Aortic Steal Correlates with Acute Organ Dysfunction and Short-Term Outcomes in Neonates with Vein of Galen Malformation.

INTRODUCTION: Vein of Galen aneurysmal malformation (VGAM) is a rare, congenital cerebrovascular malformation with high morbidity and mortality. Parameters to foresee clinical progression and allow individualized parent counseling are lacking. The aim of this study was to evaluate aortic steal measured by Doppler ultrasound as a prognostic parameter in these neonates. METHODS: A retrospective monocentric analysis of cardiac ultrasound exams before embolization in neonates with VGAM was conducted. Percentage of aortic steal measured by time-averaged maximum velocity above and below the zero flow baseline by pulsed Doppler ultrasound at the preductal aortic isthmus was calculated. Association of aortic steal with parameters of acute organ dysfunction (Bicêtre neonatal evaluation score [BNES], neonatal multiple organ dysfunction score [NeoMODS]) and mortality and determination of correlation between aortic steal and cerebral damage on initial and follow-up cerebral magnetic resonance imaging (cMRI) were evaluated. RESULTS: Twelve neonates were included, of which 3 died. Per 10 percentage point increase of aortic steal, BNES decreased by 1.64 (95% confidence interval [CI]: 1.28-2.0) points and the maximum observed NeoMODS increased by 1.25 (CI: 0.94-1.57) points. The odds for mortality increased by 2.3 (CI: 1.14-13.67) per 10 percentage point increase of aortic steal. There was a correlation between aortic steal and cerebral damage at baseline (white matter ρ [rho] = 0.34, gray matter ρ = 0.81) and follow-up (white matter ρ = 0.80, gray matter ρ = 0.72). CONCLUSION: The degree of aortic steal in neonates with VGAM was highly associated with the severity of organ dysfunction, disease progression on cMRI, and mortality.

Long-term results of wide-necked intracranial bifurcation aneurysms treated with stent-assisted coiling using low-profile acandis acclino stents.

PURPOSE: Little data exists on endovascular treatment of complex intracranial aneurysms with the Acandis Acclino low-profile self-expanding closed-cell stent systems and is mainly limited to short- or midterm results. We report our long-term, single-centre experience with three generations of Acclino stents treating complex intracranial aneurysms. METHODS: 62 wide-necked intracranial aneurysms were treated electively using 88 Acclino stent systems. Single stent-assisted coiling was the preferred treatment in 38 cases and the kissing-Y stenting technique in 24 cases. We analysed demographic data and long-term follow-up results. RESULTS: All stents were successfully deployed with immediate complete (Raymond Roy occlusion classification, RROC I) or near-complete occlusion (RROC II) achieved in 93,5%. Follow-up was available in 55 cases with a mean follow-up of 36 months (range 9-80 months). Long-term RROC I or II was achieved in 49 cases (89,1%). Three cases of stable residual aneurysmal filling were observed (5,5%). Seven aneurysms (12,7%) demonstrated a worsening on follow-up leading either to a neck remnant (4 cases, 7,3%) or to an aneurysm recurrence (3 cases, 5,5%). One recurrent aneurysm was retreated with coilembolization (1,8%). The directly procedural-related complication rate was 4,8%. Seven cases of clinically silent in-stent stenosis (12,7%; morbidity n = 0) were detected on long-term follow-up, six of them using the kissing-Y stenting technique. CONCLUSION: Endovascular treatment of various intracranial aneurysms using the Acandis Acclino stent systems is safe and efficient with high aneurysm occlusion rates combined with low complication rates on long-term follow-up. Overall, rates of in-stent stenosis are low but may depend on the treatment technique (single stent-assisted coiling versus kissing-Y stenting with coiling).

Axis fracture due to giant cranial AVM.

Cerebral arteriovenous malformations (AVMs) are a vascular anomaly consisting of a bundle of direct connection of arteries and veins. AVMs clinical expression ranges from complete asymptomatic, and thus incidentally found, to life threatening with rupturing and bleeding. In this wide spectrum, osteolysis is considered as a rare complication of interosseous AVMs, and only few cases of mandible and maxilla osteolysis have been reported. We present, herein, a case of an intracranial AVM, which has caused in the course of the time an osteolysis of the dens and axis.

Mechanical thrombectomy of M2 occlusions with distal access catheters using ADAPT.

BACKGROUND AND PURPOSE: The direct aspiration first pass technique (ADAPT) using distal access catheters (DAC) has proven to be an effective and safe endovascular treatment strategy of acute ischemic stroke with large vessel occlusions (LVO). However, data about direct aspiration using DAC in M2 segment occlusions is limited. We assess the safety and efficacy of DACs in acute M2 occlusions using ADAPT with large bore (5 French /6 French) aspiration catheters as the primary method for endovascular recanalization. MATERIALS AND METHODS: From January 2017 to July 2018, 52 patients with an acute ischemic stroke due to M2 occlusions underwent mechanical thrombectomy using ADAPT with DACs (SOFIA 5 French/Catalyst 6) as frontline therapy. Patient demographics, technical parameters and outcome data were recorded. RESULTS: Median National Institutes of Health Strokes Scale (NIHSS) Score was 12 at admission. Successful revascularization to mTICI 2b-3 with ADAPT alone was achieved in 45 of 52 patients (86.5%) with mTICI 3 achieved in 32 patients (61.5%). Additional stent retrievers were used in 6 patients and led to an overall successful revascularisation of 92.3% (48/52). Median NIHSS at discharge was 4. 29 of 52 (55.8%) patients had a modified Rankin Scale (mRS) Score 0-2 at three months. Symptomatic intracranial hemorrhage did not occur. CONCLUSION: DACs can safely be used for mechanical thrombectomy of acute M2 occlusions by the ADAPT approach. Their use alone can be a high efficacious treatment of distal intracranial thromboembolic occlusions.

Craniofacial venous malformations treated by percutaneous sclerotherapy using polidocanol: a single-center experience.

BACKGROUND: Percutaneous therapy with various sclerosants is an established treatment of venous malformations in general. We investigated the safety and effectiveness of polidocanol in the craniofacial region. PURPOSE: To present and evaluate our subjective and objective mid- and long-term results of patients with craniofacial venous malformations (CFVM) after percutaneous sclerotherapy using polidocanol. MATERIAL AND METHODS: Twenty patients with CFVM treated by percutaneous sclerotherapy were followed up and asked to fill in a questionnaire comparing levels of the following CFVM-related symptoms before and after treatment: pain; functional impairment; cosmetic deformities; and impairment in daily life. Additionally, both size reduction as well as procedural-related complication rates were analyzed. RESULTS: Evaluation of the questionnaire revealed an improvement or complete relief of CFVM-related symptoms with significant reduced impairment in daily life after percutaneous sclerotherapy. Eighteen (90%) patients noticed a post-sclerotherapy improvement of at least one of their corresponding symptoms and expressed satisfaction with regard to their treatment. For 13 patients, a > 50% size reduction of the CFVM could be observed, while seven exhibited a < 50% size reduction. One minor complication was encountered in 56 treatment sessions (1.8%). CONCLUSION: Percutaneous sclerotherapy using polidocanol is a well-tolerated treatment for CFVM with a low complication rate. Size reduction and positive results with improvement of different clinical symptoms can be achieved.

Anatomy of the deep venous system in vein of Galen malformation and its changes after endovascular treatment depicted by magnetic resonance venography.

BACKGROUND AND PURPOSE: It is classically thought that the internal cerebral veins (ICV) do not communicate with the venous pouch of vein of Galen malformations (VGM). We report on the anatomy of the deep venous system in VGM with special emphasis on the drainage of the ICV and possible changes after endovascular treatment. MATERIALS AND METHODS: We retrospectively analyzed DSA and 2D time-of-flight MR venograms of 55 children with VGM. We evaluated all pre- and post-operative images for the presence of the ICVs and determined their route of venous drainage. RESULTS: Of 55 children, pre-operative 2D MRV detected the ICVs in 19 cases (35%) compared with one case (2%) for pre-embolization DSA (2%) (P<0.0001). Of the cases in which the ICVs were seen preoperatively, in 15 cases (78.9%) the ICV drained directly into the VGM while in the other four cases, the ICV used alternative venous drainage routes. On post-operative MRV, the ICVs were seen in 17 cases (31%) on MRV and 10 cases (18.2%) on DSA with drainage into an adult-like vein of Galen in 13 cases (76%), respectively (P=0.08). In four cases normal ICV drainage into the vein of Galen was seen even when the venous sac was closed. In two cases there was a change in ICV drainage from the vein of Galen to the lateral mesencephalic vein. CONCLUSION: The communication of the ICV with the VGM is a common phenomenon. Different changes of venous drainage routes do occur after treatment and are best seen on MRV.

Non-enhanced MR imaging for preinterventional assessment of the angioarchitecture in vein of Galen malformations.

BACKGROUND AND PURPOSE: Endovascular treatment of vein of Galen malformations (VGMs) requires sufficient preceding MR imaging. Standardized, preinterventional, non-invasive imaging has not been established. Our study is the first to examine the role of a dedicated, standardized, non-invasive imaging protocol in the evaluation of VGM angioarchitecture by non-contrast MRI/MR angiography. MATERIALS AND METHODS: We retrospectively evaluated a consecutive series of VGM patients who underwent a 1.5 T MRI protocol, including standard T2 weighted images (T2WI), arterial time of flight (TOF), and thin T2WI without flow compensation (T2OffPh). The primary outcome was the proportion of patients in whom VGM subtypes and all arterial feeders (anterior (AChA) and posterior (PChA) choroidal arteries, pericallosal arteries, basilar tip, and leptomeningeal supply) could be accurately identified compared with a DSA gold standard. RESULTS: A total of 26 VGM patients who underwent 108 studies were used in the statistical analysis. VGM subtype was best seen in axial T2OffPh (92.1%) and TOF (89.8%). AChA feeders were best seen in TOF (86.5%) and axial T2OffPh (72.2%). PChA feeders were best seen in TOF (95.1%) and axial T2OffPh (88.1%). Pericallosal feeders were best seen in axial T2OffPh (95.4%) and TOF (95.1%). Basilar tip feeders were best seen in TOF (90.6%) and axial T2OffPh (88.4%). CONCLUSION: VGM angioarchitecture is best seen in TOF and axial T2OffPh. It can be used as an alternative to global angiographic series.

Delayed and incomplete treatment may result in dural fistula development in children with Vein of Galen malformation.

The association of dural arteriovenous fistulas (DAVF) in children with Vein of Galen malformation (VGM) has recently been reported for the first time. In a larger series of cases treated with transarterial NBCA embolization, 30% had DAVF. We wanted to analyze the development of DAVF in our cohort of children with VGM and to evaluate whether their occurrence depends on different treatment timing and embolic materials. We analyzed 43 VGM cases treated with a combined transarterial and transvenous approach between 2003 and 2016. In our early series until 2011, we used coils solely in 21 children. Since 2012, 22 children were treated with the combination of coils and Onyx. In the early series treated with coils solely, no case presented initially with or developed DAVF over time on follow-up angiograms. In our recent series we found four cases (9%) with DAVF. In two patients (5%), DAVF were found on the initial angiogram. Both patients presented at our department at age >2 years and were not treated elsewhere before. One patient (2%) presented at our department with too proximal occlusion of arterial feeders performed at another institution before. Only one patient (2%) developed DAVF in our department after the transarterial use of Onyx. Interestingly, this child did not develop DAVF as long as we used coils solely and his DAVF was localized exactly where an Onyx cast was identified. In conclusion, delayed and incomplete treatment may have a considerable impact on the occurrence of DAVF in VGM.

Vascular angular remodeling by kissing-Y stenting in wide necked intracranial bifurcation aneurysms.

INTRODUCTION: Single stent deployment leads to a change in vascular geometry in wide necked bifurcation aneurysms. In some complex cases, the use of the single stent technique might not be sufficient or may not be feasible. The kissing-Y stenting technique appears to be an alternative endovascular treatment option. The aim of this study was to evaluate the effects of the kissing-Y stenting technique on vascular angular remodeling. METHODS: 21 patients with wide necked intracranial bifurcation aneurysms at different sites (10 anterior communicating artery, 6 middle cerebral artery, 3 basilar artery, 1 vertebral artery/posterior inferior cerebellar artery, 1 internal carotid artery/posterior communicating artery) were treated with 44 closed cell stents (follow-up 2012-2016) using the kissing-Y stenting technique. We analyzed vascular angle geometry between the mother and both affected daughter vessels by digital subtraction angiography, before and after stent deployment, using standard working projections. RESULTS: Endovascular treatment of wide necked intracranial aneurysms using the kissing-Y stenting technique significantly decreased the angle between the bifurcation branches from 130.4±9.5° to 91.5±9.1° (p<0.0001). CONCLUSIONS: Kissing-Y stenting in wide necked bifurcation aneurysms leads to vascular angular remodeling of both affected branches. The resulting straightening of the bifurcation angle may prevent aneurysmal recurrence.

Endovascular treatment of head and neck arteriovenous malformations: long-term angiographic and quality of life results.

AIM: To present the long-term angiographic and subjective results of patients with head and neck arteriovenous malformations (HNAVMs) after endovascular treatment. METHODS: We retrospectively analyzed the medical files of 14 patients with HNAVM who were treated between 2000 and 2014. The treatment of choice was a transarterial superselective microcatheter-based approach followed by embolization using liquid embolic agents. The patients were asked to answer a quality of life questionnaire about the following symptoms before and after treatment: pain, functional impairment, cosmetic deformity, impairment in daily life, and bleeding. RESULTS: Complete or >90% closure of the AVM was achieved in 6 of 14 patients (43%). >50% shunt reduction was achieved in 10 patients (71%). Three complications were encountered in a total of 86 interventional procedures. Six patients presented with bleeding which was cured in all cases (100%). Four of the 14 patients (29%) specified pain which was resolved in two of them. Another six patients (43%) presented with functional impairment; four were cured and two noted an improvement. All 14 patients presented with cosmetic concerns; four were cured and eight experienced a clearly visible improvement. Nine of 13 patients (69%) presented with impairment in daily life which was resolved in five patients and four reported an improvement. CONCLUSIONS: Endovascular embolization is a well-tolerated therapy for HNAVM with a low complication rate. Good angiographic results, positive subjective results, and improvement in different aspects of quality of life can be achieved.

Endovascular treatment of complex intracranial aneurysms using Acandis Acclino stents.

OBJECTIVE: To determine the safety and effectiveness of a new low-profile, laser-cut, closed-cell stent system in the treatment of complex intracranial aneurysms. METHODS: A total number of 43 patients with complex intracranial aneurysms were treated using 60 Acandis Acclino stent systems (follow-up 2012-2016; mean 11 months). 36 patients presented with wide-necked intracranial aneurysms, dissecting aneurysms were seen in 7 patients. 39 patients received stent-assisted coiling. We analyzed demographic data and follow-up results. RESULTS: Sixty stents were successfully deployed. In one paraophthalmic internal carotid artery aneurysm the stent could not be placed. Thirty-three wide necked aneurysms were treated by single or multiple stent-assisted coiling. Complete occlusion was achieved in 31 of those cases (94% Raymond-Roy occlusion classification, RROC 1). Two patients showed stable residual aneurysmal filling (RROC 3). In three wide-necked aneurysms, sole stenting was the preferred treatment. For dual stent-assisted procedures the kissing-Y stenting technique was successfully performed in 11 aneurysms. In all dissecting aneurysms constructive therapy with stenting and preservation of the affected parent artery was achieved. Additional subsequent coil embolization was intentionally planned and successfully performed in 6 of the 7 dissecting aneurysms. The overall directly procedure-related complication rate was 7%, including one death. CONCLUSIONS: Endovascular treatment of complex intracranial aneurysms using Acclino stents is a feasible and safe procedure with low complication rates. Even severe cases can be treated among others using the kissing-Y stenting technique, with good mid-term results.

Fistulous-type vein of Galen malformation phantom model for endovascular training and research.

INTRODUCTION: Vein of Galen malformation (VGM), a high-flow intracranial arteriovenous shunt, is among the most severe neurovascular diseases in childhood. In many cases untreated children die or survive only severely disabled. Endovascular embolization is the preferred treatment. OBJECTIVE: To develop a simple fistulous-type VGM phantom model for teaching and training of different endovascular treatment methods and to investigate new treatment options and devices. METHODS: An experimental in vitro pulsatile phantom model was developed imitating a high-flow fistulous-type VGM, which is typical, especially in the neonatal phase. Pressure measurements at different arterial sites were performed before and after closure of the VGM. Closure of the VGM was achieved by coiling using a combined microcatheter-based transvenous and transarterial approach called 'kissing microcatheter technique'. RESULTS: The behaviour of the phantom model in vitro under fluoroscopy and under angiographic runs was extremely similar to that in in vivo conditions in children. The results showed that intra-arterial pressures changed and increased statistically significantly at all measurement sites after embolization, as in human arteriovenous malformation. We also demonstrated different and complementary visualizations of hemodynamics and angioarchitecture by antegrade and retrograde microcatheter injections. CONCLUSIONS: Our phantom model behaves like a typical fistulous-type VGM and can be used in vitro for teaching and training and for further research. It offers a new and better understanding of hemodynamics and angioarchitecture in the endovascular management of VGM.

Hydrocephalus in vein of Galen malformation: etiologies and therapeutic management implications.

BACKGROUND: Up to now, only little is known about hydrocephalus (HC) in vein of Galen malformation (VGM). We want to present the different etiologies and our long-term experience (1992-2015) in the management of HC. METHODS: Out of 44 treated children with VGM, we retrospectively reviewed all cases with HC. We analyzed the etiologies, our treatment results and complications. RESULTS: Twenty-one children (48 %) presented either with HC or developed it over time. In 21 % of those cases, high venous pressure was presumably the sole cause. Until 2009, seven of them received ventriculoperitoneal (VP) shunting; six of those resulted in severe postoperative complications. The remaining children have been treated successfully by endovascular embolization. Five out of the 44 children (11 %) developed HC after intraventricular hemorrhage. In four cases, those children were treated with positive results by using transient external ventricular drainages. In one case a VP shunt with highest valve pressure was inserted. Another four children (9 %) presented with aqueductal stenosis-related HC caused by either dilated venous outflow or space-occupying coil masses after embolization. The latter case was successfully treated by ventriculocisternostomy, whereas endovascular treatment decreased the venous outflow in size and thus resolved the HC in the other cases. In the remaining cases (7 %), atrophy due to melting brain syndrome led to HC ex vacuo. CONCLUSIONS: HC in VGM is a common phenomenon with several etiologies requiring different treatments. In most cases, embolization of the VGM as sole treatment is completely sufficient in order to decrease high venous pressure. However, certain other causes of HC should be treated in an interdisciplinary setting by specialized neurosurgeons.

Outcome and periprocedural time management in referred versus directly admitted stroke patients treated with thrombectomy.

BACKGROUND: After thrombectomy has shown to be effective in acute stroke patients with large vessel occlusion, the potential benefit of secondary referral for such an intervention needs to be validated. AIMS: We aimed to compare consecutive stoke patients directly admitted and treated with thrombectomy at a neurointerventional centre with patients secondarily referred for such a procedure from hospitals with a stroke unit. METHODS: Periprocedure times and mortality in 300 patients primarily treated in eight neurointerventional centres were compared with 343 patients referred from nine other hospitals in a prospective multicentre study of a German neurovascular network. Data on functional outcome at 3 months was available in 430 (76.4%) patients. RESULTS: In-hospital mortality (14.8% versus 11.7%, p = 0.26) and 3 months mortality (21.9% versus 24.1%, p = 0.53) were not statistically different in both patient groups despite a significant shorter symptom to groin puncture time in directly admitted patients, which was mainly caused by a longer interfacility transfer time. We found a nonsignificant trend for better functional outcome at 3 months in directly admitted patients (modified Rankin Scale 0-2, 44.0% versus 35.7%, p = 0.08). CONCLUSIONS: Our results show that a drip-and-ship thrombectomy concept can be effectively organized in a metropolitan stroke network. Every effort should be made to speed up the emergency interfacility transfer to a neurointerventional centre in stroke patients eligible for thrombectomy after initial brain imaging.

Kissing-Y stenting for endovascular treatment of complex wide necked bifurcation aneurysms using Acandis Acclino stents: results and literature review.

INTRODUCTION: Y-configured stent assisted coiling is a promising therapeutic option to ensure safe coil embolization and preserve the affected arteries in complex wide necked aneurysms. We present our experience with self-expanding Acandis Acclino stents for the treatment of complex aneurysms using the kissing-Y technique. METHODS: We retrospectively reviewed seven patients with seven complex aneurysms (three anterior communicating artery (AcomA), two middle cerebral artery, one basilar artery/superior cerebellar artery, and one vertebral artery/posterior inferior cerebellar artery) who were treated with the kissing-Y technique by stent assisted coiling from June 2013 to July 2014, with follow-up until January 2015. DSA follow-up was up to 17 months, with a mean follow-up period of 10 months. Six patients were treated electively and one in the acute phase of a subarachnoid hemorrhage. In all cases, closed cell Acandis Acclino stents were used. We evaluated procedural complications, clinical outcomes, and mid term angiographic follow-up. Additionally, a literature review is provided. RESULTS: In all patients, stents were successfully placed and implanted. One patient developed a periprocedural thromboembolic complication not directly related to the stents. No other periprocedural or postprocedural complications were encountered. Follow-up examinations showed stable and total occlusion of all coiled aneurysms. CONCLUSIONS: The results of our study show that the kissing-Y technique using closed cell Acandis Acclino stents followed by coil embolization is a feasible treatment option for selected complex bifurcation aneurysms.

Cranial Doppler ultrasound in Vein of Galen malformation.

INTRODUCTION: Vein of Galen malformation (VGM) is the severest paediatric neurovascular disease usually requiring multiple staged embolisations. In the high-risk group of children with high-flow arteriovenous shunts, timing of treatment is uncertain. Low Doppler resistance index (RI) is known to be associated with adverse outcome in hypoxic-ischaemic brain injury in children. In this study, we want to present our long-term results of cranial transfontanellar Doppler ultrasound in children with VGM. METHODS: We identified and retrospectively analysed 264 transfontanellar Doppler measurements in 19 endovascular-treated true VGM (five females, 14 males) between 2000 and 2013. The recordings were obtained from the internal carotid arteries (ICA), the anterior cerebral arteries (ACA) and the basilar arteries (BA). Maximal systolic velocity (Vs), end-diastolic velocity (Ved) and the RI were measured before and after embolisation. RESULTS: Untreated, nearly all cases showed pathologic high systolic (up to >1.0 m/s), very high diastolic velocities (up to >0.5 m/s) and low RI (<0.6). There were statistically significant differences (p = 0.012) between the pre-embolisation RI and the post-embolisation RI with pathologic low RI before and nearly normal RI after successful shunt reduction. CONCLUSION: Successful endovascular shunt reduction in VGM leads to significant changes of cranial Doppler RI from pathologic low values to normal values. We propose cranial Doppler ultrasound as an adjunctive technique to other screenings in the management of VGM. Further research is warranted to evaluate the role of the RI in the treatment timing decision.

Caroli disease associated with vein of Galen malformation in a male child.

We report the first case of a male child with both Caroli disease and vein of Galen malformation. The neonate presented to our department with congestive heart failure as a result of the intracranial arteriovenous high-flow shunt. Over time, several endovascular embolizations led to a complete angiographic occlusion of the shunt. Additionally, the diagnosis of Caroli disease was made at the age of 2 months. He developed choledocholithiasis necessitating endoscopic sphincterotomy and stone extraction. As a prolonged medical treatment he received ursodeoxycholic acid and antibiotics. A coincidence of Caroli disease and vein of Galen malformation has not yet been described. Both diseases are very rare, leading to the question of whether there is a link in the pathogenesis. Based on the few previously described underlying mechanisms, we develop hypotheses about the relationship between both rare diseases. We consider overexpression of vascular endothelial growth factor and its receptors as a possible common molecular mechanism in their pathogenesis. We also highlight the critical role of increased expression of the Notch ligand Jagged 1 both in the development of cerebral arteriovenous malformations in general and in the formation of dilated intrahepatic bile ducts (eg, in Caroli disease).

Estimated low risk of rupture of small-sized unruptured intracranial aneurysms (UIAs) in relation to intracranial aneurysms in patients with subarachnoid haemorrhage.

OBJECTIVE: International guidelines for the management of unruptured intracranial aneurysms (UIAs) recommend observation in aneurysms <10 mm due to the estimated low risk of rupture. The aim of our study was analyse the data of recently treated patients with ruptured cerebral aneurysms with the special focus on size and configuration in view of the frequency scale in a daily routine setting. METHODS: We reviewed the data of all patients with aneurysmal subarachnoid haemorrhage (SAH) during the last 24 months at our institution. Configuration and size of the aneurysms were measured. Clinical data were collected using the following classifications for analysis: Hunt and Hess (H&H), modified Rankin Scale (mRS) and Fisher classification. RESULTS: Data of 135 patients with aneurysmal SAH (98 women, 37 men; ratio 2.6:1) were analysed. Analysis showed that 19 aneurysms (14 %) were >10 mm (mean size, 19.2 mm) and 116 aneurysms (85.9 %) <10 mm (mean size, 6.2 mm). In total, 112 were categorised as berry-like configured aneurysms (n = 113 <10 mm, n = 3 >10 mm), 18 as multi-lobar (n = 16 <10 mm, n = 2 >10 mm) and 5 as fusiform (n = 4 <10 mm, n = 1, >10 mm). CONCLUSION: Since the results of our study showed that the majority of the aneurysms are <10 mm (mean, 6.2 mm), it is justified to challenge the recommendations of the international guidelines in a daily routine setting. We believe that the published data are not convincing enough to play a guidance role in daily routine. Due to improving surgical and endovascular techniques with satisfying results and the high number of ruptured small aneurysms, we believe a change in attitude in management of small-sized aneurysms is needed. Further diagnostic models are needed to determine the risk of rupture of intracranial aneurysms properly to obtain adequate treatment for UIAs.

Intermittent hypoglossal nerve palsy caused by a calcified persistent hypoglossal artery: an uncommon neurovascular compression syndrome.

Neurovascular compression is assumed to cause symptoms like trigeminal neuralgia, hemifacial spasm and vestibular paroxysmia. We present a patient with recurrent episodes of transient dysarthria due to isolated right hypoglossal nerve (HN) palsy. We describe the first case of a calcified persistent hypoglossal artery (PHA) as the putative cause of a hypoglossal neurovascular compression syndrome. Our patient received a daily low-dose medication of carbamazepine resulting in complete relief of symptoms. In conclusion, PHA is not only an anatomic variation but also a possible cause of a neurovascular compression syndrome leading to intermittent HN palsy.