Systematic review and comparative analysis of endovascular and microsurgical management of giant ruptured fusiform mca aneurysms with illustrative cases.

BACKGROUND: Despite advances in neurosurgical techniques and technology, the management of ruptured giant fusiform MCA aneurysms remains challenging. In the literature, microsurgical intervention is the most commonly described approach. However, recent advancements in endovascular techniques have expanded therapeutic options and as a result there is no consensus on the optimal management of these aneurysms. METHODS: A literature search was performed through the PubMed, Google Scholar, and Embase databases, for surgical and endovascular management of ruptured giant fusiform MCA aneurysms. Inclusion criteria included: fusiform morphology, hemorrhage, major diameter greater than 2.5 cm and located along the MCA. RESULTS: Literature review yielded 21 studies published from 1981 to 2023 and a total of 32 patients ages 33.40 ± 18.28. The male to female ratio was 1.9:1. The average Hunt and Hess score upon presentation in the total population was 2.78 ± 1.48, and the average pre-operative mRS of the total population was 2.75 ± 1.83. The average major diameter was 3.80 ± 1.85 cm. Average follow-up was 8.9 ± 9.74 months. There was no statistical difference in age (p = 0.5609), pre-operative mRS (p = 0.2355), Hunt and Hess scale (p = 0.183), aneurysm major diameter (p = 0.594) or follow-up (0.8922) between the two modalities. There was no significant difference in clinical outcome between microsurgical and endovascular intervention, nor was there a significant difference when stratified according to sex, major diameter, or location along the MCA. Two case examples are presented after management with cerebral revascularization. CONCLUSION: Our analysis underscores the absence of statistical differences in clinical outcomes between microsurgical and endovascular strategies for ruptured giant fusiform MCA aneurysms, which highlights the need for complex surgical revascularization as represented on the illustrative cases where no endovascular option was available.

Treatment Outcome of Flow Diverter Device for Medium-Sized Cerebral Aneurysms: A Single-Center Report.

Objective: Flow diverters (FDs), first introduced in Japan in 2015, were initially limited to wide-necked large cerebral aneurysms, which pose a high treatment risk. However, based on the results of the PREMIER study, the indications have expanded since 2020, and the number of treatment cases is increasing in Japan. At our hospital, FD placement with adjunctive coil embolization has been actively performed for medium-sized cerebral aneurysms, as indicated in the PREMIER study; herein, we report the outcomes of this treatment. Methods: Of the 25 patients with 28 aneurysms who underwent FD placement at our institution between April 2022 and June 2023, 15 with 17 wide-necked unruptured cerebral aneurysms with a maximum diameter of <12 mm in the internal carotid artery (ICA) or vertebral artery (VA) were included. Postoperative complications were investigated in each case, and the aneurysm occlusion status was assessed using ultrashort echo time (UTE)-MRA at 3 months postoperatively and angiography at 6 months postoperatively. Fifteen patients who underwent coiling or stent-assisted coiling (SAC) for the same criteria during the same period were compared. Baseline characteristics and treatment results were compared between FD and coiling/SAC cases. Results: Four males and 11 females with a mean age of 61.7 ± 12.8 years were included, and the median follow-up period was 9 months (6-18 months). There were 14 aneurysms of the ICA and 3 of the VA, and the mean maximum aneurysm diameter was 7.9 ± 1.7 mm. All patients were treated using the Pipeline Flex with Shield Technology (Medtronic, Minneapolis, MN, USA), and 14 aneurysms (82.4%) were treated with adjunctive coil embolization. There were no symptomatic strokes in the perioperative period; only one patient receiving corticosteroid therapy for thyroid eye disease had asymptomatic ICA occlusion at 3 months. Fifteen aneurysms (88.2%) were not visible on UTE-MRA at 3 months postoperatively, and angiography at 6 months showed complete occlusion in 16 (94.1%) aneurysms. The coiling/SAC group had a smaller neck size and higher volume embolization ratio than the FD group; however, complete occlusion was higher in the FD group. Conclusion: FD placement with adjunctive coil embolization for medium-sized cerebral aneurysms is expected to result in good occlusion rates in the early postoperative period.

Predictive Methods for Thrombus Formation in the Treatment of Aortic Dissection and Cerebral Aneurysms: A Comprehensive Review.

Thrombus formation plays a crucial role in the clinical treatment of certain diseases. In conditions such as aortic dissection and cerebral aneurysm, complete thrombus occlusion in the affected region is desired to reduce blood flow into the false lumen or aneurysm sac, leading to a decrease in the tension exerted on the vascular wall and making it less likely to rupture. However, desired thrombosis sometimes fails to occur. Predicting thrombus formation can provide valuable information in such cases. This article offers a comprehensive review of conventional methods for predicting thrombus formation. In reviews conducted from the year 2000 to the present, the number of published related papers every five years has increased more than tenfold. We also found that the predictive methods can be classified into two categories: those based on the hemodynamic evaluation parameters and those based on hemodynamic and mathematical models that simulate the transport and reaction of blood components. Through our discussions, we identified several challenges that need to be resolved, including predictions based on patient-specific condition, model validation, multi-scale problems, the mechanisms of thrombus formation, and ensuring cost effectiveness. This review aims to guide researchers interested in exploring thrombus formation prediction within clinical treatments.

Outcomes and predictors of intraprocedural rupture in patients with cerebral aneurysm.

BACKGROUND: Intraprocedural rupture (IPR) is a devastating complication of cerebral aneurysm treatment. While several studies have investigated its risk factors and clinical impact, further research with larger populations is warranted. METHODS: We retrospectively reviewed data from 4,039 patients with 4,233 cerebral aneurysms treated at our institution between January 2009 and December 2018. Multivariate logistic regression with stepwise elimination was performed to identify the independent risk factors of IPR. Unfavorable clinical outcome was defined as a Modified Rankin Scale (mRS) ≥ 3 points at 3 months post-treatment. RESULTS: IPR occurred in 61 (1.44%) of the 4,233 aneurysms. Multivariate analysis showed that previously ruptured aneurysms (odds ratio [OR] 3.182; 95% confidence interval [CI] 1.851-5.470; p < 0.001), surgical clipping (OR 3.598; 95% CI 1.894-6.836; p < 0.001), and higher aspect ratio (OR 1.310; 95% CI 1.032-1.663; p = 0.024) were independent risk factors for IPR. Patients with IPR had significantly higher rates of unfavorable clinical outcomes (mRS ≥ 3) compared to those without (18.0% vs. 3.3%, p < 0.001). However, within the ruptured aneurysm subgroup, the rate of unfavorable outcomes did not differ significantly between IPR and non-IPR groups (22.7% vs. 19.2%, p = 0.594). CONCLUSION: Ruptured aneurysms, surgical clipping, and higher aspect ratio were independently associated with IPR. IPR significantly increased the risk of unfavorable clinical outcomes regardless of treatment approach, except in the subgroup of ruptured aneurysms.

Spontaneous disappearance of a small unruptured cerebral aneurysm in the clinoid segment of the internal carotid artery: A case report and literature review.

Background: Various degrees of thrombosis have been reported in patients with giant aneurysms. However, small, unruptured aneurysms rarely resolve spontaneously. Herein, we report a case of a small unruptured aneurysm in the clinoid segment (C3) of the left internal carotid artery (ICA) that showed almost complete occlusion at the 1-year follow-up. Case Description: A 66-year-old woman developed a subarachnoid hemorrhage on the left side of the perimesencephalic cistern. Cerebral angiography performed on admission revealed no evidence of hemorrhage. Subsequent cerebral angiography on day 12 revealed a dissecting aneurysm on a branch of the superior cerebellar artery (SCA), and the patient underwent parental artery occlusion with 25% n-butyl-2-cyanoacrylate. The postoperative course was uneventful, and the patient was discharged on day 22 with a modified Rankin Scale score of 1. The 1 year follow-up cerebral angiogram demonstrated that the dissecting aneurysm in the SCA branch remained occluded. Notably, a small 2-mm unruptured aneurysm in the clinoid segment (C3) of the left ICA, which was present at the onset of subarachnoid hemorrhage, was almost completely occluded without intervention. Magnetic resonance angiography 1 year after spontaneous resolution of the aneurysm showed no apparent recurrence. Conclusion: This case highlights that even small, unruptured aneurysms can develop spontaneous occlusions.

A rescue treatment to release the twist of a flow re-direction endoluminal device.

Background: A flow redirection endoluminal device (FRED) is a widely used flow diverter stent. Although high technical success and good treatment results were reported in the SAFE study, cases of technical failure of deployment have also been reported. A case in which a FRED was deployed with the proximal part twisted, but successful deployment was achieved, is presented. Case Description: A woman in her 40s was diagnosed with a left internal carotid artery aneurysm during radiological investigations for headaches. Due to her family's strong history of cerebral aneurysms, she opted for preventive treatment. A 5.5-mm FRED was selected because the proximal vessel diameter was ≥5 mm. However, the stent was deployed with the proximal side twisted. Fortunately, using a Scepter C and a CHIKAI 315 cm, the true lumen could be secure, the wire was guided distally, and the FRED was successfully placed. Later, with the patient's consent, a 3D blood vessel model was created, and whether the stent was difficult to open or whether it was just a technical problem which was verified experimentally. Precisely, the same situation as during the surgery was recreated, and the stent was deployed in the same way. Conclusion: A FRED is an effective device, but there are cases of difficult deployment. The present method may be an option if a FRED is difficult to open.

Comparative anatomical analysis between lateral supraorbital and minipterional approaches.

Background: The pterional craniotomy, described by Yasargil and Fox in 1975, constitutes the most traditional and important surgical access in vascular neurosurgery. Minimally invasive alternatives include the minipterional (MP) and lateral supraorbital (LSO) craniotomies, which avoid complications such as injury to the frontal branch of the facial nerve, temporal muscle dysfunction, depression of the craniotomy site, frontal sinus opening, and cosmetically unacceptable outcomes. We evaluated and compared the exposures provided by MP and LSO craniotomies through quantitative measurements of the surgical exposure area around the circle of Willis and parasellar regions, as well as angular and linear exposures of the internal carotid artery (ICA) bifurcation, middle cerebral artery (MCA), midpoint of the anterior communicating artery, and tip of the basilar artery (BA). Methods: Seven fresh cadavers were dissected at the São Paulo Medical Examiner's Office, SP, and three at the skull base laboratory of Weill Cornell Medical College, New York, USA. The craniotomies were performed sequentially, initially with the LSO craniotomy followed by the MP. After the craniotomy, the surgical exposure area, craniotomy area, and angular exposures in the horizontal and vertical axes were determined. Results: The MP craniotomy provided better angular exposure for the ipsilateral MCA, while the LSO craniotomy and BA provided better vertical axis exposures. The LSO craniotomy provided better angular exposure in the vertical axis for the midpoint of the anterior communicating artery and contralateral ICA bifurcation. Regarding surgical exposure and craniotomy area, there were no statistically significant differences. Conclusion: The MP craniotomy offers a significantly larger surgical exposure compared to the LSO craniotomy, with specific advantages regarding angular exposure to important neurovascular structures. This study provides important quantitative data to guide the choice between these minimally invasive access techniques in vascular neurosurgery.

[The effect of surgical technique on the long-term results of treatment of brain aneurysms]. / Vliyanie khirurgicheskoi metodiki na otdalennye rezul'taty lecheniya anevrizm golovnogo mozga.

OBJECTIVE: To study the long-term outcomes of surgical treatment of cerebral aneurysms (CA) after using different methods of excluding the aneurysm from the bloodstream. MATERIAL AND METHODS: We analyzed the long-term results of surgical treatment of 311 patients for CA (on average after 3.5 years). Two hundred and one patients were operated after CA rupture, 110 for an unruptured aneurysm. Microsurgical or endovascular methods were used to isolate the aneurysm from the bloodstream. Upon admission to the hospital for surgical treatment, a clinical diagnostic examination was performed to confirm the diagnosis and determine the timing and type of intervention. In the long-term period, a clinical neurological study, including an assessment of disability with the Barthel index and the modified Rankin scale, cognitive functions (MoCA test) and the psycho-emotional sphere (HADS) was carried out. RESULTS: In the long-term period of aneurysm surgery, symptoms of disability were identified in 49 patients (16%), severe and complete limitation of self-care in 17 (8%), and cognitive impairment in 212 (68%). Endovascular embolization performance of an aneurysm was associated with a higher proportion of favorable functional outcomes compared with the use of a microsurgical method (10% versus 17%), as well as preservation of cognitive functions (9% and 17%, respectively). Blood clots fibrinolysis was associated with severe disability and dependence in the long-term period (p=0.04). Patients treated with extra-intracranial shunting (EICS) demonstrated better cognitive functions; fibrinolysis, on the contrary, was a predictor of dementia (p=0.02). There was no relationship between symptoms of anxiety and depression in the long-term period and surgical treatment method. CONCLUSIONS: Disability, dependence and disturbance of cognitive functions in the long-term period of CA surgical treatment are higher in patients after microsurgical clipping compared to endovascular embolization. Performance of blood clots fibrinolysis is associated with severe disability and dementia in patients with massive basal aneurysmal subarachnoid hemorrhage. Performing EICS is associated with a favorable prognosis for the recovery of cognitive functions.

The relationship between intraoperative surrogates of vascular stiffness, cerebral aneurysms, and surgical outcomes.

OBJECTIVE: Increased arterial stiffness has been linked to aneurysm formation in the systemic and cerebral circulations, though the role played by arterial stiffness in the cerebral vasculature continues to be refined. This study assesses whether intraoperative surrogates of arterial stiffness differ between patients with cerebral aneurysms and controls, and the extend that these indices relate to outcomes following open surgical treatment. METHODS: We evaluated patients in a prospectively maintained database who underwent cerebral aneurysm surgery, and compared them to controls without cerebral aneurysms. Arterial stiffness was estimated using the intraoperative ambulatory arterial stiffness index (AASI) and average pulse pressure (PP). RESULTS: We analyzed 214 cerebral aneurysm patients and 234 controls. Patients in the aneurysm group were predominantly female and had a higher incidence of hypertension, diabetes mellitus, and vascular disease. They also demonstrate elevated AASI and average PP. When stratified by the occurrence of subarachnoid hemorrhage (SAH) or unfavorable neurological outcome, the AASI and average PP were not highly associated with the occurrence of SAH but were highly associated with unfavorable neurological outcomes. After multivariable analysis, both the AASI and average PP were no longer associated with unfavorable neurological outcomes, however elevated age, strongly linked with arterial stiffness, became a key predictive variable. CONCLUSION: Readily obtained intraoperative surrogates of arterial stiffening demonstrates its presence in those with cerebral aneurysm disease and the extent that it does it may meaningfully direct their clinical course. However, multivariable analysis demonstrates limitations of using arterial stiffness measures to predict clinical outcomes.

Temporal Trends and Practice Variation in Early Repair of the Ruptured Aneurysm Among Patients with Aneurysmal Subarachnoid Hemorrhage in the United States, 2012-2019.

BACKGROUND: Early repair of the ruptured cerebral aneurysm (RRCA), preferably within 24 hours of onset, is endorsed by clinical guideline as the preferred management strategy for patients with aneurysmal subarachnoid hemorrhage (aSAH). However, a comprehensive picture of this guideline-recommended usage in contemporary clinical practice is not available. AIMS: This study aimed to characterize trends over time and practice variation in the implementation of an early RRCA strategy among patients with aSAH in a large, national representative data. METHODS: Using data from the 2012-2019 National Inpatient Sample, we measured trends in the proportion of early RRCA, defined as within day 1 of admission, overall, and by demographic and geographical subgroups. Additionally, we created multilevel regression models to quantify hospital-level variation in the early RRCA rates. RESULTS: We identified 82,615 aSAH hospitalizations (mean age, 56.1 years; 68.9% women) undergoing RRCA and, among these, 84.0% (95% CI, 83.4-84.7%) receiving early RRCA. The proportion of early RRCA increased steadily from 82.5% in 2012 to 85.8% in 2019 (P for trend <0.001). The proportion of patients receiving early RRCA across geographic regions ranged from 78.7% to 87.9%, with a median (IQR) of 84.2% (83.0-86.1%). In contrast, the delivery of early RRCA varied widely among hospitals, with a median (IQR) rate of 86.1% (75.0-100.0%) and a range from 0 to 100.0%. The median odds ratio for the early use of RRCA treatment was 1.24 (95% CI, 1.21-1.27) in 2019, indicating 24% increased odds of implementing early RRCA if moving from a lower-use to a higher-use hospital. CONCLUSIONS: Most patients in the United States with aSAH received early RRCA treatment and exhibited an upward trend over the recent 8-year period. However, substantial variation in access to early RRCA was been observed across population subgroups, particularly at the hospital level. Future efforts are necessary to identify further sources of this variation and to develop initiatives that could represent an opportunity to optimize guideline-based quality of care in aSAH management.

Coexistence of cerebral aneurysm and meningioma: A case report.

The coexistence of a meningioma and an unruptured intracranial aneurysm was considered a rare phenomenon, accidentally detected by radiological assessment. The relationship between these 2 entities is complex and represents a neurosurgical challenge. We share our experience of a case involving a 36-year-old male patient with no prior medical history who consulted for chronic unilateral left periorbital headaches. The imaging diagnosis revealed 2 lesions, including a partially calcified jugo-olfactory meningioma and an anterior communicating artery aneurysm. He was successfully treated in a single surgical procedure using a left pterional craniotomy for excision of the meningioma followed by clipping of the aneurysm. The patient was discharged home on the fifth postoperative day in good clinical condition. This experience underlines the importance of preoperative imaging assessment, in order to make the right therapeutic decision and avoid unexpected intraoperative disasters.

Risk factors and predictive indicators of rupture in cerebral aneurysms.

Cerebral aneurysms are abnormal dilations of blood vessels in the brain that have the potential to rupture, leading to subarachnoid hemorrhage and other serious complications. Early detection and prediction of aneurysm rupture are crucial for effective management and prevention of rupture-related morbidities and mortalities. This review aims to summarize the current knowledge on risk factors and predictive indicators of rupture in cerebral aneurysms. Morphological characteristics such as aneurysm size, shape, and location, as well as hemodynamic factors including blood flow patterns and wall shear stress, have been identified as important factors influencing aneurysm stability and rupture risk. In addition to these traditional factors, emerging evidence suggests that biological and genetic factors, such as inflammation, extracellular matrix remodeling, and genetic polymorphisms, may also play significant roles in aneurysm rupture. Furthermore, advancements in computational fluid dynamics and machine learning algorithms have enabled the development of novel predictive models for rupture risk assessment. However, challenges remain in accurately predicting aneurysm rupture, and further research is needed to validate these predictors and integrate them into clinical practice. By elucidating and identifying the various risk factors and predictive indicators associated with aneurysm rupture, we can enhance personalized risk assessment and optimize treatment strategies for patients with cerebral aneurysms.

Clinical and Anatomical Characteristics of Perforator Aneurysms of the Posterior Cerebral Artery: A Single-Center Experience.

INTRODUCTION: Posterior cerebral artery (PCA) aneurysms represent up to 1% of all cerebral aneurysms. P1-P2 perforator aneurysms are thought to be even less prevalent and often require complex treatment strategies due to their anatomical and morphological characteristics, with risk of a perforator infarct. We studied the treatment of P1-P2 perforator aneurysms in a single-center cohort from a high-volume tertiary center, reporting clinical and anatomical characteristics, treatment strategies, and outcomes. METHODS: A retrospective analysis of adult patients with a P1-P2 perforator aneurysm who presented at our institution between January 2000 and January 2023 was performed. The patients were analyzed for demographics, clinical presentation, imaging findings, treatment techniques, outcomes, and complications. Subgroup analyses between ruptured versus non-ruptured cases were included. RESULTS: Out of 2733 patients with a cerebral aneurysm, 14 patients (0.5%) presented with a P1-P2 perforator aneurysm. All six patients with a ruptured aneurysm were treated by endovascular coiling, of whom one patient (16.7%) required surgical clipping of a recurrence. One out of eight (12.5%) patients with unruptured aneurysms was treated by surgical clipping. P1-P2 perforator aneurysms predominantly affected middle-aged individuals (median 59.5 years), with 10/14 (71.4%) being female. Endovascular coiling was the primary treatment modality overall, yielding favorable technical outcomes, however, it was complicated by a perforator infarct in two patients (33.3%) without new permanent morbidity or mortality secondary to treatment. CONCLUSIONS: P1-P2 perforator aneurysms are a rare subtype of intracranial aneurysm. Endovascular coiling could present an effective treatment modality; however, care should be taken for ischemic complications in the dependent perforator territory. Larger studies are required to provide more insights.

Endothelial Cell Transcription Modulation in Cerebral Aneurysms After Endovascular Flow Diversion.

PURPOSE: Flow diverting stents (FDS) are used to treat cerebral aneurysms, by promoting thrombosis and occlusion of the aneurysm sac. However, retreatment is required in some cases, and the biologic basis behind treatment outcome is not known. The goal of this study was to understand how changes in hemodynamic flow after FDS placement affect aneurysmal endothelial cell (EC) activity. METHODS: Three-dimensional models of patient-specific aneurysms were created to quantify the EC response to FDS placement. Computational fluid dynamic simulations were used to determine the hemodynamic impact of FDS. Two identical models were created for each patient; into one a FDS was inserted. Each model was then populated with human carotid ECs and subjected to patient-specific pulsatile flow for 24 h. ECs were isolated from aneurysm dome from each model and bulk RNA sequencing was performed. RESULTS: Paired untreated and treated models were created for four patients. Aneurysm dome EC analysis revealed 366 (2.6%) significant gene changes between the untreated and FDS conditions, out of 13909 total expressed genes. Gene set enrichment analysis of the untreated models demonstrated enriched gene ontology terms related to cell adhesion, growth/tensile activity, cytoskeletal organization, and calcium ion binding. In the FDS models, enriched terms were related to cellular proliferation, ribosomal activity, RNA splicing, and protein folding. CONCLUSION: Treatment of cerebral aneurysms with FDS induces significant EC gene transcription changes related to aneurysm hemodynamics in patient-specific in vitro 3D-printed models subjected to pulsatile flow. Further investigation is needed into the relationship between transcriptional change and treatment outcome.

Single Neuroform Atlas stent: a reliable approach for treating complex wide-neck bifurcated aneurysms.

Background: Treating wide-neck bifurcated cerebral aneurysms (WNBAs) using various techniques and new devices has shown favorable outcomes. However, endovascular coiling can be technically challenging when the aneurysm neck is incorporated into the parent vessel. Furthermore, although recent research has reported favorable outcomes of Neuroform Atlas stent (NAS)-assisted coiling, broad inclusion criteria have hampered precise evaluations of their effectiveness and safety for treating complex WNBAs. Therefore, this study evaluated whether the use of a single NAS is a safe and effective approach for treating complex WNBAs. Methods: We treated 76 complex WNBAs (unruptured, n = 49; ruptured, n = 27) using single NAS-assisted coil embolization and retrospectively analyzed the clinical and angiographic outcomes. Results: In a cohort of 68 patients (mean age, 58.3 ± 11.6 years; males n = 20, 29.4%; females, n = 48, 70.6%), 76 stents were successfully delivered to the target aneurysms, yielding a technical success rate of 98.6%. Complete occlusion was evident in 59 (77.6%) of 76 aneurysms, with neck remnants found in 16 (21.1%) and partial occlusion in 1 (1.3%). Treatment-related morbidities comprised one branch occlusion and one parenchymal hemorrhage. However, no new neurological symptoms of unruptured aneurysms were evident at discharge. The outcomes of 20 of the 27 ruptured aneurysms were favorable (Glasgow Outcome Scale scores of 4 or 5) at the final follow-up assessment (mean 12.2 [6-29] months), except for one initial subarachnoid hemorrhage. Post-treatment angiography revealed complete occlusion in 89.1%, neck remnants in 7.8%, and incomplete occlusion in 3.1% of the aneurysms. Approximately 88.2% of the patients were assessed at least once by follow-up diagnostic or magnetic resonance angiography (mean, 12.5 ± 4.3 [range, 6-29] months), with five (7.8%) minor and two (3.1%) major recurrences. Conclusion: A single NAS is safe and effective for treating WNBAs incorporated into parent vessels.

Revolutionizing Aneurysm detection: The role of artificial intelligence in reducing rupture rates.

Cerebral aneurysms, affecting 2-5% of the global population, are often asymptomatic and commonly located within the Circle of Willis. A recent study in Neurosurgical Review highlights a significant reduction in the annual rupture rates of unruptured cerebral aneurysms (UCAs) in Japan from 2003 to 2018. By analyzing age-adjusted mortality rates of subarachnoid hemorrhage (SAH) and the number of treated ruptured cerebral aneurysms (RCAs), researchers found a substantial decrease in rupture rates-from 1.44 to 0.87% and from 0.92 to 0.76%, respectively (p < 0.001). This 88% reduction was largely attributed to improved hypertension management. Recent advancements in artificial intelligence (AI) and machine learning (ML) further support these findings. The RAPID Aneurysm software demonstrated high accuracy in detecting cerebral aneurysms on CT Angiography (CTA), while ML algorithms showed promise in predicting aneurysm rupture risk. A meta-analysis indicated that ML models could achieve 83% sensitivity and specificity in rupture prediction. Additionally, deep learning techniques, such as the PointNet + + architecture, achieved an AUC of 0.85 in rupture risk prediction. These technological advancements in AI and ML are poised to enhance early detection and risk management, potentially contributing to the observed reduction in UCA rupture rates and improving patient outcomes.

Microsurgical clipping of large MCA aneurysm in a 2-month-old child.

BACKGROUND: Cerebral aneurysms in children have a low incidence and accounts for less than 4% of all cerebral aneurysms. These aneurysms have been linked to various factors. Severe headache, seizures, and motor-sensory deficits are common presentations. CASE REPORT: We describe the case of a 2-month-old male patient who presented with generalized tonic-clonic seizures for 4 days. At the hospital, he was stabilized with ventilatory support, sedation, and antiepileptic drugs. A NCCT (Head) showed intraparenchymal hemorrhage in the left fronto-parieto-temporal lobe and subarachnoid hemorrhage. Subsequently a CT angiogram revealed an aneurysm of the left M3 segment of MCA. Successfully, the patient underwent microsurgical clipping of aneurysm and evacuation of hematoma. CONCLUSIONS: Pediatric cerebral aneurysms differ from their adult counterparts, mainly in their etiology and evolution. As per literature, aneurysmal clipping and neurological endovascular therapy have shown similar results.

Flow diversion of cerebral aneurysms in Type I osteogenesis imperfecta: A case report of the first two treatments in humans.

Osteogenesis imperfecta (OI) predisposes individuals to easy bone fracture, vessel fragility, and platelet dysfunction. We report the first known case of neurointerventional treatment with flow diversion of intracranial aneurysms in a patient with OI. A 62 year-old female with known OI Type I, history of >40 lifetime bone fractures and hypertension, underwent workup for transient ischemic attacks revealing a 4-mm right A1 segment aneurysm in 2016. Perioperative dual antiplatelet therapy was aspirin 81 mg and clopidogrel 37.5 mg daily. Tri-axial access was utilized to deploy a 3.5 × 16-mm Pipeline Flex device without complication. Two-month follow-up revealed Raymond I (O'Kelly Marotta I) obliteration of the aneurysm. Five-year follow-up revealed a de novo left-sided 3-mm A1-A2 junction aneurysm. A 4 × 12-mm Surpass Evolve was placed without complication. Six-month follow-up revealed Raymond I (O'Kelly Marotta I) obliteration of the second aneurysm. The patient remained asymptomatic at all follow-up visits.

Mendelian randomization did not support the causal effect of diabetes on aortic diseases.

Observational studies revealed paradoxically inverse associations between diabetes and aortic diseases (aortic aneurysm or aortic dissection), yet the causality remains to be determined. To investigate the causal associations between diabetes and aortic diseases using Mendelian randomization (MR) analyses. Summary-level data for exposures (type 1 diabetes, type 2 diabetes, fasting glucose, fasting insulin, glycated hemoglobin) and outcomes (aortic dissection and aortic aneurysm) were obtained from public genome-wide association study data. The principal analysis was the inverse-variance weighted (IVW) method. Sensitivity analyses were also carried out, including weighted median, MR-Egger, and multivariable MR methods. According to IVW results, type 1 diabetes (odds ratio [OR]: 0.99; 95% confidence interval [CI] 0.93-1.07; P = 0.87), type 2 diabetes (OR: 0.97; 95% CI 0.77-1.20; P = 0.75), fasting glucose (OR: 1.16; 95% CI 0.48-2.84; P = 0.74), fasting insulin (OR: 2.75; 95% CI 0.53-14.26; P = 0.23), or glycated hemoglobin (OR: 0.33; 95% CI 0.09-1.17; P = 0.09) had no causal effect on aortic dissection. Similarly, type 1 diabetes, type 2 diabetes, fasting glucose, fasting insulin, or glycated hemoglobin had no causal effect on aortic aneurysm. Sensitivity analyses revealed consistent results. MR-Egger method and funnel plot yielded no indication of directional pleiotropy. Diabetes had no causal associations with aortic dissection or aortic aneurysm. The observed inverse associations in previous cohort studies may be explained by confounding factors or reverse causation.

How Flow Diverter Selection Can Affect the Flow Changes within a Jailed Ophthalmic Artery: A Computational Fluid Dynamics Study.

Introduction Flow diverter (FD) stents are widely used to treat giant aneurysms by reducing blood flow into the aneurysm sac. However, choosing the optimal FD for a patient can be challenging when a nearby artery, such as the ophthalmic artery (OA), is jailed by the FD placement. This study compares the impact of two FD stents with different effective metal surface area (EMSA) values on OA occlusion. Materials and Methods A numerical model of a 59-year-old female patient with a giant aneurysm in the left internal carotid artery and a jailed OA was created based on clinical data. Two FD stents, FRED4017 and FRED4518, with different EMSA values at the aneurysm neck and OA inlet, were virtually deployed in the model. Blood flow and occlusion amount in the OA were simulated and compared between the two FD stents. Results FRED4017 had higher EMSA values than FRED4518 at the aneurysm neck (35% vs. 24.6%) and lower EMSA values at the OA inlet (15% vs. 21.2%). FRED4017 caused more occlusion in the OA than FRED4518 (40% vs. 28%), indicating a higher risk of ocular ischemic syndrome. Conclusion The EMSA value of FD stents affects the blood flow and occlusion amount in the jailed OA. Therefore, selecting an FD stent with a low EMSA value at the OA inlet may be beneficial for patients with a nearby jailed artery at the aneurysm neck.