalities in the SOKHA group, while the pterional group had 1.92 % mortality rate. At the last follow-up, 77.4 % of SOKHA cases and 75.9 % of pterional cases had a favorable outcome (Glasgow Outcome Scale IV and V), with no significant difference. CONCLUSION: SOKHA offers the advantage of potential cosmetic benefit with neurological outcomes comparable to those of the traditional pterional approach, in properly selected patients.

[Cerebral persistent primitive arteries. Clinical case of combination with intracranial aneurysm and review of the literature]. / Tserebral'nye persistiruyushchie primitivnye arterii. Klinicheskii sluchai sochetaniya s intrakranial'noi anevrizmoi i obzor literatury.

Cerebral persistent primitive arteries are uncommon and associated with cerebrovascular diseases, like cerebral aneurysms. They can cause vertebrobasilar ischemia and neuropathy of the cranial nerves. The authors present a patient with trigeminal artery associated with giant partially thrombosed cavernous internal cerebral artery aneurysm.

Basilar artery perforator aneurysms: a comparison with non-perforator saccular aneurysms.

BACKGROUND: Basilar artery perforator aneurysms (BAPAs) are rare. There is no systematic description of their presentation, imaging, natural history and outcomes and how these compare to conventional non-perforator aneurysms. Thus, the authors in this study aimed to compare BAPAs to non-perforator aneurysms. METHODS: Cases were identified from a prospective neurovascular database, notes and imaging retrospectively reviewed and compared to a consecutive series of patients with non-perforator aneurysms. Blood volume on CT and vessel wall imaging (VWI) were compared to controls. RESULTS: 9/739 patients with aneurysmal subarachnoid haemorrhage (aSAH) harboured BAPAs. Compared to 103 with aSAH from posterior circulation aneurysms, they were more likely to be male (6/9, p = 0.008), but of equal severity (4/9 poor grade, p = 0.736) and need of CSF drainage (5/9, p = 0.154). Blood volume was similar to controls (30.2 ml vs 26.7 ml, p = 0.716). 6/9 BAPAs were initially missed on CTA. VWI showed thick (2.9 mm ± 2.7) bright enhancement (stalk ratio 1.05 ± 0.12), similar to controls with ruptured aneurysms (0.95 ± 0.23, p = 0.551), and greater than unruptured aneurysms (0.43 ± 0.11, p < 0.001). All were initially managed conservatively. Six thrombosed spontaneously. Three grew and had difficult access with few good endovascular options and were treated through a subtemporal craniotomy without complication. None rebled. At 3 months, all presenting in poor grade were mRS 3-4 and those in good grade mRS 1-2. CONCLUSIONS: Despite their small size, BAPAs present with similar volume SAH, WFNS grade and hydrocephalus to other aneurysms. They are difficult to identify on CTA but enhance strikingly on VWI. The majority thrombosed. Initial conservative management reserving treatment for growth was associated with no rebleeds or complications.

Middle Cerebral Artery Ischemic Complications After Flow Diverter Deployment from Internal Carotid Artery Extending into M1 Segment.

AIM: To gain a better understanding of ischemia risk related to in-stent stenosis (ISS) or in-stent thrombosis (IST) of the middle cerebral artery (MCA) and lenticulostriate arteries after flow-diverting devices (FDD) deployment from the internal carotid artery (ICA) to proximal middle cerebral artery (M1). MATERIAL AND METHODS: Using data from a prospectively maintained database, we retrospectively evaluated patients who were treated with FDD between January 2015 and 2020 at a single academic center. Only patients with unruptured ICA aneurysms where the FDD was extended into M1 were included. RESULTS: In total, 89 patients with 94 ICA aneurysms were treated with FDD. A total of 34 patients with 36 aneurysms had FDD extending into M1. Of the 34 patients, four experienced MCA, and lenticulostriate territory ischemia. Three patients had in-stent thrombosis (IST), and one patient had severe in-stent stenosis (ISS). The overall ischemic complication rate was 17.6%, which resulted in a permanent neurological deficit in 11.7% of the patients. CONCLUSION: If the distance of the distal neck of the aneurysm to the ICA terminus (ICAT) is ≤5 mm, or if the aneurysm is located directly at the ICAT, FDD should be considered only as a last option when other treatment modalities are not suitable. In addition, in the treatment of distal ICA aneurysms, extra effort should be exerted during the procedure to deploy the FDD without extending into M1. However, when traditional microsurgical clipping and other endovascular procedures are not suitable, the use of FDD is effective in terms of high aneurysm occlusion rates and preventing aneurysm rupture.