Use of the Tubridge flow diverter in the treatment of intracranial aneurysms: a single center experience.

To investigate the safety and effect of Tubridge flow diverter deployment for the treatment of intracranial aneurysms, 85 patients with intracranial aneurysms treated with the Tubridge flow diverter were retrospectively enrolled. The clinical data including the baseline data, aneurysm parameters before and after treatment, and follow-up outcomes were assessed. Among 85 patients, there were 35 (41.2%) males and 50 females (58.8%) aged 17-77 (mean 56.7 ± 11.1) years with 110 aneurysms. Five (5.9%) patients initially presented with subarachnoid hemorrhage from aneurysm rupture. The aneurysm size was 2-30 (mean 8.6) mm, and the aneurysm neck was 2-10.6 (mean 5.7 ± 2.3) mm. Ninety-three Tubridge stents were deployed. Twenty-five (29.4%) patients experienced adjunctive loose coiling. Blood flow was significantly reduced from entering the aneurysm after stent deployment. Periprocedural complications occurred in three (3.5%) patients, including in-stent thrombosis during embolization in one patient (1.2%), conjunctiva edema on the right in one patient (1.2%), and acute multiple cerebral infarctions in one patient (1.2%). Angiographic follow-up was conducted in 67 (78.8%) patients 3-36 (mean 15.3 ± 5.6) months later. In 11 (16.4% or 11/67) patients, blood flow still entered the aneurysm with the O'Kelly-Marotta (OKM) grade B in two (3.0%) patients and grade C in nine (13.4%), whereas complete occlusion (OKM grade D) was achieved in the other 56 (83.6% or 56/67) aneurysms. In-stent stenosis was present in five (7.5%) patients with approximately 25% stenosis in three (4.5%) patients and 50% in two (3.0%). In conclusion, the Tubridge flow diverter can be safely and efficiently applied in the treatment of small and large intracranial aneurysms, with a low periprocedural complication rate, a high occlusion degree, and a low in-stent stenosis rate at follow-up even though large aneurysms may necessitate a longer surgical time and adjunctive coiling.

Dual Layer vs Single Layer Woven EndoBridge Device in the Treatment of Intracranial Aneurysms: A Propensity Score-Matched Analysis.

BACKGROUND: The Woven EndoBridge (WEB) devices have been used for treating wide neck bifurcation aneurysms (WNBAs) with several generational enhancements to improve clinical outcomes. The original device dual-layer (WEB DL) was replaced by a single-layer (WEB SL) device in 2013. This study aimed to compare the effectiveness and safety of these devices in managing intracranial aneurysms. METHODS: A multicenter cohort study was conducted, and data from 1,289 patients with intracranial aneurysms treated with either the WEB SL or WEB DL devices were retrospectively analyzed. Propensity score matching was utilized to balance the baseline characteristics between the two groups. Outcomes assessed included immediate occlusion rate, complete occlusion at last follow-up, retreatment rate, device compaction, and aneurysmal rupture. RESULTS: Before propensity score matching, patients treated with the WEB SL had a significantly higher rate of complete occlusion at the last follow-up and a lower rate of retreatment. After matching, there was no significant difference in immediate occlusion rate, retreatment rate, or device compaction between the WEB SL and DL groups. However, the SL group maintained a higher rate of complete occlusion at the final follow-up. Regression analysis showed that SL was associated with higher rates of complete occlusion (OR: 0.19; CI: 0.04 to 0.8, p = 0.029) and lower rates of retreatment (OR: 0.12; CI: 0 to 4.12, p = 0.23). CONCLUSION: The WEB SL and DL devices demonstrated similar performances in immediate occlusion rates and retreatment requirements for intracranial aneurysms. The SL device showed a higher rate of complete occlusion at the final follow-up.

CNS-associated macrophages contribute to intracerebral aneurysm pathophysiology.

Intracerebral aneurysms (IAs) are pathological dilatations of cerebral arteries whose rupture leads to subarachnoid hemorrhage, a significant cause of disability and death. Inflammation is recognized as a critical contributor to the formation, growth, and rupture of IAs; however, its precise actors have not yet been fully elucidated. Here, we report CNS-associated macrophages (CAMs), also known as border-associated macrophages, as one of the key players in IA pathogenesis, acting as critical mediators of inflammatory processes related to IA ruptures. Using a new mouse model of middle cerebral artery (MCA) aneurysms we show that CAMs accumulate in the IA walls. This finding was confirmed in a human MCA aneurysm obtained after surgical clipping, together with other pathological characteristics found in the experimental model including morphological changes and inflammatory cell infiltration. In addition, in vivo longitudinal molecular MRI studies revealed vascular inflammation strongly associated with the aneurysm area, i.e., high expression of VCAM-1 and P-selectin adhesion molecules, which precedes and predicts the bleeding extent in the case of IA rupture. Specific CAM depletion by intracerebroventricular injection of clodronate liposomes prior to IA induction reduced IA formation and rupture rate. Moreover, the absence of CAMs ameliorated the outcome severity of IA ruptures resulting in smaller hemorrhages, accompanied by reduced neutrophil infiltration. Our data shed light on the unexplored role of CAMs as main actors orchestrating the progression of IAs towards a rupture-prone state.

Flow diversion of ruptured intracranial aneurysms: a single-center study with a standardized antithrombotic treatment protocol.

BACKGROUND: The use of antithrombotic medication following acute flow diversion for a ruptured intracranial aneurysm (IA) is challenging with no current guidelines. We investigated the incidence of treatment-related complications and patient outcomes after flow diversion for a ruptured IA before and after the implementation of a standardized antithrombotic medication protocol. METHODS: We conducted a single-center retrospective study including consecutive patients treated for acutely ruptured IAs with flow diversion during 2015-2023. We divided the patients into two groups: those treated before the implementation of the protocol (pre-protocol) and those treated after the implementation of the protocol (post-protocol). The primary outcomes were hemorrhagic and ischemic complications. A secondary outcome was clinical outcome using the modified Ranking Scale (mRS). RESULTS: Totally 39 patients with 40 ruptured IAs were treated with flow diversion (69% pre-protocol, 31% post-protocol). The patient mean age was 55 years, 62% were female, 63% of aneurysms were in the posterior circulation, 92% of aneurysms were non-saccular, and 44% were in poor grade on admission. Treatment differences included the use of glycoprotein IIb/IIIa inhibitors (pre-group 48% vs. post-group 100%), and the use of early dual antiplatelets (pre-group 44% vs. 92% post-group). The incidence of ischemic complications was 37% and 42% and the incidence of hemorrhagic complications was 30% and 33% in the pre- and post-groups, respectively, with no between-group differences. There were three (11%) aneurysm re-ruptures in the pre-group and none in the post-group. There were no differences in mortality or mRS 0-2 between the groups at 6 months. CONCLUSION: We found no major differences in the incidence of ischemic or hemorrhagic complications after the implementation of a standardized antithrombotic protocol for acute flow diversion for ruptured IAs. There is an urgent need for more evidence-based guidelines to optimize antithrombotic treatment after flow diversion in the setting of subarachnoid hemorrhage.

Optimizing surgical approaches for anterior communicating artery aneurysms: Development and internal validation of a novel surgical scoring system.

BACKGROUND: The objective was to provide comprehensive preoperative information on both the aneurysm orientation and the side and method of surgical approach for optimal preoperative information and safe clipping using 3D imaging modalities. This was achieved by making an objective risk assessment on the surgical side/method and evaluating its effectiveness with internal validation. MATERIALS AND METHODS: Radiologic data of 61 ACoA aneurysm patients between 2012 and 2020 were retrospectively analyzed. A scoring system based on five criteria; ACoA aneurysm dome orientation, A1 symmetry/control, perforating artery control, A2 trace orientation, and A2 fork symmetry was developed. The system is designed to align with the most common surgical approaches in ACoA aneurysm surgery. The patients were categorized into three groups based on the scoring results to determine the most appropriate surgical method. Group I was recommended, Group II was less recommended, and Group III was least recommended. Internal validation was performed to assess the system's effectiveness. Outcomes and complication rates were statistically evaluated. RESULTS: When the scoring system was utilized, the mean score difference between the first group and the other groups was 2.71 and 4.62, respectively. There was a homogeneous distribution among the groups in terms of age, sex, WFNS, and Fisher scores. Complication occurred in three patients in Group I and nine patients each in Group II and Group III. The further the deviation from the first option, the higher the complication rate (p = 0.016), and a significant cause-effect relationship was identified (p = 0.021). The ROC curve established a cut-off value of 12.5 points for complications and outcomes. CONCLUSION: Our study introduces a new scoring system for ACoA aneurysms, enhancing the use of 3D CTA in daily practice and providing internal validation for the proposed approach. By evaluating objective criteria, this scoring system helps predict surgical risks, prevent complications, and supports personalized evaluation and selection of the surgical approach based on objective criteria.

Traumatic middle meningeal artery aneurysm: a case report.

INTRODUCTION: Traumatic intracranial aneurysms are rare, making up about 1% of all intracranial aneurysms. They can happen due to direct injury or blunt force, with the middle cerebral artery being the most frequent site. The middle meningeal artery (MMA) is the main artery that supplies the cranial dura mater, and, because of its location, is susceptible to damage after trauma. This article reported an unusual case of giant post-traumatic MMA pseudoaneurysm. CASE: A 45 year-old man was referred to our department with a history of craniectomy. He complained of non-specific headache, but neurological examination was normal. A follow-up brain CT scan identified a right temporal fossa hyperdense mass. Digital subtraction angiography diagnosed a traumatic MMA aneurysm. The patient was treated with preoperative aneurysm embolization and surgical resection. DISCUSSION: Traumatic MMA aneurysm is a rare presentation after head trauma. It can manifest as epidural hematoma, subdural hematoma or intraparenchymal hematoma, and sometimes resembles the present case, which was discovered incidentally. CONCLUSION: Pseudoaneurysm is a rare complication of MMA trauma, with late presentation. It should be considered in patients with history of traumatic brain injury and temporal fossa extra-axial mass lesion with vascular characteristics.

Statistical Analysis of the Factors that Affect Postoperative Length of Hospital Stay after Unruptured Intracranial Aneurysm Treatment in Japan: A 20-year Nationwide Multicenter Study.

Treatment strategies for unruptured intracranial aneurysms (UIAs) should be carefully considered with reference to rupture and complication rates. It is also important to minimize the length of hospital stay (LOS) and to ensure a high quality of medical care. In this study, we aim to clarify the factors that affect the LOS of patients treated for UIAs using the Inpatient Clinico-Occupational Database of the Rosai Hospital Group (ICOD-R). This was a nationwide-multicenter study based on ICOD-R data from 2000 to 2019. Patients diagnosed with UIAs who were treated with clipping or coiling were included in the study. Multivariate analysis was performed to identify the factors affecting LOS. LOS was also compared between groups classified by surgical procedure or treatment period. We identified 3294 patients on the database who underwent clipping or coiling of UIAs during the study period. Multivariate analysis revealed hospital admission during the early 2000s and the late 2010s, age, and treating institution to be significantly correlated with LOS (p < 0.05). There was a significant difference between the mean LOS of the clipping group (20.3 days) and the coiling group (9.65 days) (p < 0.001). Compared by treatment period, LOS significantly shortened over time. Our results suggest that the type of treatment, time of treatment, patient age, and the treating institution affect postoperative LOS for UIAs. Although coiling was found to lead to a lower average LOS than clipping, treatment selection should take the characteristics of each patient's aneurysm into consideration.

Evaluation of the Significance of Persistent Remnant Filling and Enlargement After Flow Diversion for Intracranial Aneurysms.

BACKGROUND: This study aimed to evaluate the clinical course after flow diversion (FD) treatment with a focus on aneurysms with remnant sac filling, by analyzing angiographic outcomes, aneurysm volume, and clinical events. METHODS: We retrospectively reviewed the medical records of 61 patients who underwent FD for intracranial aneurysms between July 2014 and June 2021. RESULTS: The majority of aneurysms (52.5%) were located in the internal carotid artery, with a median diameter of 16.6 mm and neck size of 9.3 mm. Remnant filling was observed in 17 aneurysms (27.9%) more than 18 months after FD, 10 (16.4%) of these aneurysms underwent enlargement, which occurred only in cases with subtotal filling or entry remnant states. Eleven patients experienced major adverse events, and three exhibited unfavorable functional outcomes. The incidence of major adverse events and unfavorable functional outcomes was significantly higher in the aneurysm enlargement group than that in the no-filling or stable remnant filling groups (P < 0.001). Aneurysmal diameter and the presence of incorporated branches were independent predictors of aneurysm enlargement, while the presence of incorporated branches was the only independent predictor of persistent remnant filling. CONCLUSIONS: Aneurysm enlargement after FD is not uncommon, particularly when the aneurysm is large, has incorporated vessels, or does not undergo occlusion within 12 months, often culminating in major adverse events and unfavorable functional outcomes. In addition to investigating angiographic results, it is necessary to evaluate the changes in aneurysm size and clinical events when assessing the efficacy of FD.

Safety and efficacy of the flow diverter device for treating middle cerebral artery aneurysms of the proximal (M1) segment related to the lenticulostriate arteries: A single-center experience.

BACKGROUND: Experience using flow diverter devices (FDDs) to treat proximal (M1) middle cerebral artery aneurysms associated with the lenticulostriate artery (M1A-LA) remains limited. This study aimed to examine the efficacy and safety of an FDD to manage M1A-LA. METHOD: Patients with M1A-LA who received FDD treatment at a single center were included in the analysis. Data on the baseline characteristics, postoperative conditions, and follow-up results of the participants were recorded and analyzed. The aneurysms were categorized into three subtypes based on morphology and location. Aneurysms confined to the M1 segment were categorized as subtype A. Those extending to the M2 segment were classified as subtype B. Aneurysms designated as subtype C were confined to the M1 segment but with another independent aneurysm in the distal artery and the presence of healthy vessels between the two. Subgroup analyses were conducted on these subtypes and aneurysm sizes. To assess the consistency of follow-up results, Cronbach's kappa/alpha was used to calculate inter-rater variability. Somers's D coefficient was used to assess the correlation between each subgroup and the imaging outcomes; Fisher's exact test was used to compare the variability among the subgroups. RESULT: The cohort comprised 11 patients. Their Modified Rankin Scale scores between the perioperative and follow-up periods did not differ. During the follow-up period, four patients had completely occluded aneurysms, and five patients had partial occlusions. The remaining patients did not present with changes in their aneurysms. The kappa coefficient was 0.864 (p < 0.001). M1A-LA was divided into subtypes A, B, and C. Subtype A (defined as an aneurysm completely located in the M1 segment) had a higher complete occlusion rate than that of subtypes B and C, Somers's D R/C correlation coefficient was 0.553, with a 95% confidence interval of 0.1229-0.9823 (p = 0.009). The radiographic follow-up findings were not significantly correlated with the size of the aneurysm (p = 0.121) or the use of coiling (p = 0.903). No significant differences in subtypes (p = 0.264), aneurysm size (p = 0.657), or coiling use (p > 0.999) were observed. CONCLUSION: FDDs were safe and possibly effective against M1A-LA. However, they were not as effective as for intracranial aneurysms in other locations. FDDs are a satisfactory treatment option for M1A-LA, particularly for subtype A aneurysms.

Increased serum levels of high-mobility group box 1 protein and the location characteristics in the patients of intracranial aneurysms.

OBJECTIVE: Inflammation-related factors play a crucial role in intracranial aneurysms (IA) initiation, progression, and rupture. High mobility group box 1 (HMGB-1) serves as an alarm to drive the pathogenesis of the inflammatory disease. This study aimed to evaluate the role of HMGB-1 in IA and explore the correlation with other inflammatory-related factors. METHODS: A total of twenty-eight adult male Japanese white rabbits were included in with elastase-induced aneurysms, n = 18) and the control group (normal rabbits, n = 10). To assess the expression of HMGB-1, both reverse transcription-polymerase chain reaction (RT-PCR) and enzyme-linked immunosorbent assay (ELISA) was performed on serum samples obtained from human subjects (10 patients with IA and 10 healthy donors) as well as from rabbits (aneurysm group and control group). Immunohistochemistry and immunofluorescence were employed to evaluate the expression levels of elastic fibers, HMGB-1, tumor necrosis factor-alpha (TNF-α), and triggering receptor expressed on myeloid cells-1 (TREM-1). RESULTS: The expression of HMGB-1 was found to be significantly higher in the IA group compared to the control group, both at the mRNA and protein levels (P < 0.0001). Similar findings were observed in the rabbit aneurysm model group compared to the control group (P < 0.0001). HMGB-1 expression was observed to be more abundant in the inner wall of the aneurysm compared to the external wall, whereas in the control group, it was rarely scattered. Additionally, the localization patterns of TNF-α and TREM-1 exhibited similar characteristics to HMGB-1. CONCLUSION: Our findings demonstrate that HMGB-1 is highly expressed in both IA patients and rabbit aneurysm models. Furthermore, the similar localization patterns of HMGB-1, TNF-α, and TREM-1 suggest their potential involvement in the inflammatory processes associated with IA. These results highlight the potential of HMGB-1 as a novel therapeutic target for IA.

Endovascular treatment of brain aneurysms under conscious sedation: a systematic review of procedural feasibility and safety.

Over the last decades, minimally invasive techniques have revolutionized the endovascular treatment (EVT) of brain aneurysms. In parallel, the development of conscious sedation (CS), a potentially less harmful anesthetic protocol than general anesthesia (GA), has led to the course optimization of surgeries, patient outcomes, and healthcare costs. Nevertheless, the feasibility and safety of EVT of brain aneurysms under CS have yet to be assessed thoroughly. Herein, we systematically reviewed the medical literature about this procedure. In accordance with the PRISMA guidelines, four databases (PubMed, EMBASE, SCOPUS, and Cochrane Library) were queried to identify articles describing the EVT of brain aneurysms under CS. Successful procedural completion, complete aneurysm occlusion outcomes, intraoperative complications, clinical outcomes, and mortality rates assessed the feasibility and safety. Our search strategy yielded 567 records, of which 11 articles were included in the qualitative synthesis. These studies entailed a total of 1142 patients (40.7% females), 1183 intracranial aneurysms (78.4% in the anterior circulation and 60.9% unruptured at presentation), and 1391 endovascular procedures (91.9% performed under CS). EVT modalities under CS included coiling alone (63.2%), flow diversion (17.7%), stent-assisted coiling (10.6%), stenting alone (6.5%), onyx embolization alone (1.7%), onyx + stenting (0.2%), and onyx + coiling (0.2%). CS was achieved by combining two or more anesthetics, such as midazolam, fentanyl, and remifentanil. Selection criteria for CS were heterogenous and included patients' history of pulmonary and cardiovascular diseases, outweighing the benefits of CS versus GA, a Hunt and Hess score of I-II, a median score of 3 in the American Society of Anesthesiology scale, and patient's compliance with elective CS. Procedures were deemed successful or achieving complete aneurysm occlusion in 88.1% and 9.4% of reported cases, respectively. Good clinical outcomes were described in 90.4% of patients with available data at follow-up (mean time: 10.7 months). The procedural complication rate was 16%, and the mortality rate was 2.8%. No complications or mortality were explicitly attributed to CS. On the other hand, procedure abortion and conversion from CS to GA were deemed necessary in 5% and 1% of cases, respectively. The present study highlights the feasibility of performing EVT of brain aneurysms under CS as an alternative anesthetic protocol to GA. However, the limited nature of observational studies, methodological quality, the predominant absence of a comparative GA group, and clinical data during follow-up restrict a conclusive statement about the safety of EVT under CS. Accordingly, further research endeavors are warranted toward a higher level of evidence that can be translated into surgical practice.

Extended monitoring of re-coiled cerebral aneurysms after initial postcoiling recanalization: Safety and durability of repeat coil embolization.

PURPOSE: In the endovascular era, postcoiling recanalization of cerebral aneurysms is occurring with greater frequency. Repeat coiling is usually done to prevent rebleeding, although long-term outcomes of re-embolization have yet to be adequately investigated. The present study was undertaken to assess clinical and radiographic outcomes of re-embolization in recanalized aneurysms, focusing on procedural safety, efficacy, and durability. METHOD: In this retrospective review, we examined 308 patients with 310 recurrent aneurysms. All lesions were re-coiled, once major recanalization (after initial coil embolization) was established. Medical records and radiologic data amassed during extended follow-up were then subject to review. Cox proportional hazards regression analysis was undertaken to identify risk factors for subsequent recurrence. RESULT: During a lengthy follow-up (mean, 40.2 ± 33.0 months), major recanalization developed again in 87 aneurysms (28.1%). Multivariable Cox regression analysis linked re-recanalization to initial saccular neck width (p=.003) and autosomal dominant polycystic kidney disease (ADPKD; p<.001). Stent implantation (p=.038) and successful occlusion at second coiling (p=.012) were protective against later recanalization in this setting. The more recent the second embolization was performed, the lower the risk of further recurrence (p=.023). Procedure-related complications included asymptomatic thromboembolism (n = 9), transient ischemic neurologic deficits (n = 2), procedural bleeding (n = 1), and coil migration (n = 1), but there were no residual effects or deaths. CONCLUSION: Repeat coil embolization is a safe therapeutic option for recanalized cerebral aneurysms. Wide-necked status and ADPKD emerged as risks for subsequent recanalization, whereas successful occlusion and stent implantation seemed to reduce the likelihood of recurrence after re-embolization procedures.

Ongoing Geometric Remodeling of the Parent Artery After Flow-Diverter Stent Reconstruction in Cerebral Aneurysms: The Device Design Matters.

OBJECTIVE: Configuration changes of the parent artery (PA) after flow-diverter (FD) stent reconstruction, caused by the bending force of the device, may have an additional role in aneurysm occlusion as a result of the secondary alteration of intra-aneurysmal hemodynamics related to the geometry alteration of the vessel. To determine the degree of PA deformation and aneurysm occlusion rates after deployment of 2 different types of FD. METHODS: Patients treated with 2 different designs of cobalt-chromium braid (48 and 64 wire braid) structure FD were subject to analysis. Vascular angle changes at the level of the reconstructed segment immediately after FD deployment and at 1 year follow-up were measured and the potential relationship with aneurysmal occlusion rate was analyzed. RESULTS: Forty-two patients harboring 48 aneurysms were included in the present study. The aneurysms were divided into side wall (85.4%) and bifurcation types (14.6%). Twenty-six aneurysms were treated using the Pipeline FD (48 wire braid; 54.2%) and 22 using the Evolve FD (64 wire braid; 45.8%). Of the 48 aneurysms, 42 (87.5%) met the primary end point of complete occlusion at 12 months. The median postdeployment angle change was 7.04°± 4.59° for the Pipeline and 5.05°± 2.49° for the Evolve, whereas the median 12 months follow-up angle change was 15.49°± 10.99° and 10.01°± 8.83°, respectively. PA angle changes were significantly higher in the bifurcation group compared with the side wall group both during procedure and at 12 months follow-up. Angle change had a statistically nonsignificant association with complete aneurysm occlusion. CONCLUSIONS: PA deformation starts immediately after deployment and remodeling continues for 1 year after. Aneurysms located in the vessel bifurcation were more prone to PA straightening after FD deployment than were side wall aneurysms. Furthermore, Pipeline seemed to be more prone to inducing vascular deformation, compared with Evolve.

Comparison of PED/PED Flex and PED Shield in the treatment of unruptured intracerebral aneurysms.

OBJECTIVE: The object of this study was to compare the efficacy and safety profile of the Pipeline embolization device (PED)/Pipeline Flex embolization device (PED Flex) with that of the Pipeline Flex embolization device with Shield Technology (PED Shield). After introducing the first-generation PED and the second-generation PED Flex with its updated delivery system, the PED Shield was launched with a synthetic layer of phosphorylcholine surface modification to reduce thrombogenicity. METHODS: This is a retrospective review of unruptured aneurysms treated with PED/PED Flex versus PED Shield between 2017 and 2022 at the authors' institution. Patients with ruptured aneurysms, adjunctive treatment, failed flow diverter deployment, and prior treatment of the target aneurysm were excluded. Baseline characteristics were collected for all patients, including age, sex, past medical history (hypertension, hyperlipidemia, diabetes mellitus), smoking status, aneurysm location, and aneurysm dimensions (neck, width, height) and morphology (saccular, nonsaccular). The primary outcome was procedural and periprocedural complication rates. RESULTS: The study cohort comprised 200 patients with 200 aneurysms, including 150 aneurysms treated with the PED/PED Flex and 50 treated with the PED Shield. With respect to intraprocedural and periprocedural complications, length of stay, length of follow-up, and functional outcome at discharge, there was no significant difference between the two cohorts. At the midterm follow-up, the rate of in-stent stenosis (PED/PED Flex: 14.2% vs PED Shield: 14.6%, p = 0.927), aneurysm occlusion (complete occlusion: 79.5% vs 80.5%, respectively; neck remnant: 4.7% vs 12.2%; dome remnant: 15.7% vs 7.3%; p = 0.119), and the need for retreatment (5.3% vs 0%, p = 0.097) were comparable between the two cohorts. CONCLUSIONS: This study suggests that, as compared to first- and second-generation PED and PED Flex, the third-generation PED Shield offers similar rates of complications, aneurysm occlusion, and in-stent stenosis at the midterm follow-up.

Rupture of a flow aneurysm secondary to spontaneous extracranial to intracranial revascularisation in the posterior fossa following radiation-induced vasculopathy for cerebellar tumour.

Paediatric patients receiving cranial irradiation therapy for brain tumours are at increased risk of cerebrovascular complications. Radiation-induced moyamoya syndrome (MMS) is a well-recognised complication of this. We present a case of an 8-year-old boy with a history of medulloblastoma, who underwent surgical excision followed by post-operative adjuvant oncological treatment. Six years later, he developed cerebellar/intraventricular haemorrhage. He underwent an emergency external ventricular drain (EVD) insertion followed by posterior fossa suboccipital craniotomy. On dural opening, an abnormal vessel was visualised on the surface of the right cerebellar hemisphere, which was not disturbed. No obvious abnormalities were identified intra-operatively. Cerebral catheter angiography confirmed the presence of a right-sided occipital artery (OA) to posterior inferior cerebellar artery (PICA) extracranial to intracranial (EC-IC) bypass with a zone of the distal PICA territory supplied by this EC-IC bypass. A presumed flow aneurysm originated from the bypass in the distal PICA, identified as cause for the haemorrhage. We highlight a rare cause for intracranial haemorrhage in this cohort of patients. Children who have undergone radiotherapy may have exquisitely sensitive cerebral vasculature and need careful vigilance and evaluation for vasculopathic complications following spontaneous haemorrhage.

High signal intensity of the intraaneurysmal sac on T1 CUBE imaging as a predictor of aneurysm stability after coil embolization.

OBJECTIVE: Histopathological studies of aneurysms after coil embolization showed that thrombus formation during the first month after endovascular treatment (EVT) played an important role in the healing process. The authors hypothesized that dedicated T1-weighted imaging may be used to predict stable aneurysms by visualizing the thrombus status within coil-treated aneurysms. Therefore, this study investigated the relationship between the signal intensity (SI) of the intraaneurysmal sac after coil embolization and aneurysm stability. METHODS: The study population included 82 patients with 86 aneurysms who underwent T1-weighted 3D black-blood fast spin-echo (T1 CUBE) imaging within 1 month after coil embolization between 2019 and 2022. The relative SI of a coil-treated aneurysm (RSIcoiled) was calculated as follows: the mean SI of the intraaneurysmal sac/the mean SI of the genu of the corpus callosum. Aneurysms with enlarged remnants on MR angiography (MRA) within 6 months after EVT were defined as recurrence, while a decrease of intraaneurysmal flow on MRA was defined as improved embolization status. Stable aneurysms were defined as improvement or no change in embolization status 6 months after coil embolization. The volume embolization ratio (VER) was calculated as the ratio of the packed coil volume to the aneurysm volume. Differences between stable and recurrent aneurysms were examined. All aneurysms were divided into high and low RSIcoiled groups based on the cutoff value of RSIcoiled, and differences between the two groups were also evaluated. RESULTS: Recurrence was confirmed for 26 of 86 aneurysms. A univariable analysis showed that small aneurysms, high VER, and high RSIcoiled were associated with aneurysm stability. In the receiver operating characteristic curve analysis, the optimal cutoff value for RSIcoiled to differentiate stable from recurrent aneurysms was 0.54. The cutoff value for RSIcoiled was selected as 0.50 (sensitivity 0.77, specificity 0.70) because it was half the value of the SI of the corpus callosum and close to the optimal cutoff value. In a multivariable analysis, RSIcoiled > 0.50 (OR 8.1, 95% CI 2.5-27) remained a significant factor for aneurysm stability. The high RSIcoiled group showed a higher rate of an improved embolization status (26% vs 6.1%, p = 0.022) and stable aneurysms (85% vs 15%, p = 0.0002). CONCLUSIONS: RSIcoiled was associated with postcoiling aneurysm stability. High RSIcoiled might imply intraaneurysmal thrombus formation associated with the healing process of coil-treated aneurysms.

[Traumatic intracranial aneurysms following combat damage]. / Travmaticheskie anevrizmy golovnogo mozga pri boevykh povrezhdeniyakh.

OBJECTIVE: To develop the principles for the treatment of traumatic intracranial aneurysms after combat damage to skull and brain. MATERIAL AND METHODS: There were 18 patients with traumatic intracranial aneurysms from February 2022 to the present. Of these, 15 ones had gunshot penetrating wounds of the skull and brain. In 3 cases, aneurysms developed after explosive injury. All patients underwent computed tomography (CT) of the brain, CT angiography of brain vessels and selective cerebral angiography. We analyzed nature of brain damage, trajectory of the wounding projectile and aneurysm location to determine predictors of traumatic intracranial aneurysms. Surgical treatment was performed in all cases. RESULTS: Hemorrhagic manifestations were observed in 11 patients. In 4 cases, traumatic intracranial aneurysms were diagnosed before rupture. Blunt head injury was followed by subarachnoid hemorrhage in 2 cases and ischemic stroke in 1 case. Endovascular or microsurgical intervention was performed depending on location of aneurysm, clinical manifestations and severity of brain damage. In case of distal aneurysms, endovascular and microsurgical destructive interventions prevailed. At the same time, proximal aneurysms (within or below the circle of Willis) required reconstructive endovascular treatment. CONCLUSION: Traumatic aneurysms should be suspected in all patients with penetrating craniocerebral injuries. Follow-up is contraindicated for traumatic intracranial aneurysms due to high risk of hemorrhage.

Intracranial Aneurysms and Lipid Metabolism Disorders: From Molecular Mechanisms to Clinical Implications.

Many vascular diseases are linked to lipid metabolism disorders, which cause lipid accumulation and peroxidation in the vascular wall. These processes lead to degenerative changes in the vessel, such as phenotypic transformation of smooth muscle cells and dysfunction and apoptosis of endothelial cells. In intracranial aneurysms, the coexistence of lipid plaques is often observed, indicating localized lipid metabolism disorders. These disorders may impair the function of the vascular wall or result from it. We summarize the literature on the relationship between lipid metabolism disorders and intracranial aneurysms below.

The Safety and Efficacy of eCLIPs for Treatment of Wide-Necked Bifurcation Aneurysms: A Systematic Review and Meta-Analysis.

BACKGROUND: Wide-necked bifurcation aneurysms (WNBAs) are challenging intracranial aneurysms. Several device and treatment approaches have been proposed for the treatment of WNBAs. The endovascular clip system (eCLIPs) is a newly developed endovascular device with flow diverter and flow disruptor features. This study aims to investigate the safety and efficacy of the eCLIPs for treatment of patients with WNBAs. METHODS: This is a systematic review and meta-analysis study conducted in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. The electronic databases of PubMed, Embase, Scopus, and Web of Science were systematically reviewed from inception to June 19, 2023. The rate of complete and near-complete occlusion, successful device implantation, and serious adverse events were pooled using STATA, version 17. RESULTS: A total of 5 studies with 110 patients with WNBAs were systematically investigated. Our findings show that the immediate successful implantation rate of eCLIPs was 0.93 (95% confidence interval [CI], 0.88-0.97). Moreover, the immediate postoperative complete occlusion rate was 0.34 (95% CI, 0.10-0.58), and the immediate postoperative near-complete occlusion rate was 0.35 (95% CI, 0.24-0.45). Also, the near-complete occlusion rate at the latest follow-up was 0.3 (95% CI, 0.16-0.44). The serious adverse event rate was 0.14 (95% CI, 0.05-0.22). Stroke was also reported in 2 studies, with 1 study reporting 1 patient who experienced stroke within the first 24 hours and 1 study reporting no patients with stroke. CONCLUSIONS: Our findings document that the eCLIPs is a safe and effective device for treating patients with WNBAs and associated with favorable outcomes.