Anterior Circulation Aneurysms Research Articles

Lamina Terminalis Fenestration: A Beneficial Approach to Reduce Shunt-dependent Hydrocephalus in Patients with Aneurysmal Subarachnoid Hemorrhage with a Review of Literature

ABSTRACT Objective: Hydrocephalus requiring shunt placement (12%–20%) is a common complication after aneurysmal subarachnoid hemorrhage (aSAH). Various studies suggest that fenestration of lamina terminalis (LT) during microsurgery for aSAH may be associated with a reduced rate of shunt-dependent hydrocephalus. We report a prospective analysis correlating fenestration of the LT with decreased shunt-dependent hydrocephalus after aSAH managed by microsurgical repair. Methodology: A total of 106 patients over a period of 1.5 years with aSAH treated by microsurgical aneurysm repair along with fenestration of LT were analyzed. Patients were treated by same surgical team and those patients where surgical clipping of anterior circulation aneurysms with LT fenestration was performed were included in the study. We compared the rate of shunting in patients operated on by routinely fenestration of the LT with that in cases where LT fenestration was not carried out (taking literature as control). This study design isolates the effect of fenestration of the LT on the incidence of shunt-dependent hydrocephalus. Results: There has been significantly lower rate of shunting (2.3%) in the patients where LT fenestration was done, versus 12%–20% in the cases where it was not preformed (P < 0.05). Furthermore, post-aSAH, hydrocephalus is associated with a higher grade of Fischer’s scale (Grade III and IV). Conclusion: Fenestration of the LT appears to be associated with a decreased incidence of shunt-dependent hydrocephalus of more than 80% after aSAH. This straightforward microsurgical maneuver should be performed whenever possible during aneurysm surgery.

Endovascular management of intracranial aneurysms at Chris Hani Baragwanath Academic Hospital.

Worldwide, intracranial aneurysms are associated with a high mortality rate. While endovascular management has proven to be the choice of treatment in selected patients, patient demographics and aneurysm characteristics differ between study populations. This study aimed to investigate the profile of patients with intracranial aneurysms who underwent endovascular management in the Interventional Neuroradiology Unit at Chris Hani Baragwanath Academic Hospital. Patient demographics, risk factors, indications, aneurysm characteristics and intra-operative complications were studied. This was a 3-year retrospective study of all adult patients between 01 January 2018 and 31 January 2021. The Chi-square test was used to compare categorical variables. A total of 77 patients were included in this study. The mean age of the patients was 47 ± 11.6 with a male-to-female ratio of 1:1.8. Hypertension was the most reported risk factor in 27% of patients. There was no statistical correlation between the gender groups according to presentation, multiplicity, aneurysmal size dimensions and locations. According to the presentation, there was statistical significance in ruptured intracranial aneurysms (p = 0.020), neck size dimensions less than 4 mm (p = 0.010), and aneurysms located in the internal cerebral artery (ICA) circulation (p = 0.001). The study findings support known parameters including females and anterior circulation aneurysm preponderance, and the low complication risk of endovascular management. Interestingly, intracranial aneurysms presented with rupture at smaller size dimensions. This study provides valuable insights into intracranial aneurysm characteristics and endovascular management efficacy in a resource-limited setting.

Sympathetic Nervous Hyperactivity Impairs Microcirculation Leading to Early Brain Injury After Subarachnoid Hemorrhage.

Although early brain injury (EBI) is recognized as a critical step following subarachnoid hemorrhage (SAH), its pathophysiology and underlying mechanisms remain poorly understood. Herein, we investigated the role of cerebral circulation in the acute phase using patient data and a mouse SAH model and evaluated its regulation via the sympathetic nervous system. The cerebral circulation time and neurological outcomes in the human body were retrospectively examined in 34 SAH cases with ruptured anterior circulation aneurysms and 85 cases with unruptured anterior circulation cerebral aneurysms at Kanazawa University Hospital from January 2016 to December 2021. In a mouse study, a SAH model was created via endovascular perforation, and India-ink angiography was performed over time. Additionally, bilateral superior cervical ganglionectomy was performed immediately before surgery, and neurological scores and brain water content were evaluated after SAH. Cerebral circulation time was prolonged in the acute phase of SAH compared with that in the unruptured cerebral aneurysm group, especially in those with electrocardiographic changes. Furthermore, it was more prolonged in the poor prognosis group (modified Rankin Scale scores 3-6) than in the good prognosis group (modified Rankin Scale scores 0-2) at discharge. In mice, cerebral perfusion was significantly reduced at 1 and 3 hours after SAH and recovered at 6 hours. superior cervical ganglionectomy improved cerebral perfusion without altering the diameter of the middle cerebral artery at 1 hour and improved neurological outcomes at 48 hours after SAH. Consistently, brain edema, quantified by brain water content, was improved by superior cervical ganglionectomy 24 hours after SAH. Sympathetic hyperactivity may play a critical role in the development of EBI by impairing cerebral microcirculation and edema in the acute phase following SAH.

Complementary role of Indocyanine green video angiography, dual-image video angiography and flow-800

Background Visualization of cerebral vessels, their branches and the surrounding structures are essential during cerebrovascular surgery. Indocyanine green dye-based video angiography is a commonly used technique in cerebrovascular surgery. This paper aims to analyze the real-time imaging of ICG-AG, DIVA, and the use of ICG-VA with Flow 800 to compare their usefulness in surgery. Methods Intraoperative real-time identification of vascular and surrounding structures in twenty nine anterior circulation aneurysms and three posterior circulation aneurysm clipping, one STA-MCA bypass, and two carotid endarterectomies were performed in patients using ICG-VA alone, DIVA, ICG-VA with Flow 800 to analyze and compare each of these methods in details. Results ICG-VA and DIVA couldn’t visualize perforators in twenty-three cases of cerebral aneurysms clipping when used alone. Compared to that by adding Flow 800 perforators were easily visualized. In three cases, occlusion of perforators after clip application was visualized by DIVA and solved by repositioning surgical clips. In one STA-MCA bypass surgery, adequate blood flow to cortical branches of MCA (M4) from STA branches was assessed with ICG-VA, DIVA, and the use of ICG-VA with Flow 800 color mapping. ICG-VA, DIVA, and Flow 800 observed the lack of blood flow and fluttering atherosclerotic plaques in carotid endarterectomy. In one case of basilar tip aneurysm, we used ICG-VA with Flow 800; the intensity diagram drawn after determining regions of interest showed that there was no flow within the aneurysm sac after clipping. Conclusion In real-time surgery, a multimodal approach using ICG-VA, DIVA, and ICG-VA with Flow 800 colour mapping can serve as useful tools for better visualization of vascular and surrounding structures. The benefits of flow 800 color mapping, such as determining regions of interest, intensity diagrams, and color-coded images, outweigh the advantages over the ICG-VA and DIVA in the visualization of critical vascular anatomy in humans during surgical procedures.

How I do it: the endoscopic endonasal transclival approach for clipping of the ruptured vertebral artery aneurysm.

Vertebral artery aneurysms account for less than 5% of all cerebral aneurysms. They have a high risk of rupture and are associated with threatening clinical outcomes compared with anterior circulation aneurysms. The endoscopic endonasal transclival approach (EETA) was used. During the temporary clipping, the neck of the aneurysm was dissected, and a permanent clip was applied. The repair of the skull base defect was carried out with the nasoseptal mucoperiosteal flap on the vascular pedicle. The EETA is a feasible alternative for the clipping of the medially located ruptured vertebral artery aneurysm. EETA can be recommended for centers with a large volume of cerebrovascular and endoscopic neurosurgical procedures.

Evaluation of Intraoperative and Post-Operative Benefits of Supraorbital Keyhole Approach for Anterior Circulation Aneurysm Surgery

Objective: To evaluate the intraoperative and post-operative benefits of the supraorbital keyhole approach for anterior circulation aneurysm surgery.
 Study Design: Cross-sectional analytical study
 Place and Duration of Study: Neurosurgery Department, Combined Military Hospital (CMH), Rawalpindi Pakistan, from Mar 2021 to Apr 2022.
 Methodology: Forty patients came for anterior circulation aneurysm surgery during the above said period in the hospital who met the inclusion and exclusion criteria of the study. Ambulation time against all patients was 24 hours. Patients were treated with clipping. After surgery, patients were followed till the resolution of complications.
 Results: Of 40 cases, 21(52.5%) were males, and 19(47.5%) were females. The average age of the patients was 51.97±9.73 years. The aneurysm location of patients was not associated with the gender of the patient, with a p-value of 0.115. Similarly, the average age of the patient was not significantly different for the patients' aneurysms location with a p-value of 0.106. Satisfaction appearance was claimed in all 40(100%) cases after surgery. The research study showed no complications in 18(45%) patients out of 40 after treatment, with a p-value of 0.041.
 Conclusion: Supraorbital keyhole approach for anterior circulation aneurysm surgery is better regarding intraoperative tissue trauma and post-operative cosmetic outcome. The patient and all post-operative complications will be cured within six months after surgery.

Supraorbital vs pterional keyhole for anterior circulation aneurysms: A systematic review and meta-analysis

BackgroundThe supraorbital approach is a modification of the traditional pterional approach, and it offers the benefits of a shorter skin incision and a smaller craniotomy than the pterional approach. The purpose of this systemic review study was to compare the two surgical approaches for raptured and unruptured anterior cerebral circulation aneurysms. MethodsWe searched PubMed, EMBASE, Cochrane Library, SCOPUS, and MEDLINE, up to August 2021, for published studies on the supraorbital vs pterional keyhole approach for anterior cerebral circulation aneurysms, and reviewers performed a brief qualitative descriptive analysis of both approaches. ResultsFourteen eligible studies were included in this systemic review. Results indicated that the supraorbital approach for anterior cerebral circulation aneurysms had fewer ischemic events compared to pterional approach. However, no significant difference between both groups in terms of complications such as intraoperative aneurysm rupture, brain hematoma, and postoperative infections for ruptured aneurysms. ConclusionThe meta-analysis suggests that the supraorbital method for clipping anterior cerebral circulation aneurysms might be a viable alternative to the traditional pterional method as the supraorbital group had decreased ischemic events compared to the pterional group, however, the associated difficulties in utilizing this approach among ruptured aneurysms with cerebral oedema and midline shifts further needs to be understood.

348 Risk of Rupture and Treatment Outcomes of Giant Pediatric Aneurysms: Multi-Institutional Case Series and Meta-Meta-Analysis

INTRODUCTION: Giant pediatric aneurysms are vascular malformations that can cause significant neurologic morbidity and mortality. Their rarity has precluded large cohort studies to inform their management. METHODS: Multi-institutional cohort study of cases from Boston Children’s Hospital (BCH) and the Barrow Neurologic Institute (BNI) along with systematic review and meta-analysis of previously reported cases. RESULTS: A total of 15 patients were included in the multi-institutional cohort, and an additional 88 patients were included from 14 series to yield 103 patients within the meta-analysis. Amongst the BCH patients, male sex was associated with giant size (OR .2; 95% CI 1.2-162.0).The most common aneurysm locations were in the MCA (38%), ICA (25%), vertebral artery (VA; 11%), and VBJ (8%). Within 69 reports containing radiographic data within the meta-analysis, 38% of aneurysms were saccular. Twenty-eight cases presented with rupture (28%). 0% of cavernous ICA aneurysms, 26% of other anterior circulation aneurysms, and 44% of posterior circulation aneurysms presented with rupture. Increasing age (OR 1.2; 95% CI 1.0-1.4) and saccular morphology (OR 5.3, 95% CI 1.5-18.9) were associated with presentation with rupture, while posterior location trended towards an association (OR 3.1, 95% CI 0.9-11.0). The majority of cases in the systematic review were treated (97%) rather than observed (3%). Endovascular and open treatments were utilized in 40 and 56% of cases. Survival was 97% for unruptured aneurysms and 82% for ruptured aneurysms. A favorable neurologic outcome occurred in 80% of unruptured cases and 54% of ruptured cases. Unruptured presentation (OR 3.7, 95% CI 1.3-11.1) and endovascular treatment modality were associated with a favorable outcome (OR 5.0; 95% CI 1.6-15.8). CONCLUSIONS: Giant pediatric aneurysms are unlikely to be discovered incidentally and often merit treatment. Increasing age and saccular morphology are r predict rupture, and should elevate the concern for semi-urgent treatment.

The Effect of Pharmacologically Induced Blood Pressure Manipulation on Cardiac Output and Cerebral Blood Flow Velocity in Patients with Aneurysmal Subarachnoid Hemorrhage.

Vasopressors are used in patients with subarachnoid hemorrhage (SAH) to increase blood pressure with the idea of reversing the ischemic process. The current study is designed to evaluate the changes in systemic and cerebral hemodynamics, including cerebral blood flow autoregulation, at different pharmacologically augmented blood pressure levels using norepinephrine in patients with spontaneous aneurysmal SAH following surgery. This prospective observational study was carried out in patients with ruptured anterior circulation aneurysms who underwent surgical clipping and required norepinephrine infusion. Postoperatively, when the treating physician decided to start a vasopressor, norepinephrine infusion was started at 0.05 µg/kg/min. The infusion rate was increased by 0.05 µg/kg/min every 5 minutes to achieve a 20% and then 40% increase in the systolic blood pressure (SBP). When the blood pressure stabilized at each level for 5 minutes, hemodynamic and transcranial doppler (TCD) parameters in the middle cerebral artery (MCA) were recorded. Peak systolic, end-diastolic, and mean flow velocities in the MCA increased with targeted blood pressure increase in the hemispheres with impaired autoregulation and not in the hemispheres with intact autoregulation. The interaction of changes in TCD flow velocities between hemispheres with and without intact autoregulation was significant (p < 0.001). Cardiac output changes following norepinephrine infusion were not significant (p = 0.113). Hypertensive therapy with norepinephrine increases cerebral blood flow velocity only when autoregulation is impaired, an effect that is desirable in patients with focal cerebral ischemia following SAH. Lakshmegowda M, Muthuchellapan R, Sharma M, Ganne SUR, Chakrabarti D, Muthukalai S. The Effect of Pharmacologically Induced Blood Pressure Manipulation on Cardiac Output and Cerebral Blood Flow Velocity in Patients with Aneurysmal Subarachnoid Hemorrhage. Indian J Crit Care Med 2023;27(4):254-259.

Outcomes and complications of cerebral aneurysms operated on by eyebrow incision according to aneurysm type and location

ObjectiveTrans-eyebrow supraorbital aneurysmal neck clipping, also known as keyhole surgery, have many advantages of minimal invasive surgery. However, there are few studies on whether there is a difference in keyhole surgery according to the location of the aneurysm, and how the complications after keyhole approach differ from the conventional approach. The authors investigated the surgical outcome of keyhole aneurysmal surgery for clarify the characteristics of keyhole surgery.MethodsA retrospective study was performed with review of medical records and images of patients with anterior circulation aneurysm undergoing aneurysmal clipping with keyhole surgery. The patient's clinical condition, imaging, surgical condition, and outcome were investigated.ResultsAs a result of analysis about the location of the aneurysm, middle cerebral artery (MCA) aneurysm group had a longer operation time than internal carotid artery and anterior cerebral artery aneurysm groups, but there was no significant difference in complication rate. The olfactory dysfunction occurred more than that of conventional surgery and occurred less in MCA aneurysm group than others. Scalp sensory change in the surgical site was more common in patients with unruptured aneurysms.ConclusionBy accurately investigating the frequency and severity of complications associated with trans-eyebrow aneurysmal neck clipping surgery, it can help to select a surgical approach considering risk versus benefit. In addition, patient’s satisfaction can be increased by providing information to patients and caregivers in advance about the outcome of this approach and the anticipated complications.

Abstract Number ‐ 135: Surpass Evolve® Flow Diversion for Embolization of Unruptured Anterior Circulation Aneurysms: 6‐month Obliteration Rates

Introduction The Surpass Evolve flow diverter (FD) is a 64‐wire cobalt‐chromium device with improved ease of deployment and conformability, compared to its predecessor. Data on procedural outcomes and aneurysm obliteration rate remain limited. The objective of this study was to describe the procedural outcomes, including 6‐month obliteration rates, for patients who underwent Surpass Evolve FD embolization of an unruptured anterior circulation aneurysm. Methods All consecutive patients with an unruptured anterior circulation aneurysm who were treated with the Surpass Evolve FD between Aug 2020 and May 2022 were included. Patients with a ruptured or posterior circulation aneurysm were excluded. Demographic and clinical features, aneurysm morphology, arterial access, and procedural factors and outcome were extracted from our departmental neurointerventional database. Summary statistics included frequencies, and measures of central tendency and dispersion as appropriate. Results Sixty patients (82% female, mean age 57.9 years ± 15.5) underwent elective Surpass Evolve flow diversion for an unruptured anterior circulation aneurysm. In 47 (78%) patients, a native aneurysm was flow‐diverted, and in 13 (22%) patients, FD was performed for a recurrent aneurysm. Distribution of aneurysm location was: supraclinoid ICA (65%), cavernous ICA (12%), cervical ICA (10%) and anterior cerebral artery (13%). Thirty‐nine (65%) patients underwent left‐sided intervention. Mean aneurysm maximal diameter was 8.7 ± 5.7 mm. The majority of patients (49, 82%) underwent radial arterial access. Balloon angioplasty or J‐wire manipulation was used to enhance apposition in 37 (62%) cases. To date, thirty‐five (58%) patients have had a follow up angiogram (mean 0.65 years ± 0.2 from intervention); in 5 patients, there was mild non‐flow‐limiting stenosis. Based on the Raymond‐Roy Occlusion Classification, 25 (71%) had complete occlusion, 1 (2%) had a residual neck, and 9 (26%) had residual aneurysm. Conclusions The Surpass Evolve FD is safe and associated with favorable occlusion rates at six months. In our early experience, complication rates are well within the acceptable limits.

A challenging case of recurrent and progressive fusiform anterior circulation intracranial aneurysms: illustrative case.

Intracranial fusiform aneurysms are circumferential dilations of cerebral arteries that can lead to complications including ischemic stroke due to vessel occlusion, subarachnoid hemorrhage, or intracerebral hemorrhage. Treatment options for fusiform aneurysms have expanded significantly in recent years. Microsurgical treatment options include proximal and distal surgical occlusion and microsurgical trapping of the aneurysm, usually in association with high-flow bypass procedures. Endovascular treatment options include the placement of coils and/or flow diverters. Here the authors report a case of aggressive surveillance and treatment of a man with multiple progressive, recurrent, and de novo fusiform aneurysms of the left anterior cerebral circulation over 16 years. Because the long-term course of his treatment coincided with the recent expansion of endovascular treatment options, he underwent every type of treatment listed above. This case demonstrates the wide range of therapeutic options for fusiform aneurysms and how the treatment model for these lesions has evolved.

Is it time to rethink microsurgical training for the treatment of intracranial aneurysms in Australia?

BackgroundCase volume and complexity for microsurgical treatment of cerebral aneurysms have changed due to the growing use of endovascular therapy in clinical practice. The authors sought to quantify the clinical exposure of Australian neurosurgery trainees to cerebral aneurysm microsurgery. MethodsThis observational, retrospective cross-sectional study examined the Australian National Hospital Morbidity database for all admissions related to microsurgical and endovascular treatment of aneurysmal subarachnoid haemorrhage (aSAH) and unruptured intracranial aneurysms (UIAs) for the years 2008 to 2018. Procedural volumes were compared with neurosurgical trainee figures to investigate the rate of procedural exposure relative to the neurosurgical workforce. ResultsA total of 8,874 (41.6%) microsurgical procedures (3,662 for aSAH, 5,212 for UIAs), and 12,481 (58.4%) endovascular procedures (6,018 for aSAH, 6,463 for UIAs) were performed. Trainee exposure to microsurgery in aSAH declined from 9.1 to 7.3 cases per trainee per annum (mean 7.7), with case complexity confined mostly to simple anterior circulation aneurysms. There are significant state-by-state differences in the preferred treatment modality for aSAH. During the same study period, the number of microsurgical cases for UIAs increased (from 8.9 to 13.5 cases per trainee per annum, mean 11.0). Significantly more endovascular procedures are performed than microsurgery (10.7 to 17.0, mean 12.7 cases, for aSAH; 8.0 to 21.5, mean 13.7 cases, for UIAs). ConclusionsTrainee exposure to open aneurysm surgery for aSAH have significantly declined in both case volume and complexity. There is an overall increase in the number of surgeries for elective aneurysms, but this varies widely from state-to-state.

Roadmapping technique in the hybrid operating room for the microsurgical treatment of complex intracranial aneurysms.

To describe the roadmapping technique and our three-year experience in the management of intracranial aneurysms in the hybrid operating room. We analyzed all patients who underwent surgical clipping for cerebral aneurysms with the roadmapping technique from January 2017 to September 2019. We report demographic, clinical, and morphological variables, as well as clinical and radiological outcomes. We further describe three illustrative cases of the technique. A total of 13 patients were included, 9 of which (69.2%) presented with subarachnoid hemorrhage, with a total of 23 treated aneurysms. All patients were female, with a mean age of 47.7 years (range 31-63). All cases were anterior circulation aneurysms, the most frequent location being the ophthalmic segment of the internal carotid artery (ICA) in 11 cases (48%), followed by posterior communicating in 8 (36%), and ICA bifurcation in 2 (8%). Intraoperative clip repositioning was required in 9 aneurysms (36%) as a result of the roadmapping technique in the hybrid operating room. There were no residual aneurysms in our series, nor reported mortality. The roadmapping technique in the hybrid operating room offers a complementary tool for the adequate occlusion of complex intracranial aneurysms, as it provides a real time fluoroscopic-guided clipping technique, and clip repositioning is possible in a single surgical stage, whenever a residual portion of the aneurysm is identified. This technique also provides some advantages, such as immediate vasospasm identification and treatment with intra-arterial vasodilators, balloon proximal control for certain paraclinoid aneurysms, and simultaneous endovascular treatment in selected cases during a single stage.

Flow diversion for posterior circulation aneurysms: a multicenter retrospective study.

The prevalence of intracranial aneurysms is approximately 3% worldwide. Posterior circulation (PC) aneurysms have a higher risk of treatment complications than anterior circulation aneurysms. Improving the survival rate and quality of life of patients with PC aneurysms remains one of the most important issues in the field. Flow diverter (FD) treatment of PC aneurysms remains controversial. We aimed to investigate the effects of FD treatment and analyze differences among different application methods or aneurysm types in PC aneurysms. This is a multicenter retrospective study. Patients with PC aneurysms treated with the pipeline embolization device (PED) or Tubridge embolization device (TED) between 2015 and 2020 in five neurovascular centers were retrospectively enrolled. The primary outcomes were major perioperative complication, clinical outcome, and aneurysm occlusion rates. Univariable and multivariable logistic regression analyses were used to determine the risk factors of each outcome. In total, 252 aneurysms were included. Major perioperative complication, favorable clinical outcome, and complete occlusion rates were 7.5%, 91.0%, and 79.1%, respectively. Compared with other types of aneurysms, dissecting aneurysms had the best clinical outcome and highest occlusion rate. Both clinical and angiographic outcomes were independently associated with the aneurysm location at the basilar artery. Aneurysm size was not associated with any outcome. TED had similar clinical and angiographic outcomes compared with PED but more perioperative major complications. Tandem treatment and coiling assistance may have poorer clinical outcomes but similar occlusion rates. Single- and multiple-stent treatments had similar outcomes. FD treatment of PC aneurysms achieved favorable clinical outcomes and long-term aneurysm occlusion rates with acceptable perioperative complication rates, especially in dissecting and non-basilar artery aneurysms. There was no additional improvement in outcomes with coiling assistance, multi-stent application, or tandem treatment. Therefore, the use of PC aneurysms should be carefully considered.

Selection of Surgical Approaches for Anterior Circulation and Basilar Artery Apex Aneurysms

Selection of Surgical Approaches for Anterior Circulation and Basilar Artery Apex Aneurysms

The off-label uses of pipeline embolization device for complex cerebral aneurysms: Mid-term follow-up in a single center.

To describe the off-label uses of pipeline embolization device for a variety of types of aneurysms including ruptured aneurysms, posterior circulation aneurysms, small aneurysms, distal aneurysms, and recurrent aneurysms. Clinical and angiographic data of patients who underwent pipeline embolization device treatment on off-label use at our center were retrospectively reviewed. For categorical variables, Fisher's exact test was used, and a two-sample Wilcoxon rank-sum test was used for patients' age to analyze the correlation with outcomes. In this study, 121 aneurysms in 107 patients received off-label pipeline embolization device treatments. The overall rate of complete aneurysm occlusion was 77.8% (28/36 in 35 patients) for posterior circulation aneurysms and 95.3% (81/85 in 72 patients) for anterior circulation aneurysms. The posterior circulation aneurysms have a lower rate of aneurysm occlusion (p = 0.0372). The small aneurysms have a higher rate of aneurysm occlusion (p = 0.0104). The patient's sex, age, and aneurismal size were associated with ischemic stroke complications (p = 0.0397, 0.0166, and 0.0178). In posterior circulation aneurysm patients, only two basilar apex aneurysms underwent pipeline embolization device treatment, both of whom died of thrombotic complications. There was no difference in mortality between posterior circulation aneurysm patients (8.6%, 3/35) and anterior circulation aneurysm patients (1.4%, 1/72) (p = 0.1015). Patients of older age have a higher risk of death rate (p = 0.0053). The off-label use of pipeline embolization device is often performed in clinical practice and can achieve efficacy in complex aneurysms. The off-label use of pipeline embolization device was found to carry an increased rate of mortality in older patients. Excluding basilar apex aneurysms, the pipeline embolization device is as safe as anterior circulation aneurysms in the treatment of posterior circulation aneurysms elsewhere.

Effect of combined fenestration of lamina terminalis and Liliequist membrane during surgical clipping on the incidence of chronic hydrocephalus in patients with anterior circulation ruptured aneurysms

PurposeTo explore the effects of combined fenestration of lamina terminalis and Liliequist membrane during surgical clipping on the occurrence of chronic hydrocephalus in patients with ruptured anterior circulation aneurysm. MethodsClinical data of 78 patients with anterior circulation ruptured aneurysms who were treated between June 2018 and January 2021 were retrospectively analyzed. Based on the surgical treatment, patients were divided into 3 groups: clipping group (26 cases); fenestration group (lamina terminalis fenestration combined with clipping, 28 cases); and combination group (lamina terminalis fenestration and Liliequist membrane opening combined with clipping, 24 cases). The incidence of postoperative chronic hydrocephalus, the postoperative hydrocephalus shunt rate, and the Glasgow prognostic score (GOS) were evaluated. ResultsThe incidence of postoperative chronic hydrocephalus in the combined group (16.6 %, 4/24) was significantly lower than that in the clipping group (46.1 %, 12/26) and the fenestration group (35.7 %, 10/28; P < 0.05). The shunt rate of chronic hydrocephalus in the combined group (4.1 %, 1/24) was significantly lower than that in the clipping group (30.7 %, 8/26) and the fenestration group (17.8 %, 5/28; P < 0.05). The rate of postoperative GOS score of 5 in the combined group (75.0 %, 18/24) was significantly higher than that in the clipping group (23.0 %, 6/26) and the fenestration group (57.1 %, 16/28; P < 0.05). ConclusionAneurysm clipping combined with lamina terminalis fenestration and Liliequist membrane opening can reduce the occurrence of chronic hydrocephalus and the rate of chronic hydrocephalus shunt surgery, thereby improving the prognosis of patients.

Safety and effectiveness of double microcatheter technique in the treatment of ruptured aneurysms of anterior cerebral circulation.

To evaluate the safety and effectiveness of the double microcatheter technique in the treatment of ruptured aneurysms of the anterior cerebral circulation. Between 2012 and 2019, 113 patients with ruptured aneurysms of the anterior cerebral circulation were treated using the double microcatheter technique. Clinical records, angiographic results, and procedure-related complications were reviewed. Clinical and angiographic follow-up was performed. Complete occlusion, neck remnant, and partial occlusion were, respectively, recorded in 56.6, 38.9, and 4.4% of the total cases. For all patients, the incidence of intraoperative complications was 5.3% (6/113), and the overall rate of morbidity was 10.6% (12/113). Before discharge, three patients (2.7%) died. There was no procedure-related mortality. At discharge, favorable outcomes were observed in 79.6% (90/113) of the patients. High Hunt-Hess grades and receiving a craniotomy or external ventricular drainage were risk factors for clinical outcomes at discharge. Clinical follow-up was performed in 91 patients at a mean interval of 14.07 ± 11.68 months. At follow-up, favorable outcomes were observed in 92.3% (84/91) of the patients. Angiographic follow-up was performed in 66 patients at an average of 11.53 ± 11.13 months. The recurrence rate was 37.9%. Of these patients, 13 (19.7%) received retreatment. The double microcatheter technique can be performed in ruptured aneurysms with high technical success and low morbidity/mortality. However, recurrence remains a problem, and patients should be followed up regularly.

Mid basilar saccular aneurysm: A case report

Basilar artery aneurysms are less common than anterior circulation aneurysms, and rupture less frequently, but their critical location necessitates careful evaluation. Unruptured basilar artery aneurysms occurs in 3% of all intracranial aneurysms. We present one case of mid basilar artery aneurysm in our center