Relationship Between Brain Tumors and Intracranial Aneurysms: A Systematic Review.

AIM: To investigate the possible relationship between intracranial aneurysms and brain neoplasms. MATERIAL AND METHODS: A comprehensive literature review involving a search of the databases PubMed and Embase to identify relevant articles was conducted in March 2021. The initial search retrieved 451 articles. After deduplication and screening of abstracts, 56 articles were selected. After reading of the full texts, 19 articles were included in the review. RESULTS: There insufficient evidence to support that people with brain neoplasms have a higher incidence rate of IAs. However, the prevalence of IAs appears to be higher in patients with pituitary tumors than in the general population. The key factors affecting prognosis were tumor type in patients with unruptured aneurysms and progression of subarachnoid hemorrhage in individuals with ruptured aneurysms. Treatment should be individualized according to patient age, tumor pathology, location, and aneurysm rupture risk. CONCLUSION: There is a lack of evidence to affirm that the existence of brain neoplasm plays a role in the formation and rupture of intracranial aneurysms. Additionally, there is insufficient evidence to confirm a greater prevalence of intracranial aneurysms in individuals with brain tumors. The association of these two disorders does not appear to worsen patient outcome. Prognosis depends on tumor pathology for malignant cases and on subarachnoid hemorrhage in patients with ruptured aneurysms.

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

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

Pediatric intracranial aneurysms in a Southern Brazilian population.

INTRODUCTION: Intracranial aneurysms are rare in the pediatric population, and their diagnosis can be challenging. They differ from their adult counterparts in several aspects, and hemorrhage is the most common presentation. OBJECTIVE: To evaluate clinical data, aneurysm characteristics, and therapeutic results in a series of patients younger than 19 years of age with intracranial aneurysms. METHOD: A retrospective cross-sectional observational study design analyzed medical records and imaging studies. Variables included age, sex, clinical presentation, comorbidities, aneurysmal characteristics, treatment modality, and clinical outcomes. RESULTS: We identified 15 intracranial aneurysms in 11 patients (6 male), with ages ranging from 3 months to 15 years (mean age 5.2 years). Five patients had associated medical conditions, and hemorrhage was the most frequent clinical presentation (45%). Three patients (27%) had multiple aneurysms, and seven aneurysms were fusiform or dysplastic. The internal carotid artery was the most affected site, involved in 47% of cases. Aneurysm size ranged from 2 to 60 mm (mean 16.8 mm), with giant aneurysms in 27%. Seven patients were treated with endovascular procedures, while three aneurysms were clipped. Symptomatic vasospasm requiring angioplasty occurred in two patients and led to worse outcomes. One patient died due to severe aspiration pneumonia and sepsis that precluded treatment. Good functional outcome (modified Rankin scale - mRS ≤ 2) was achieved in all treated patients (91%). CONCLUSION: The patients with aneurysms in this series were mostly male, presented mostly hemorrhagic syndromes, and mainly had internal carotid artery involvement. The outcome of treated patients was favorable, regardless of treatment modality.

Risks for Oculomotor Nerve Palsy and Time to Recovery After Surgical Clipping of Posterior Communicating Artery Aneurysms: A Multicenter Retrospective Cohort Study.

BACKGROUND: Aneurysms of the posterior communicating segment of carotid artery (PcomA) have a high risk of rupture; when these nonruptured aneurysms are associated with oculomotor nerve palsy (ONP), the risk of rupture increases compared with asymptomatic nonruptured PcomA. OBJECTIVE: To retrospectively analyze the risk factors involved in ONP secondary to PcomA aneurysm and to study the factors involved in the recovery time of ONP once it is established. METHODS: This was a retrospective study of patients from 10 neurosurgery centers from October 2008 to December 2020. We analyzed age at diagnosis, presence of compressive neuropathy of the oculomotor nerve, presence of aneurysm rupture, largest aneurysm diameter, aneurysm projection, smoking, hypertension, diabetes, time between diagnosis and surgical treatment, as well as the outcome. RESULTS: Approximately 1 in 5 patients (119/511 23.3%) with a PcomA presented with ONP. We found that patients with aneurysms measuring greater than or equal to 7.5 mm were 1.6 times more likely to have ONP than those with aneurysms smaller than 7.5 mm. In our study, the prevalence of smoking in the PcomA + ONP group was 57.76%, and we also found that smokers were 2.51 times more likely to develop ONP. A total of 80.7% showed some degree of improvement, and 45.4% showed complete improvement with a median recovery time of 90 days. CONCLUSION: This study showed that 80.7% of patients with PcomA aneurysms undergoing surgical treatment with aneurysm clipping showed some degree of improvement of the ONP, with a median time to recovery between 90 and 120 days.

Aneurismas intracraneales, no rotos en pacientes de la provincia Sancti Spíritus / Non-ruptured intracranial aneurysms in patients from Sancti Spíritus province

Fundamento: Los aneurismas intracraneales cuando se fisuran provocan una hemorragia subaracnoidea. No obstante, no todos se rompen y algunos pueden ser encontrados de manera casual en un estudio imaginológico y se les denomina incidentales o asintomáticos según el paciente presente, o no, historia previa de otro saco que se haya roto con anterioridad. Tratar un aneurisma intracraneal no roto es un desafío para líderes clínicos y quirúrgicos. Objetivo: Describir las características y evolución de una serie de 91 aneurismas intracraneales incidentales y asintomáticos en pacientes atendidos en el Hospital General Camilo Cienfuegos de Sancti Spíritus entre los años 2010 y 2020. Metodología: Estudio descriptivo y cuantitativo con una muestra no probabilística de 91 aneurismas incidentales y asintomáticos encontrados en 72 pacientes mediante estudios imaginológicos. Las variables estudiadas fueron: edad, sexo, dimensiones, forma irregular, sitio de localización, método de tratamientos empleados, mortalidad y morbilidad. Resultados: Predominaron los pacientes con edad entre 45 y 65 años y hubo un predominio del sexo femenino. Fue mayoritario el aneurisma de mediano tamaño y la localización más frecuente fue la comunicante anterior. Se detectaron variables clínicas y morfológicas predictivas de complicaciones. Los pacientes no intervenidos quirúrgicamente evolucionaron mejor. Se detectaron varios pacientes con familiares de primer y segundo grado afectados por aneurismas intracraneales. Conclusiones: Los aneurismas intracraneales no rotos predominan en mujeres de la quinta y sexta década de la vida. Factores morfológicos como el tamaño del saco, la altura máxima del domo y la razón de aspecto se relacionaron con la aparición de complicaciones en los pacientes operados. El síndrome de aneurisma intracraneal familiar debe tenerse en cuenta en pacientes con antecedentes de familiares de primer y segundo grado con aneurismas intracraneales.

Background: Intracranial aneurysms when ruptured cause subarachnoid hemorrhage. However, not always they rupture and some may be found by chance in an imaging study and they are called incidental or asymptomatic depending on whether or not the patient has a prior event of additional ruptured sac formerly. Treating a non-ruptured intracranial aneurysm is a challenge for foremost clinical physicians and surgeons. Objective: To describe the characteristics and evolution of a series of 91 incidental and asymptomatic intracranial aneurysms in patients treated at the General Hospital Camilo Cienfuegos in Sancti Spíritus between 2010 and 2020. Methodology: Descriptive and quantitative study with a non-probabilistic sample of 91 incidental and asymptomatic aneurysms found in 72 patients through imaging studies. The variables studied were: age, sex, dimensions, irregular shape, site of location, method of treatment used, mortality and morbidity. Results: Patients aged between 45 and 65 years predominated with a predominance of female sex. The majority were medium-sized aneurysms and the most frequent location was the anterior connecting aneurysm. Clinical and morphological variables predictive of complications were detected. Patients who did not undergo surgery had a better evolution. Several patients with first and second relatives' degree affected by intracranial aneurysms were detected. Conclusions: Non-ruptured intracranial aneurysms predominate in women in the fifth and sixth decade of life. Morphological factors such as sac size, maximum dome height and aspect ratio were related to the happening of complications in operated patients. Family intracranial aneurysm syndrome should be considered in patients with a history of first and second relatives' degree affected by intracranial aneurysms.

Prevalence of Intracranial Aneurysms in Hereditary Hemorrhagic Telangiectasia: Report from a Single Reference Center.

BACKGROUND AND PURPOSE: Neurologic manifestations in hereditary hemorrhagic telangiectasia include an increased incidence of brain abscesses and ischemic strokes due to paradoxic embolization in addition to a wide spectrum of symptoms and complications due to typical brain vascular malformations. Intracranial aneurysms are not part of this brain vascular malformation spectrum. The aim of this study was to determine their prevalence in patients with hereditary hemorrhagic telangiectasia. MATERIALS AND METHODS: This was a single-center, retrospective study. Adult patients from the institutional Hereditary Hemorrhagic Telangiectasia registry with a definitive diagnosis of hereditary hemorrhagic telangiectasia and an available report or angiographic imaging study were included and reviewed to determine the intracranial aneurysm prevalence. In addition, the morphologic characteristics of intracranial aneurysms and possible associated risk factors were collected. RESULTS: Two hundred twenty-eight patients were analyzed. Thirty-seven aneurysms in 33 patients (14.5%; 95% CI, 9.9%-19%) were found. The median diameter of intracranial aneurysms was 3.2 mm (interquartile range, 2.6-4.4 mm). No association between intracranial aneurysm and sex, age, or genetic background was noted. There were no subarachnoid hemorrhagic events due to intracranial aneurysm rupture. CONCLUSIONS: Due to the high prevalence of intracranial aneurysms in adult patients with hereditary hemorrhagic telangiectasia, further studies regarding bleeding risks and monitoring should be addressed.

Multiple and mirror intracranial aneurysms: study of prevalence and associated risk factors.

OBJECTIVE: Multiple intracranial aneurysms (MIA) account for 30% of all intracranial aneurysms, while mirror aneurysms, a subgroup of MIA, are present in 5% of all patients with cerebral aneurysms. We investigated the risk factors associated with the presence of multiple and mirror intracranial aneurysms. METHODS: 1404 patients, 314 males (22.4%) and 1090 female (77.6%) were enrolled for this study. Diagnosis was performed with a digital subtraction angiography (DSA). Multiplicity was defined as the presence of two or more aneurysms and mirror aneurysms as one pair of aneurysms involving bilateral corresponding arteries. Patients were followed-up from September 2009 till August 2018. Individuals' characteristics such as sex, age, smoking, hypertension and use of contraceptives were evaluated. RESULTS: Five hundred and twelve patients (36.4%) were diagnosed with MIA, approximately 4%/year. We observed 203 pairs of mirror aneurysms, accounting for 406 aneurysms (13% of the population). There was an increased frequency of females with multiple (p < 0.001, OR = 1.883, 95% CI = 1.386-2.560) and mirror aneurysms (p < 0.001, OR = 2.828, 95% CI = 1.725-4.636). Smoking was associated with multiplicity (p< 0.001, OR = 1.458, 95% CI = 1.160-1.833), as well as advanced age (p < 0.001, OR = 1.938, 95% CI = 1.438-2.611), but there was no significant relation with presence of mirror aneurysms. We observed higher frequency of baby aneurysms (<3mm) in the group of patients with MIA, while giant aneurysms (>25 mm) were most found in patients with only one aneurysm (p < 0.001). No differences between patients who used contraceptives against patients who did not use were found (p = 0.600). CONCLUSIONS: Gender and smoking, known risk factors to the development of a single intracranial aneurysm, are proportionally increased in patients with MIA. Hypertension and oral contraceptives were not associated with multiplicity.

C-Reactive Protein Levels Are Higher in Patients With Fusiform Intracranial Aneurysms: A Case-Control Study.

BACKGROUND: Comprehending the risk factors that contribute to the formation of fusiform aneurysms (FAs) might provide some insight into treatment and prevention strategies. This case-control study aimed to compare the levels of serum C-reactive protein (CRP), as a biomarker, between patients with fusiform and saccular intracranial aneurysms. METHODS: We retrospectively analyzed medical records from 2010 to 2019. Thirty-five patients were identified as having FAs: 13 (37.1%) were ruptured, and 22 were unruptured. An age-matched sample of 70 controls (2:1) with saccular aneurysms was obtained from the same records: 36 (51.4%) ruptured and 34 unruptured. RESULTS: Patients with FAs had median CRP values of 0.61 mg/dL (IQR: 1.5), compared with 0.29 mg/dL (IQR: 0.42) in controls (P < 0.01). Within both the ruptured and the unruptured group, median CRP was higher in patients with FAs compared with controls (P < 0.01). Diabetes, smoking status, hypertension, and sex did not significantly influence CRP levels. Age-adjusted analyses showed that fusiform morphology was independently associated with higher CRP levels for unruptured aneurysms (OR 1.2, 95% CI 1.05-1.43), but not for ruptured aneurysms (OR 1.02, 95%CI 0.99-1.05). CONCLUSIONS: CRP was higher in patients with FAs than controls, and it constituted an independent predictor of fusiform morphology for patients with unruptured aneurysms. Inflammation might be an especially important factor in FA formation and growth, and further studies could use this finding to design new treatment strategies.

Residual lesions in patients undergoing microsurgical clipping of cerebral aneurysms in a reference university hospital.

OBJECTIVES: This study aimed to analyze the incidence and epidemiological, angiographic, and surgical aspects associated with incomplete clipping of brain aneurysms in a cohort of patients undergoing microsurgical treatment. METHODS: The medical record data of patients who underwent microsurgery for cerebral aneurysm treatment and postoperative digital subtraction angiography, treated at the same teaching hospital between 2014 and 2019, were retrospectively analyzed. The studied variables involved epidemiological and clinical data, as well as neurological status and findings on neuroimaging. The time elapsed between hemorrhage and microsurgical treatment, data on the neurosurgical procedure employed for aneurysm occlusion, and factors associated with the treated aneurysm, specifically location and size, were also evaluated. RESULTS: One hundred and seventeen patients were submitted to 139 neurosurgical procedures, in which 167 aneurysms were clipped. The overall rate of residual injury was 23%. Smoking (odds ratio [OR]: 3.38, 95% confidence interval [CI95%]: 1.372-8.300, p=0.008), lesion size >10 mm (OR: 5.136, CI95%: 2.240-11.779, p<0.001) and surgery duration >6 h (OR: 8.667, CI95%: 2.713-27.681, p<0.001) were found to significantly impact incomplete aneurysm occlusion in the univariate analyses. CONCLUSION: Incomplete microsurgical aneurysm occlusion is associated with aneurysm size, complexity, and current smoking status. Currently, there is no consensus on postoperative assessment of clipped aneurysms, hindering the correct assessment of treatment outcomes.

Microsurgical clipping of multiple cerebral aneurysms in the acute phase of aneurysmal subarachnoid hemorrhage through a minipterional approach: The Chilean experience.

OBJECTIVE: The minipterional craniotomy (MPTc) has been widely accepted as a minimally invasive alternative to the pterional approach for the treatment of certain small non-ruptured anterior circulation aneurysms. The aim of this study was to determine the effectiveness and safety of the MPTc in the context of a complex and potentially harmful scenario: acute onset of subarachnoid hemorrhage (SAH) in patients harboring multiple intracranial aneurysms (MIA). METHODS: Patients harboring MIA clipped through a unilateral MPTc were selected from four retrospective databases of four high-volume neurosurgical centers. Patients with a Hunt & Hess score 4 or 5 were not considered candidates for clipping through a MPTc. Medical records and radiological images were retrospectively reviewed. Epidemiological, clinical and radiological data, as well as short-term outcome (modified Rankin scale at 6 month-follow-up) were analyzed. RESULTS: 16 patients harboring 33 aneurysms (16 ruptured, 17 non ruptured) met the inclusion criteria. Each aneurysm size was 5.7 ± 2.1 mm (range 3-11). 12 out of 33 aneurysms were located in the middle cerebral artery (MCA). Anterior communicating (ACom) and MCA aneurysms were the aneurysm locations most commonly ruptured (5 each, 62 %). Complete occlusion was achieved in 32 aneurysms (97 %) and near-complete occlusion in 1 (3%). 13 patients (93 %) were independent at 6 month-follow-up. Mortality rate was 0%. Complications included 1 cerebrospinal-fluid leakage. CONCLUSION: When indicated (Hunt Hess < 4), performing a MPTc is safe and effective in aSAH cases with multiple aneurysms.

Association between intracranial aneurysm and meningiomas: An integrative survival Analysis with identification of prognostic factors.

OBJECTIVE: To analyze prognostic factors in clinical association between intracranial aneurysm (IA) and meningioma. Prognostic factors on overall survival (OS) were evaluated. METHODS: We selected articles, published from January 1944 to December 2018 on the Medical databases (Web of Sciences, Medline and EMBASE) and included case series and reports. Clinical information was obtained and variables associated with the primary outcome of 27-mo survival were identified through Cox regression models. RESULTS: The study evaluated 77 patients. Female represented 76.6 % (n = 59), a ratio of 3.27 female: 1 male. The age range was 7-84 years old, with an average of 54.74 (SD: 14.30). Age and sex were not significant statistically different between the two groups for overall survival (OS) (log-rank P = 0.806), (log-rank P = 0.983) respectively. 77.9 % (n = 60) were ipsilateral, the same side was 4 times more common in univariate analysis (P = 0.052; 95 % CI, 0.924-17.319). Most aneurysms were detected in the internal carotid artery, 29.87 %. In Clinical data, 62.33 % (n = 48) had exclusive tumor symptoms, while 25.97 % (n = 20) presented exclusively subarachnoid hemorrhage (SAH). In multivariate analysis, although there is an independent protective factor for those who did not have SAH (HR; 0.099; CI; 0.010-0.986; P = 0.049) and the treatment is an independent predictor for OS (HR, 42.096; CI, 4.270-415.056; P = 0.01). CONCLUSION: This is the first study to approach this association. This is not just an occasional finding, but it seems to have a shared pathophysiology. Unruptured aneurysms and treatment modality were protective independent factors for OS. Prospective studies are warranted to provide definitive answers.

Microsurgery of Cerebral Aneurysm: Epidemiological Profile

Objectives Intracranial aneurysm consists of localized dilatation of the vascular wall. Its importance includes the fearsome event of rupture and subarachnoid hemorrhage, which presents high morbimortality rates. The present study aimed to analyze the profile and clinical outcome of patients submitted to the microsurgical approach of cerebral aneurysm in the city of Criciúma, state of Santa Catarina, Brazil, from 2015 to 2018. Methods A retrospective observational study was performed, with secondary data collection and a quantitative approach of 47 charts. Results A predominance of females (74.5%) and amean age of 53 years old (53.53 9.64) was observed. The middle cerebral artery was the most affected vessel (36.2%), with the highest percentage of aneurysms being between 2.1mmand 7.0mm(65.9%). Therewas a correlation between consciousness level and classification on the Hunt-Hess (HH) scale. Patients with GlasgowComa Scale (GCS)> 7 points had a better prognostic score in the HH scale, and those with GCS 7 points had a worse prognostic score in the HH scale. Conclusions The present study observed the presence of important risk factors for cerebral aneurysm formation, such as gender, age, smoking, and systemic arterial hypertension. The present study can measure a correlation of the level of consciousness with the HH classification.

Casuística, manejo y resultados de los aneurismas cerebrales en el Hospital de Clínicas - Paraguay, desde el 2011 al 2019 / Casuistry, management and results of brain aneurysms at the Hospital de Clínicas - Paraguay, from 2011 to 2019

Introducción: La Hemorragia Subaracnoidea es el sangrado en el espacio subaracnoideo. La causa espontánea en la mayoría de las veces se debe a ruptura de un aneurisma cerebral. Objetivo: Describir la casuística, manejo y resultados de los aneurismas cerebrales en el Hospital de Clínicas. Pacientes y método: Estudio observacional, descriptivo, transversal, incluyendo pacientes operados de aneurismas cerebrales, mayores de 17 años, en el Hospital de Clínicas del 2011 al 2019. Las variables descriptas fueron: edad, sexo, motivo de consulta, estudios radiológicos, escala de Glasgow y Hunt y Hess, localización, segmento, cantidad, fase, clipado temporario, vasoespasmo e hidrocefalia. Resultados: Se incluyó 249 pacientes; 45% masculino, 65% femenino, con edad promedio de 47,5 años. El motivo de consulta más frecuente fue cefalea. Al ingreso tuvieron predominantemente Hunt y Hess 2, y, Glasgow 15. El 43,2% eran Fisher 4. El Glasgow de egreso fue mayor o igual a 14 en 82,1%. Se diagnosticó el 51,7% con arteriografía; el 50,9% de los aneurismas en la carótida interna y, fueron múltiples en 10,84%. Se operaron en fase aguda 28,3%, 65% en fase tardía y, el 6,7% de los aneurismas fue de hallazgo casual. En 36,44% de los casos se realizó clipado temporario y, en el 70,4% se perforó la lámina terminalis. La mortalidad fue de 4,2%. Presentaron vasoespasmo radiológico en un 46% y, vasoespasmo clínico en 24,5 %. El 11% fue sometido a craniectomía descompresiva y, 5,5% desarrolló hidrocefalia dependiente de VDVP. Conclusión: El clipado de los aneurismas cerebrales es una técnica con buenos resultados y la única accesible en el sector público.

Introduction: Subarachnoid hemorrhage is bleeding in the subarachnoid space. The spontaneous is caused most of the time by rupture of a cerebral aneurysm. Objective: Describe the casuistry, management and results of cerebral aneurysms at the Hospital de Clínicas. Patients and methods: Observational, descriptive, cross-sectional study including patients operated for cerebral aneurysms, older than 17 years, at the Hospital de Clínicas from 2011 to 2019. The variables described were: age, sex, reason for consultation, radiological studies, Glasgow and Hunt and Hess scale, location, segment, quantity, phase, temporary clipping, vasospasm and hydrocephalus. Results: 249 patients were included; 45% male, 65% female, average age 47.5 years. The most frequent reason for consultation was headache. At admission they had predominantly Hunt and Hess 2, and Glasgow 15. 43.2% were Fisher 4. The Glasgow of discharge was greater than or equal to 14 in 82.1%. 51.7% were diagnosed with arteriography; 50.9% internal carotid aneurysms, multiple 10.84%. 28.3% were operated in acute phase, 65% late phase, 6.7% were a casually found. In 36.44% of cases a temporary clipping was performed and in 70.4% the lamina terminalis was perforated. Mortality was 4.2%, radiological vasospasm 46%, clinical vasospasm 24.5%, 11% underwent decompressive craniectomy and 5.5% developed VDVP-dependent hydrocephalus. Conclusion: The clipping of cerebral aneurysms is a technique with good results and the only one in the public sector.

Descriptive Study of Aneurysmal and Nonaneurysmal Subarachnoid Hemorrhage and the Role of Confirmative Digital Subtraction Angiography in Patients with Nonaneurysmal Subarachnoid in Puerto Rico.

BACKGROUND: Cerebrovascular disease is the fifth cause of mortality in Puerto Rico. There is no descriptive study for the presentation of spontaneous subarachnoid hemorrhage (SAH) in our institution. Therefore, our primary aim was to perform a retrospective analysis of adult patients with spontaneous SAH and assess the need for digital subtraction angiography (DSA) after initially aneurysm-negative computed tomography angiography (CTA) in nonaneurysmal SAH, specifically perimesencephalic SAH (PM-SAH). METHODS: Medical records of 324 adult patients with aneurysmal and nonaneurysmal SAH treated at the Puerto Rico Medical Center from 2015 to 2018 were retrospectively analyzed. Demographics, past medical history, clinical characteristics, and imaging information were extracted. RESULTS: Acute hydrocephalus, mortality at 30 days, prevalence of diffuse SAH pattern, and Fisher and World Federation of Neurosurgical Societies grades >2 on initial examination were higher in the aneurysmal SAH subgroup. Patients with nonaneurysmal SAH had a significantly higher prevalence of chronic kidney disease and diabetes mellitus. Of the patients with nonaneurysmal PM-SAH with initial aneurysm-negative CTA, 100% were subsequently confirmed by DSA. CONCLUSIONS: Patients in the aneurysmal SAH subgroup correlated with an increased disease burden. Furthermore, this study shows that in our population, patients with nonaneurysmal PM-SAH with a low Fisher and World Federation of Neurosurgical Societies grade and with comorbid diabetes mellitus and chronic kidney disease may not need DSA after a negative initial CTA result.

Residual lesions in patients undergoing microsurgical clipping of cerebral aneurysms in a reference university hospital

OBJECTIVES: This study aimed to analyze the incidence and epidemiological, angiographic, and surgical aspects associated with incomplete clipping of brain aneurysms in a cohort of patients undergoing microsurgical treatment. METHODS: The medical record data of patients who underwent microsurgery for cerebral aneurysm treatment and postoperative digital subtraction angiography, treated at the same teaching hospital between 2014 and 2019, were retrospectively analyzed. The studied variables involved epidemiological and clinical data, as well as neurological status and findings on neuroimaging. The time elapsed between hemorrhage and microsurgical treatment, data on the neurosurgical procedure employed for aneurysm occlusion, and factors associated with the treated aneurysm, specifically location and size, were also evaluated. RESULTS: One hundred and seventeen patients were submitted to 139 neurosurgical procedures, in which 167 aneurysms were clipped. The overall rate of residual injury was 23%. Smoking (odds ratio [OR]: 3.38, 95% confidence interval [CI95%]: 1.372-8.300, p=0.008), lesion size >10 mm (OR: 5.136, CI95%: 2.240-11.779, p<0.001) and surgery duration >6 h (OR: 8.667, CI95%: 2.713-27.681, p<0.001) were found to significantly impact incomplete aneurysm occlusion in the univariate analyses. CONCLUSION: Incomplete microsurgical aneurysm occlusion is associated with aneurysm size, complexity, and current smoking status. Currently, there is no consensus on postoperative assessment of clipped aneurysms, hindering the correct assessment of treatment outcomes.

Cavernous carotid artery aneurysms on a single institution: An epidemiological study with 201 patients.

OBJECTIVES: Cavernous carotid aneurysms (CCA) represent 2-9% of all intracranial aneurysms. For long considered benign lesions, these entities are unique when it comes to clinical presentation and management. Usually asymptomatic, CCAs can grow and rupture causing different manifestations. The lack of a long-term assessment of both treated and untreated CCAs' natural history justifies why there is no consensus regarding what are the recommended therapeutic measures. While some advocate that an intervention is always necessary, others consider that patients deserve an individualized evaluation. PATIENTS AND METHODS: We describe our single-institution experience in diagnosis, follow-up, and management of 201 CCAs. In addition, we evaluate the association of giant CCAs with aneurysms in other locations using a Chi-square test. RESULTS: 201 patients had 245 CCAs. 92% of the patients were women. The mean age at diagnosis was 61 years. Concomitant aneurysms were observed in 53.2% of the patients, and the middle cerebral artery was the most affected artery. 66 (30.6%) CCAs were considered "giant", and the follow-up period ranged from 1 to 23 years.The presence of a giant CCA seemed to hinder other aneurysms' formation - RR 0.47 (IC 95% 0.31-0.67), p < 0.0001. CONCLUSIONS: CCAs should be individually assessed. A conservative approach ought to be adopted for asymptomatic and oligosymptomatic lesions. Finally, a multidisciplinary team must evaluate the other situations, in order to define whether the microsurgical or the endovascular treatment is better option. Presence of a giant lesion within the cavernous sinus is associated with less occurrence of other aneurysms.

Derivo Embolization Device for the Treatment of Intracranial Aneurysms.

Background and Purpose- Flow diverter technology improvements are necessary to provide safe and good results and enable the treatment of a larger variety of aneurysms. We report a nationwide experience with the Derivo Embolization Device in the treatment of intracranial aneurysms. Methods- BRAIDED (Brazilian Registry of Aneurysms Assigned to Intervention With the Derivo Embolization Device) is a multicenter, prospective, interventional, single-arm trial of the Derivo Embolization Device for the treatment of intracranial aneurysms. The primary effectiveness end point was total aneurysm occlusion at 6- and 12-month angiographies. The secondary safety end point was the absence of serious adverse events during follow-up. Univariable and multivariable logistic regression was performed to identify predictors of aneurysm persistence, periprocedural complications, and adverse events during follow-up. Results- Between December 2016 and October 2018, 146 patients harboring 183 intracranial aneurysms were treated in 151 interventions at 7 centers. Derivo Embolization Device placement was technically successful in all patients. Most aneurysms (86.9%) were located at the internal carotid artery, and the mean diameter was 6.7 mm. At 6 months, 113 of 140 (80.7%) aneurysms met the study's primary end point, and 74 of 83 (89.2%) met the study's primary end point at 12 months. Saccular morphology of the aneurysm (odds ratio, 5.66; 95% CI, 1.01-31.77) and the presence of a branch arising from the sac (odds ratio, 6.36; 95% CI, 2.11-22.36) predicted persistence. A long duration of follow-up (odds ratio, 0.86; 95% CI, 0.78-0.95) predicted total occlusion. Of the 146 enrolled patients, 138 (94.5%) were treated without serious adverse events during follow-up. In the multivariable analysis, aneurysms located at a sidewall were less likely to experience these events than those located at bifurcations (odds ratio, 0.07; 95% CI, 0.01-0.51). Conclusions- The Derivo Embolization Device is a safe and effective treatment for intracranial aneurysms. Clinical Trial Registration- URL: http://plataformabrasil.saude.gov.br/login.jsf. Unique identifier: CAAE 77089717.7.1001.5125.

Worldwide Incidence of Aneurysmal Subarachnoid Hemorrhage According to Region, Time Period, Blood Pressure, and Smoking Prevalence in the Population: A Systematic Review and Meta-analysis.

Importance: Subarachnoid hemorrhage (SAH) from ruptured intracranial aneurysms is a subset of stroke with high fatality and morbidity. Better understanding of a change in incidence over time and of factors associated with this change could facilitate primary prevention. Objective: To assess worldwide SAH incidence according to region, age, sex, time period, blood pressure, and smoking prevalence. Data Sources: We searched PubMed, Web of Science, and Embase for studies on SAH incidence published between January 1960 and March 2017. Worldwide blood pressure and smoking prevalence data were extracted from the Noncommunicable Disease Risk Factor and Global Burden of Disease data sets. Study Selection: Population-based studies with prospective designs representative of the entire study population according to predefined criteria. Data Extraction and Synthesis: Two reviewers independently extracted data according to PRISMA guidelines. Incidence of SAH was calculated per 100 000 person-years, and risk ratios (RRs) including 95% CIs were calculated with multivariable random-effects binomial regression. The association of SAH incidence with blood pressure and smoking prevalence was assessed with linear regression. Main Outcomes and Measures: Incidence of SAH. Results: A total of 75 studies from 32 countries were included. These studies comprised 8176 patients with SAH were studied over 67 746 051 person-years. Overall crude SAH incidence across all midyears was 7.9 (95% CI, 6.9-9.0) per 100 000 person-years; the RR for women was 1.3 (95% CI, 0.98-1.7). Compared with men aged 45 to 54 years, the RR in Japanese women older than 75 years was 2.5 (95% CI, 1.8-3.4) and in European women older than 75 years was 1.5 (95% CI, 0.9-2.5). Global SAH incidence declined from 10.2 (95% CI, 8.4-12.5) per 100 000 person-years in 1980 to 6.1 (95% CI, 4.9-7.5) in 2010 or by 1.7% (95% CI, 0.6-2.8) annually between 1955 and 2014. Incidence of SAH declined between 1980 and 2010 by 40.6% in Europe, 46.2% in Asia, and 14.0% in North America and increased by 59.1% in Japan. The global SAH incidence declined with every millimeter of mercury decrease in systolic blood pressure by 7.1% (95% CI, 5.8-8.4) and with every percentage decrease in smoking prevalence by 2.4% (95% CI, 1.6-3.3). Conclusions and Relevance: Worldwide SAH incidence and its decline show large regional differences and parallel the decrease in blood pressure and smoking prevalence. Understanding determinants for regional differences and further reducing blood pressure and smoking prevalence may yield a diminished SAH burden.

Angiographic Features of Intracranial Aneurysms in Ecuador.

BACKGROUND: Most of the literature describing morphological features of intracranial aneurysms (IAs) is from North-America, East-Asia, and Europe. There is limited data from South-America. We describe the epidemiologic and angiographic features of ruptured and unruptured IAs in a cohort of patients from Ecuador. METHODS: We conducted a retrospective analysis of prospectively acquired databases from 3 different tertiary hospitals over a 3-year period (2014-2017). In a per-patient basis, odd ratios (ORs) of ruptured presentation for each variable using a univariate logistic regression model were calculated. An aneurysm-based multivariate analysis was performed to calculate rupture ORs for each variable. RESULTS: Our sample included 557 patients with 761 IAs. Mean patient age was 52.2 years (range 18-82). Sixty-eight percent were women, and almost 90% presented with ruptured aneurysms and concomitant subarachnoid hemorrhage (SAH). Mean size of all the IAs was 6.4 mm ± 3.98 mm. Most IAs were located in anterior circulation (96.6%): 28.4% medial cerebral artery, 24.4% anterior cerebral artery or anterior communicating artery (ACOM), and 23.5% posterior communicating artery (PCOM). Only 6 basilar tip aneurysms (0.8%) were reported. In the adjusted analysis, aneurysms located in the ACOM (OR 1.89, 95% CI 1.29-2.78) and PCOM (OR 1.84, 95% CI 1.25-2.71), size larger than 5 mm (OR 2.84, 95% CI 2.04-3.93) and 7 mm (OR 2.28, 95% CI 1.64-3.19), and those with non-saccular morphology (OR 9.87, 95% CI 2.21-44.14) were significantly associated with ruptured presentation. CONCLUSIONS: The prevalence of posterior circulation IAs in Ecuador, particularly basilar tip aneurysms, is low when compared to previous reports from developed countries. In our sample, IAs greater than 5 mm (and ≥7 mm) in size, ACOM and PCOM locations, and IAs with nonsaccular morphologies (blister and fusiform) were significantly associated with SAH presentation.

Hyperhomocysteinemia as a Risk Factor for Intracranial Aneurysms: A Case-Control Study.

OBJECTIVE: Homocysteine, an amino acid derived from methionine metabolism, has gained great importance as an important risk factor for cardiovascular diseases as the result of its thrombogenic properties and endothelial injury association. However, its role in the etiology and screening of intracranial aneurysms (IAs) has not been well studied. We aimed to test the hypothesis of a positive association between hyperhomocysteinemia (HHcy) and IAs. METHODS: A case-control study was performed at a vascular neurosurgery unit in Brazil between 2016 and 2017. In total, 180 patients were included: 142 patients with previous IAs (case group) and 38 patients with a previous diagnosis of arteriovenous malformation and no aneurysms on imaging evaluation (control group). HHcy was defined as homocysteine levels greater than 15 µmol/L. Multivariate models were designed to adjust for potential confounders: age, sex, hypertension, dyslipidemia, and smoker status. RESULTS: The case group was older (56.3 ± 12.6 years vs. 40.9 ± 14.0 years, P < 0.001) and had a greater prevalence of women (76.1% vs. 55.3%, P = 0.012), as well as hypertension (45.1% vs. 2.6%, P < 0.001), dyslipidemia (60.6% vs. 10.5%, P = 0.001), and smokers (41.5% vs. 0.0%, P < 0.001). Median homocysteine in the cases was similar to the controls (10.5 µmol/L [8.3-14.0] vs. 10.7 µmol/L [8.2-13.3], respectively, P = 0.450). There was a trend toward greater HHcy prevalence in the case group (20.4% vs. 7.9%, P = 0.073). HHcy was associated with greater age, male sex, hypertension, and smoking status. After multivariate adjustment, HHcy had no association with IAs (odds ratio 1.34, 95% confidence interval 0.30-5.97, P = 0.703). CONCLUSIONS: No association was found between HHcy and IAs.