AcomA Aneurysms Research Articles

Surgical Clip Ligation of Anterior Communicating Artery Aneurysm in a Resource-Limited Setting.

Anterior communicating artery (ACOM) aneurysm clipping with intraoperative measures to ensure total occlusion and avoid ischemic complications is standard in countries such as the United States. However, alternatives need to be considered in resource-limited settings. The clipping of an unruptured, superiorly projecting ACOM aneurysm in a resource-limited setting is presented and special nuances that optimize safety are described. Careful surgical technique, meticulous identification of relevant anatomy, post-ligation inspection of the aneurysm and adjacent vessels, and possibly needle puncture of the aneurysm dome are critical to achieve favorable results.

Role of preoperative computed tomography angiographic anatomical considerations and their intraoperative interpretations in prediction of outcome in microsurgical clipping of ruptured anterior communicating aneurysm

BackgroundAnatomy of anterior communicating vascular complex is variable and sometimes causes troublesome situations during microsurgical clipping of ruptured anterior communicating (Acom) aneurysms. Preoperative understanding of anatomy, expecting the presence of normal variations, knowing the exact aneurysm morphometrics and understanding flow dynamic patterns, help to reach an appropriate surgical outcome.MethodsWe analyzed the preoperative angiographic anatomical findings in computed tomography angiography and compared them to the intraoperative microscopic anatomical finding in 52 patients who underwent microsurgical clipping of ruptured Acom aneurysms, to reach angiographic prognostic factors in ruptured Acom aneurysm surgery.ResultsThere is statistically significant relation between intraoperative anatomical factors and preoperative CTA findings (closed A2 aneurysm angle, neck extending to A2, anatomical variation, hypoplastic A1, and posterior projection).ConclusionCTA is a reliable method to predict the intraoperative anatomy in Acom aneurysm clipping. Poor outcome was more common among cases with posterior projection, closed A2-aneurysm angle, aneurysm neck extension to A2, and hypoplastic A1.

Relationship of the vascular territory affected by delayed cerebral ischemia and the location of the ruptured aneurysm in patients with aneurysmal subarachnoid hemorrhage

ObjectiveTo determine the area most at risk of delayed cerebral ischemia (DCI) in relation to the location of the ruptured aneurysm in patients with aneurysmal subarachnoid hemorrhage (aSAH) and, therefore, help to choose the site for focal multimodal neuromonitoring.MethodsWe retrospectively analyzed angiographic findings, CCT scans, and patient charts of patients who were admitted with aSAH to our neurosurgical intensive care unit between 2009 and 2017. DCI was defined as infarction on CCT 2–6 weeks after aSAH.ResultsDCI occurred in 17.9% out of 357 included patients. A DCI occurring in the vascular territory of the artery carrying the ruptured aneurysm was found in 81.0% of patients with anterior circulation aneurysms but only in 16.7% with posterior circulation aneurysms (Fisher’s exact, p=0.003). The vascular territory most frequently showing a DCI was the ipsilateral MCA territory (86.7%) in ICA aneurysms, the contra- (71.4%) and the ipsilateral (64.3%) ACA territory in ACA aneurysms, the right (93.8%) and the left (81.3%) ACA territory in AcomA aneurysms, and the ipsilateral MCA territory in MCA aneurysms (69.2%) as well as in VA/PICA/SCA aneurysms (100.0%). DCI after the rupture of a BA aneurysm occurred with 33.3% in 6 out of 8 vascular territories, respectively. DCI of multiple vascular territories occurred in 100.0% of BA aneurysms, 87.5% of AcomA aneurysms, 71.4% of ACA aneurysms, 40.0% of ICA aneurysms, 38.5% of MCA aneurysms, and 33.3% of VA/PICA/SCA aneurysms.DiscussionFew studies exist that could determine the area most at risk of a DCI after an aSAH. Our data could identify the territory most at risk for DCI with a probability of > 60% except for BA aneurysms, which showed DCI in various areas and patients suffering from multiple DCIs. Either the ipsilateral ACA or MCA were affected by the DCI in about 80% of ACA and more than 90% of AcomA, ICA, MCA, and VA/PICA/SCA aneurysms. Therefore, local intraparenchymal neuromonitoring in the ACA/MCA watershed area might detect the vast majority of DCIs for all aneurysm locations, except for BA aneurysms. In ACA and AcomA aneurysms, bilateral DCI of the ACA territory was common, and bilateral probe positioning might be considered for monitoring high-risk patients. Non-focal monitoring methods might be preferably used after BA aneurysm rupture.

Computed Tomography Angiography (CTA) Evaluation of Spontaneous Subarachnoid Hemorrhage

Background: In evaluation of non-traumatic subarachnoid hemorrhage CT angiography (CTA) has 97-98% sensitivity and near 100% specificity.
 Objective: This study was conducted to evaluate the CTA findings of CT positive non traumatic subarachnoid hemorrhage.
 Methodology: This is an observational cross sectional study performed in Neurology department of National Institute of Neurosciences and Hospital, Dhaka over one year period (January 2019 to December 2019). Total 87 CT positive subarachnoid hemorrhage cases were purposively included in this study. All CT positive patients underwent CTA of Cerebral vessels for further evaluation. The angiography were evaluated by competent neuro-radiologists blinded about the study.
 Result: Among 87 patients, 40.2% were male and 59.8% were female. The average age was 53.33±11.1 years. Among the studied patient the source of bleeding was found 78.16% aneurysmal and 21.84% non-aneurysmal. 85.30% patients had single aneurysm and 14.70% had multiple aneurysm. The highest number of patient had Acom aneurysm (41.17%) followed by MCA (22.05%), ICA (13.23%), ACA (7.35%) and vertebral artery (1.14%) in order of frequency. Among the multiple aneurysm group most of the patients had combination of Acom, MCA and ICA aneurysm.
 Conclusion: From this study, we can conclude that CTA can be used as the primary diagnostic tool in evaluation of spontaneous SAH.
 Journal of National Institute of Neurosciences Bangladesh, 2020;6(2): 78-81

Rupture of a Previously Undiagnosed Anterior Communicating Artery Aneurysm following External Lumbar Drainage in a Patient with Normal Pressure Hydrocephalus: A Case Report

Background and importance: Both asymptomatic unruptured intracranial aneurysms (AUIA) and idiopathic normal pressure hydrocephalus (NPH) have been found in the elderly population to increase in incidence with advancing age. In NPH, external lumbar drainage (ELD) is a gold standard and widely accepted low-risk procedure for supplemental testing of CSF responsiveness and suitability for surgical intervention. Herein, we reported the first case of aneurysmal subarachnoid haemorrhage (SAH) as a cause of neurological decline following ELD for the testing of patients with NPH. Clinical Presentation: A 65-year-old gentleman with probable NPH was admitted for supplemental testing using ELD. He had demonstrated CSF responsiveness as evidenced by improving Tinetti score. Unfortunately, on the third day of post-insertion, his GCS deteriorated from 15 to 3 due to rupture of a previously undiagnosed anterior communicating artery (Acom) aneurysm. He underwent left frontal external ventricular drain in an emergency setting and his GCS improved to E1VtM4. After frank discussion with his family, we proceeded with craniotomy and clipping of the aneurysm. However, his neurological recovery remained poor post-operatively and he had eventually undergone tracheostomy and ventriculo-peritoneal shunt. Conclusion: As SAH is also a known trigger of secondary NPH, there may be a critical role for screening of AUIA prior to ELD for NPH. The characterization of this risk would then allow for a full discussion of surgical or endovascular treatment options for AUIA, as well as the risk-benefit ratio of proceeding with supplemental testing and intervention for NPH.

Result of coiling versus clipping of unruptured anterior communicating artery aneurysms treated by a hybrid vascular neurosurgeon.

ObjectiveThis study will evaluate the outcomes of coiling versus clipping of unruptured anterior communicating artery (A-com) aneurysms treated by a hybrid vascular neurosurgeon to suggest the best protocol of management for these conditions.MethodsWe retrospectively reviewed the records of 70 patients with an unruptured A-com aneurysm treated with coiling or clipping performed by a hybrid vascular neurosurgeon between March 2012 and December 2019. The patients were dichotomized, into the coil group or clip group. Treatment-related complications, clinical and radiological results were evaluated.ResultsOf the 70 patients identified, 37 underwent coiling and 33 clipping. Procedure-related symptomatic complications occurred in 2 patients (5.4%) in the coil group and 3 patients (9.1%) in the clip group. Poor clinical outcome (modified Rankin Scale [mRS] of 3 to 6) at 6 months of follow-up was seen in only one patient (2.7%) for the coil group, and none for the clip group. The one poor outcome was the result of intra-procedural rupture during coiling. Follow-up conventional angiography data (mean duration, 15.0 months) revealed that the major recanalization rate is 5.6% for the coil group and 10.0% for the clip group.ConclusionsManagement of A-com aneurysms requires more collaboration between microsurgical clipping and endovascular therapy. Evaluation of patient and aneurysm characteristics by considering the advantages and disadvantages of both techniques could provide an optimal treatment modality. A hybrid vascular neurosurgeon is expected to be a proper solution for the management of these conditions.

Association of Bone Mineral Density, Vitamin D, and Serum Calcium in Intracranial Aneurysm.

Aims:The objective of this study is to understand the association between bone mineral density (BMD), serum calcium, and Vitamin D in s (IA) patients.Subjects and Methods:A total of 100 patients with IA diagnosed at the department of neurosurgery between January 2019 and December 2019 were reviewed and analyzed in this study. Computed tomography angiography was used to confirm and locate the site of aneurysms. BMD, serum calcium, and Vitamin D levels were measured.Statistical Analysis Used:Linear or logistic regression statistical models were applied to found the association between BMD and IA size. To confirm the statistical significance, P < 0.05 (twos-tailed) was considered as statistically significant.Results:Of the studied 100 patients, 61 patients were female and 39 were male. According to the age group, patients were divided into five categories: below 30, 31–40, 41–50, 51–60, and ≥60 years. The most common site of aneurysm observed to be the anterior communicating artery (Acom); 39.25% of the patients had Acom aneurysm followed by the middle cerebral artery (18.69%). This clearly shows that the occurrence of aneurysm is more prominent in anterior circulation as compared to posterior circulation. The results showed that there is a negative linear correlation between BMD and size of aneurysm (P = 0.00043, r =−0.12). Sex-specific analysis showed that females have lower mean BMD value as compared to males (i.e., females 0.785 ± 0.13; males 0.887 ± 0.13; P = 0.0003). We also found that the multiplicity of IAs also shows an association with BMD (i.e. mean BMD: 0.825 ± 0.14, whereas BMD of patients with multiple aneurysms was 0.747 ± 0.08; P = 0.05). Of 100 patients, 66 were observed calcium deficient (normal range: 8.8–10.2 mg/dl). The obtained mean value of calcium was 8.56 ± 0.859 standard deviation (SD), i.e., below the normal range of calcium. In the case of Vitamin D, 85% of the patients were observed Vitamin D deficient, whereas 14 patients showed Vitamin D insufficiency and merely 1 patient has Vitamin D sufficiency. The mean 25-hydroxy Vitamin D level obtained in our study was 14.57 ± 5.60 (SD), which is considered as Vitamin D deficiency.Conclusions:The size and multiplicity of IA can be associated with BMD, calcium, and Vitamin D. The results from the research provide evidence of common pathophysiology between the development of IA and these factors.

Comparison between outcomes of endovascular and surgical treatments of ruptured anterior communicating artery aneurysms

Introduction The natural history and optimal treatment of previously ruptured anterior communicating artery (ACOM) aneurysms that recur is unknown. This study looks at rates of complications and recurrences of ruptured ACOM aneurysms treated endovascularly and surgically. Materials and methods A retrospective observational study of all patients presenting to a single tertiary neurosurgical centre with the first presentation of subarachnoid haemorrhage (SAH) secondary to a ruptured ACOM aneurysm. Data was collected from November 2012 to September 2018 and included baseline demographics, aneurysm characteristics, management, complications, follow-up imaging, and clinical outcomes. Results 137 patients were included in the study. 113 aneurysms were coiled and 19 were clipped. Management decisions were taken by the multidisciplinary team based on aneurysm morphology or the presence of a haematoma exerting mass effect. There were 187.5 patient-years of follow-up, with a median of 3 years (range 0–73 months). Rates of vasospasm, infarction, CSF diversion, rebleed, length of stay, and functional outcome were not significantly different in the two cohorts. There was a statistically significant increase in the risk of ACOM recurrence in the coiled group when compared to the clipped group at one year (p = .0433). 15 patients required further treatment at a median time of 16 months. In a subgroup group analysis of coiled aneurysms, there was no statistical differences in rates of rebleeding or the functional outcome in those that had aneurysm recurrence and those that did not. Conclusions This study suggests patients with aneurysms treated by endovascular coiling have an increased risk of recurrence versus those treated with clipping. However, the risk of rebleed was not statistically significant. The prevention and impact of recurrence and residual aneurysms remains incompletely understood. Hence, treatment decisions should be taken by patients after they have been given carefully considered recommendations from the multi-disciplinary team.

Unilateral absence of the internal carotid artery associated with anterior communicating artery aneurysms: Systematic review and a proposed management algorithm.

Background: Absence or hypoplasia of the internal carotid artery (ICA) is a rare congenital anomaly that is mostly unilateral and highly associated with other intracranial vascular anomalies, of which saccular aneurysm is the most common. Blood flow to the circulation of the affected side is maintained by collateral pathways, some of which include the anterior communicating artery (Acom) as part of their anatomy. Therefore, temporary clipping during microsurgery on Acom aneurysms in patients with unilateral ICA anomalies could jeopardize these collaterals and place the patient at risk of ischemic damage. In this paper, we review the literature on cases with a unilaterally absent ICA associated with Acom aneurysms and provide an illustrative case.Methods: We combined our experience of one case of a unilaterally absent ICA associated with an Acom aneurysm with the 33 existing publications on the same subject in the literature, for a total of 40 cases. We provide a detailed systematic literature review of this association of vascular anomalies, exploring different aspects regarding the collateral pathways and how they impact management strategies and propose a management algorithm to deal with such association.Results: The mean age was 48.2 ± 16.5 years. The aneurysmal rupture was the most common presentation (75%). Agenesis was observed in 70% of patients, followed by hypoplasia (20%) and, finally, aplasia (10%). Lie Type A was the most common pattern of collaterals (50%), with Types B and D being of almost equal proportions. Most aneurysms were located at the A1-Acom junction contralateral to the anomalous side (Fisher’s Exact test; P = 0.03). One case of temporary clipping was reported in the literature.Conclusion: Acom aneurysms in patients with unilateral ICA anomalies, given they are more commonly present contralaterally, could be of acquired etiology, warranting periodic screening in asymptomatic patients. Temporary clipping might be safe in patients with Type D collateral pattern, while those with Types A or B may require intraoperative rupture risk assessment and a tailored management plan to avoid disrupting collateral flow and causing ischemia.

Tailored Communicating Bypass for the Management of Complex Anterior Communicating Artery Aneurysms: "Flow-Counteraction" In Situ Bypass and Interposition Bypass Using Contralateral A2 Orifice as Donor Site.

The use of bypass surgery for anterior communicating artery (ACOM) aneurysms is technically challenging. Communicating bypass (COMB), such as pericallosal artery side-to-side anastomosis, is the most frequently used and anatomically directed reconstruction option. However, in many complex cases, this technique may not afford a sufficient blood supply or necessitate sacrificing the ACOM and the eloquent perforators arising from it. To evaluate tailored COMB and propose a practical algorithm for the management of complex ACOM aneurysms. For 1 patient with an aneurysm incorporating the entire ACOM, conventional in Situ A3-A3 bypass was performed as the sole treatment in order to create competing flow for aneurysm obliteration, sparing the sacrifice of eloquent perforators. In situations in which A2s were asymmetric in the other case, the contralateral A2 orifice was selected as the donor site to provide adequate blood flow by employing a short segment of the interposition graft. The aneurysm was not visualized in patients with in Situ A3-A3 bypass because of the "flow-counteraction" strategy. The second patient, who underwent implementation of the contralateral A2 orifice for ipsilateral A3 interposition bypass, demonstrated sufficient bypass patency and complete obliteration of the aneurysm. The feasibility of conventional COMB combined with complete trapping may only be constrained to selected ideal cases for the treatment of complex ACOM aneurysms. Innovative modifications should be designed in order to create individualized strategies for each patient because of the complexity of hemodynamics and the vascular architecture. Flow-counteraction in Situ bypass and interposition bypass using the contralateral A2 orifice as the donor site are 2 novel modalities for optimizing the advantages and broadening the applications of COMB for the treatment of complex ACOM aneurysms.

Recurrence and retreatment of anterior communicating artery aneurysms after endovascular treatment: a retrospective study

BackgroundSurgical treatment of anterior communicating artery (Acom) aneurysm is challenging due to anatomic complexity. We aimed to describe our experiences with endovascular treatment (EVT) of Acom aneurysms, and to evaluate the incidence and risk factors of recurrence and retreatment.MethodsThe study comprised 260 patients who were treated at a single center between January 2010 and December 2018. Patients who had EVT, including stent-assisted coiling of Acom aneurysms, were included. All medical records were retrospectively reviewed. The incidence and risk factors of recurrence and retreatment were evaluated. Univariate and multivariate analysis were conducted.ResultsRecurrence of Acom aneurysms occurred in 38 (14.6%) patients. Mean follow-up duration was 27 months (range 1–110). Multivariate logistic regression indicated that ruptured aneurysm (odds ratio [OR] 3.55, P = 0.001), dome direction (anterior) (OR 3.86, P = 0.002), maximal diameter (OR 1.19, P = 0.02), and mean age (OR 0.96, P = 0.02) were independent risk factors for aneurysm recurrence. Of 38 cases of recurrence, 10 (3.8%) patients underwent retreatment. Ruptured aneurysm (OR 14.7, P = 0.004), maximal diameter (OR 1.56, P = 0.02), inflow angle (OR 1.04, P = 0.03), and Raymond-Roy classes II and III (OR 6.19, P = 0.03) showed significant relation to retreatment in multivariate logistic regression analysis.ConclusionsIn our study, recurrence rate of Acom aneurysms after EVT was 14.6%. Rupture, anterior dome direction, maximal diameter, and mean age were significantly associated with recurrence. Retreatment rate of recurrent Acom aneurysms after EVT was 3.8%. Patients with Acom aneurysms with large inflow, rupture, large size, or incomplete occlusion may be at a high risk of retreatment of recurring aneurysm.

Clinical and morphological risk factors for the recurrence of anterior communicating artery aneurysms after clipping or coiling.

The aim of this study was to evaluate clinical and morphological factors associated with recurrence in anterior communicating artery (AcomA) aneurysms after clipping or coiling. We retrospectively reviewed the clinical and radiologic features of consecutive 214 patients with AcomA aneurysms treated between January 2012 and December 2016 in a single tertiary institute. Univariate and multivariate analyses were performed to identify the relationship between clinical and morphological variables and recurrence. Of 214 patients, 166 were unruptured aneurysms and 109 were treated with coiling. Overall recurrence rate was 13% (28 out of 214 aneurysms) during mean 36.9 ± 18.4-month follow-up. Multivariate logistic regression analysis showed that size greater than 10mm (OR = 5.651; 95% CI, 1.317-24.242; p = 0.020), smoking (OR = 3.474; 95% CI, 1.342-8.996; p = 0.010), coiling (OR = 2.98; 95% CI, 1.005-8.832; p = 0.049), and anterior direction of aneurysm (OR = 3.77; 95% CI, 1.12-12.66; p = 0.032) were significantly associated with recurrence of AcomA aneurysms after treatment. The results of this study demonstrated that coiling, large aneurysm, anterior direction, and smoking history may be independent risk factors for the recurrence of AcomA aneurysms. Therefore, careful follow-up should be needed especially in large AcomA aneurysms with anterior direction after coiling.

Intraoperative Use of Endoscope, a Valuable, Adjunctive Tool for the Surgical Management of Anterior Communicating Artery Aneurysm Surgery: Our Institutional Experience.

Background:Anterior communicating (A-com) artery region is very complex; perforators are not always visualized on the microscope. The neuroendoscope with its higher magnification, better observation, and additional illumination can provide us information that may not be available with the microscope in aneurysm surgery.Objective:The objective was to study the use of endoscope in surgical management of A-com aneurysm surgery and its advantages, whether and how it changes operative management.Materials and Methods:We studied 25 serial cases of A-com aneurysm at Bantane Hospital, Fujita University, Japan, from November 2018 to October 2019. Once aneurysm was exposed, we did preclipping indocyanine green (ICG) study and examination with endoscope. After clipping, we again did ICG and endoscopic assessment. Preclipping and postclipping endoscopic information was used and necessary changes were made in the operative decisions. Whether endoscope gives any additional information over microscope and ICG which led to change in the operative decision was assessed.Results:In six out of 25 A-com aneurysm patients, the use of endoscope has given additional information over microscope, and ICG leading to change in the operative plans such as readjustment of the clip/application of the second clip or release of perforator compromise.Conclusion:Simultaneous endoscopic and microscopic guidance can reveal important information hidden from the microscope. Thus, this method increases the safety and durability of the A-com aneurismal clipping.

Recurrent Giant Anterior Cerebral Artery (ACA) Aneurysm With Previous Coiling, Attempted Clipping Then Direct ACA-to-ACA Bypass: 2-Dimensional Operative Video.

Giant aneurysms are defined as lesions with a widest diameter of 2.5 cm or greater and account for 2% to 5% of all intracranial aneurysms. These lesions are challenging entities for microsurgical management with techniques such as direct aneurysmal neck clipping, aneurysm neck reconstructions, aneurysmotomy, and aneurysmectomy. This patient had a previously coiled, unruptured, superiorly projecting giant anterior communicating artery (ACom) aneurysm, eccentric toward the left, for which surgical intervention was undertaken. A left orbitozygomatic craniotomy was performed, and a temporary clip was applied to the bilateral proximal A1 segments. Aneurysmotomy was then performed with internal debulking of the aneurysmal thrombus. Aneurysmectomy and removal of the coil mass were performed. Next, the aneurysm neck was reconstructed using multiple surgical clips. After anticipated aneurysm neck reconstruction, indocyanine green (ICG) angiography demonstrated a lack of flow in the ipsilateral A2. The ACom was then transected along the aneurysm neck, and an end-to-end anastomosis of the distal A1 and proximal A2 was performed. Repeat ICG angiography demonstrated patency of the A1-A2 anastomosis. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Intraoperative Use of Microscope-Integrated Flow 800 - A Valuable Tool in Surgical Management of Anterior Communicating Artery Aneurysm: Our Institutional Experience.

Background:Flow 800 is microscope-integrated analytical visualization tool which analyses the indocyanine green (ICG) video sequence and converts it into an intensity diagram. This allows an objective evaluation of the result rather than subjective assessment of ICG fluorescence. The anatomy of anterior communicating artery region is complex because of multiple vessels and perforators in small space; hence, there is a need of objective assessment tool which can give precise idea about vascular compromise. Flow 800 can serve as a valuable tool in this complex surgery.Objective:The objective of this study was to evaluate the utility of microscope-integrated fluorescent ICG videoangiography (Flow 800) in A-com aneurysm surgery.Materials and Methods:We used Flow 800 in ten consecutive patients of A-com aneurysm surgery from July 2019 to October 2019. We studied patient characteristics, intraoperative observation of ICG and Flow 800, and corresponding changes made in the operative decisions.Results:The use of Flow 800 helped in intraoperative decision of four out of ten patients of A-com aneurysm. In two patients, incomplete clipping was confirmed with Flow 800 and the second clip was applied. In the third patient, perforator compromise was found hence needed clip readjustment, whereas in the fourth patient, ICG was inconclusive and Flow 800 confirmed complete clipping of aneurysm.Conclusion:Flow 800 is a conclusive reproducible and objective tool for early detection of vascular compromise of multiple vessels and perforators in A-com aneurysm surgery. It gives a better idea of vasculature, especially where ICG is ambiguous or inconclusive.

Recurrence of Previously Clipped Anterior Communicating Aneurysm: The Surgical Techniques and Strategies: A Case Series.

Background:Microsurgical aneurysm (MSA) clipping is considered as the standard therapy with the endovascular coiling. Microsurgical clipping is considered superior to endovascular in terms of the recurrence rate. The management of recurrent aneurysm following previous microsurgical clipping is challenging. The management of recurrent aneurysm following previous microsurgical clipping is challenging. This study aims to explore the management of recurrent aneurysm of the anterior communicating artery (ACoM).Materials and Methods:This is a case series of three elder women who had a recurrence of ACoM aneurysm after MSA clipping. All the three patients were operated with microsurgical clipping. We studied the preoperative images of the first surgery of all the patients. The detailed case-by-case analysis was performed based on preoperative, postoperative, and follow-up radiologic examinations and operative findings.Results:All three patients who had a recurrence after MSA clipping of ACoM aneurysm and were asymptomatic. At presentation, they were diagnosed at the postoperative imaging at follow-up. The earliest recurrence was 1 year while in one patient; the recurrence was detected 8 years after the initial MSA clipping. The cerebral aneurysms were posteriorly directed in the initial preoperative images in all the cases.Conclusion:This study revealed the recurrence as the residual neck or the enlargement of the aneurysm even after MSA in these cases of ACoM aneurysm. Even with the complete clipping, there can be recurrence at the clip site due to the change in hemodynamics over the time. We should follow-up the patients regularly even after microsurgical clipping.

Treatment of unruptured distal anterior circulation aneurysms with flow diverter stents: A meta-analysis

Background The safety and efficacy of FD among distal AC aneurysms must be proved. Purpose To analyze the outcomes after FD among MCA, AcomA, and DACA aneurysms. Data sources A systematic search of three databases was performed for studies published from 2005 to 2018. Study selection According to PRISMA guidelines, we included studies reporting FD of distal AC aneurysms. Data analysis Random-effects meta-analysis was used to pool aneurysm occlusion and complication rates. From the individual patient data, univariate and multivariate analysis were used to test predictors of occlusion and complications. Data synthesis We included 27 studies (484 aneurysms). Long-term adequate occlusion rate (OKM C-D) was 82.7 % (295/364, 95 % CI = 77.4 %–87.9 %, I2 = 52 %). Treatment-related complications were 12.5 % (63/410, 95 % CI = 9 %–16 %%, I2 = 18.8 %), with 5.4 % (29/418, 95 % CI = 3.2–7.5 %, I2 = 0 %) of morbidity. MCA location was an independent factor associated with lower occlusion (OR = 0.5, P = 0.03) and higher complication rates (OR = 1.8, P = 0.02), compared to AcomA and DACA aneurysms. PED (vs other stents) gave better occlusion rates (OR = 2.6, P = 0.002), whereas large/giant aneurysms were associated with higher odds of complications (OR = 2.2, P = 0.03). The rates of occlusion and narrowing of arteries covered by flow-diverter stents were 6.3 % (29/283, 95 % CI = 3.5 %–9.1 %, I2 = 4.2 %) and 23.8 % (69/283, 95 % CI = 15.7 %–32 %, I2 = 80 %), respectively. Symptoms related to occlusion and narrowing of the jailed arteries were 3.5 % (6/269, 95 % CI = 1.1 %–5 %, I2 = 0 %) and 3 % (6/245, 95 % CI = 1 %–4 %, I2 = 0 %), respectively. Limitations Small and retrospective series. Conclusions FD among distal AC aneurysms is effective, leading to adequate aneurysm occlusion in 83 % of cases. However, this strategy presents some limitations among MCA, and for larger lesions especially related to the higher rate of complications. Compared to the other devices, PED seems to be associated with a higher occlusion rate.

Long-term Outcomes After Intraprocedural Aneurysm Rupture During Coil Embolization of Unruptured Intracranial Aneurysms

The long-term outcomes of patients with intraprocedural aneurysm rupture (IPR) during endovascular coiling of unruptured intracranial aneurysms (UIAs) remain unclear. We investigated the long-term outcomes and predictors of neurological outcomes in patients who sustained IPR during coil embolization of UIAs. We retrospectively analyzed the medical record of 312 untreated UIAs in 284 patients who underwent endovascular coiling between April 2013 and July2018. The mean follow-up period for the entire cohort was 25.6 months. Twelve patients (3.8%) experienced IPR. The mean aneurysm size in the IPR cohort was significantly smaller than that in the no-IPR cohort (P= 0.045). The IPR cohort had a higher percentage of earlier subarachnoid hemorrhage from another aneurysm (P= 0.019), anterior communicating artery (AComA) aneurysm (P < 0.001), and basilar artery (BA) aneurysm (P= 0.022) than the no-IPR cohort. Neurologic deterioration was observed in 3 patients. The morbidity and mortality rates of the IPR cohort were 25% and 8.3%, respectively. Patients with IPR during coil embolization for AComA aneurysm did not develop neurological deterioration. Two of the 3 patients (66.7%) with a BA aneurysm had neurological deterioration. The proportion of patients with an mRS score of 0-2 at the last follow-up did not differ between the 2 cohorts (P= 0.608). The proportion of functionally independent patients did not differ between patients with and without IPR. Patients with BA aneurysms who developed an IPR tended to exhibit more unfavorable clinical courses than patients with AcomA aneurysms.

Differences in Size Between Unruptured and Ruptured Saccular Intracranial Aneurysms by Location

It is generally accepted that larger saccular intracranial aneurysms are at greater risk to rupture. We investigated whether aneurysm location influences the effect of aneurysm size on the propensity of rupture. We reviewed patient and aneurysm characteristics in a consecutive series of patients with unruptured and ruptured aneurysms presenting to our institution between 2006 and 2018. Differences between unruptured and ruptured aneurysms at different locations were subsequently investigated. A total of 766 aneurysms in 568 patients were included, with 355 and 411 unruptured and ruptured aneurysms, respectively. There were significant differences in the distribution of aneurysm location between unruptured and ruptured aneurysms (P < 0.001). The most common locations of unruptured aneurysms were the middle cerebral artery (MCA) (27.6%) and paraclinoid internal carotid artery (ICA) (25.4%), whereas the most common locations of ruptured aneurysms were the anterior communicating artery (ACOM) (34.8%) and posterior communicating artery (17.8%). Ruptured aneurysms were larger than unruptured aneurysms at all locations except at the ACOM, where there was no difference in size between unruptured and ruptured aneurysms (5.4 vs. 5.8 mm, respectively; P= 0.40). Ruptured ACOM aneurysms were also smaller than ruptured aneurysms of the paraclinoid ICA (5.8 vs. 10.3 mm; P < 0.001), MCA (5.8 vs. 8.0 mm; P= 0.021), and basilar apex (5.8 vs. 10.5 mm; P < 0.001), respectively. We observed no difference in size between unruptured and ruptured ACOM aneurysms, possibly suggesting a greater susceptibility for ACOM aneurysms to rupture at smaller sizes.

Lower limb weakness with gyrus rectus hematoma: an unusual presentation of paraclinoid aneurysm; a case report with review of literature

Lower limb weakness is usually a feature of ruptured anterior communicating (ACom) aneurysms due to spasm of the anterior cerebral arteries. Paraclinoid aneurysms, in addition to other cardinal features of subarachnoid haemorrhage (SAH), usually present with headache and visual field defects due to compression of the optic pathway. We report a case of left paraclinoid aneurysm presenting with right lower limb weakness and gyrus rectus hematoma without SAH. The aneurysm was long, passing beneath the optic nerve to emerge in the inter-optic cistern, leading to such atypical presentation. The aneurysm was clipped successfully after drilling the clinoid. As per our knowledge, such a clinical presentation of paraclinoid aneurysm has not been reported in the literature till date.