Middle Cerebral Artery Aneurysm Research Articles

Geometry and Symmetry of Willis' Circle and Middle Cerebral Artery Aneurysms Development.

Background: A relationship between the geometry and symmetry of Willis' circle and intracranial aneurysms was reported for anterior communicating and posterior communicating (PCom) aneurysms. A similar association with the middle cerebral artery (MCA) aneurysms instead appeared weaker. Methods: We reviewed 432 patients from six Italian centers with unilateral MCA aneurysms, analyzing the relationship between the caliber and symmetry of Willis' circle and the presence of ruptured and unruptured presentation. CT-angiograms were evaluated to assess Willis' circle geometrical characteristics and the MCA aneurysm side, dimension and rupture status. Results: The hypoplasia of the first segment of the anterior cerebral artery (A1) was in approximately one-quarter of patients and PCom hypoplasia was in almost 40%. About 9% had a fetal PCom ipsilaterally to the aneurysm. By comparing the aneurysmal and healthy sides, only the PCom hypoplasia appeared significantly higher in the affected side. Finally, the caliber of the internal carotid artery (ICA) and the first segment of MCA (M1) caliber were significantly greater in patients with unruptured aneurysms, and PCom hypoplasia appeared related to the incidence of an ipsilateral MCA aneurysm and its risk of rupture. Conclusions: Although according to these findings asymmetries of Willis' circle are shown to be a risk factor for MCA aneurysm formation and rupture, the indifferent association with ipsilateral or contralateral hypoplasia remains a datum of difficult hemodynamic interpretation, thereby raising the concern that this association may be more casual than causal.

A Geant Abdominal Aortic Aneurysm Who Hides Others: A Case Report

A 67-year-old man with a history of MCA (middle cerebral artery) aneurysm, smoking, and arterial hypertension, presented to the emergency department with abdominal pain and a pulsatile mass. The patient's vital signs were within normal ranges. On physical examination, the patient was mildly discomforted due to abdominal pain. His abdomen was soft, with tenderness in the right lower quadrant, and a pulsatile mass was present. A CT scan of the abdomen and pelvis with intravenous iodinated contrast revealed an aneurysmal dilatation of the abdominal aorta measuring 7 cm in diameter, beginning inferior to the level of the renal arteries and continuing to the iliac bifurcation with thrombosis of the right common iliac artery extending its branches. Associated with an aneurysmal dilatation of the celiac trunk and the splenic artery. There was extensive mural thrombus, a patent lumen, and no evidence of frank rupture.

Treating a Challenging Giant Aneurysm of Middle Cerebral Artery (MCA) with a Staged Procedure of Endovascular Coiling and Flow Diverter (FD): Case Report

Background: Giant intracranial aneurysms pose significant challenges in treatment due to a high risk of postoperative complications, including delayed rupture, cerebral edema, and aggravation of mass effect. Endovascular approaches, such as adjunctive coiling and flow diverter (FD) procedures, have become increasingly recommended for wide-necked, large, and giant aneurysms. Case Description: In this report, we present a challenging case of a staged coiling and FD procedure in a giant unruptured middle cerebral artery (MCA) aneurysm. The patient, a 26-year-old adult female, was admitted to our hospital with a history of convulsions. Digital Subtraction Angiography (DSA) revealed a massive aneurysm measuring 40 mm × 27 mm in the M1 segment of the MCA. To mitigate the risk of mass effect aggravation, we performed a two-staged procedure with a seven-day interval between the interventions. The first step involved partial endovascular coiling to shrink the aneurysm, followed by successful flow diversion. The patient did not experience further convulsions or neurologic deficits, and the follow-up angiogram showed no residual flow to the aneurysm. Conclusion: We report one of the very first cases of adjunctive coiling and FD in ‘unruptured’ giant aneurysms. Our neurovascular intervention provides valuable insights into the approach and treatment of unruptured giant aneurysms in cerebral arteries. By employing a staged procedure, effective flow diversion can be achieved even in giant unruptured aneurysms. Although further research is necessary to confirm its superiority and address critical issues, our findings may contribute to the future management of giant aneurysms and inspire avenues for research in the neurosurgical community. Bang. J Neurosurgery 2023; 12(2): 129-136

Endovascular treatment of wide-neck bifurcation aneurysms using pCONUS2 HPC bridging device with single antiplatelet: A Case Series.

Wide neck bifurcation aneurysms (WNBA) are technically challenging for both surgical and endovascular treatments. Endovascular treatment for WNBA often requires dual antiplatelet therapy (DAPT) post stent insertion. Novel devices such as the pCONUS2 HPC neck bridging device have an HPC coating which reduces the device thrombogenicity. This theoretically allows for use of single antiplatelet therapy (SAPT), which would be advantageous, particularly in treating ruptured aneurysms. This case series aims to evaluate the safety of SAPT regimen only post stent insertion, by presenting our center early clinical experience in using pCONUS2 HPC neck bridging device in patients that are not suitable for DAPT. We report the cases of 3 patients (2 females, 1 male; range: 64-71 years old) who underwent coil embolization for WNBA using the pCONUS2 HPC device (2 unruptured WNBA, and 1 ruptured WNBA). As all 3 patients were allergic to Aspirin, they could only be started on SAPT post endovascular therapy. All 3 patients were diagnosed with WNBA on angiographic studies. Patient 1 had an unruptured left middle cerebral artery aneurysm; Patient 2 had a ruptured basilar tip aneurysm; Patient 3 had an unruptured anterior communicating artery (ACOM) aneurysm. All 3 WNBA were treated with pCONUS2 HPC neck bridging device. There were no immediate complications. The immediate angiographic result of aneurysm treatment in Patient 1 and Patient 2 demonstrated incomplete occlusions, with delayed complete occlusion of aneurysm in Patient 1 and growth of aneurysmal neck in Patient 2 on follow-up angiograms (range: 6-9 months). No major thrombo-embolic or hemorrhagic complications in the first 2 patients. For Patient 3, the immediate angiographic result of the treated aneurysm demonstrated complete occlusion. However, the patient readmitted 11 days post procedure with cerebral infarction, scoring 5 on the modified Rankin scale on discharge. pCONUS2 HPC as a neck bridging device in treating WNBA has yet to be shown superior to traditional techniques and devices. The theoretical advantage of HPC coating reducing its thrombogenicity requiring only SAPT is yet to be proven safe in clinical practice.

Changes in treatment of intracranial aneurysms during the last decade in a large European neurovascular center

ObjectiveTreatment modality for ruptured and unruptured intracranial aneurysms has shifted during the last two decades from microsurgical treatment towards endovascular treatment. We present how this transition happened in a large European neurovascular center.MethodsWe conducted a retrospective observational study consecutive patients treated for an unruptured or ruptured intracranial aneurysm at Helsinki University Hospital during 2012–2022. We used Poisson regression analysis to report age-adjusted treatment trends by aneurysm location and rupture status.ResultsA total of 2491 patients with intracranial aneurysms were treated (44% ruptured, 56% unruptured): 1421 (57%) surgically and 1070 (43%) endovascularly. A general trend towards fewer treated aneurysms was noted. The proportion of patients treated surgically decreased from 90% in 2012 to 20% in 2022. The age-adjusted decrease of surgical versus endovascular treatment was 6.9%/year for all aneurysms, 6.8% for ruptured aneurysms, and 6.8% for unruptured aneurysms. The decrease of surgical treatment was most evident in unruptured vertebrobasilar aneurysms (10.8%/year), unruptured communicating artery aneurysms (10.1%/year), ruptured communicating artery aneurysms (10.0%/year), and ruptured internal carotid aneurysms (9.0%/year). There was no change in treatment modality for middle cerebral artery aneurysms, of which 85% were still surgically treated in 2022. A trend towards an increasing size for treated ruptured aneurysms was found (p = 0.033).ConclusionA significant shift of the treatment modality from surgical to endovascular treatment occurred for all aneurysm locations except for middle cerebral artery aneurysms. Whether this shift has affected long-term safety and patient outcomes should be assessed in the future.

Treatment of a Wide Neck Middle Cerebral Artery Aneurysm with Secondary Lobule Using Combination Woven EndoBridge and Coil Embolization (P5-5.010)

Treatment of a Wide Neck Middle Cerebral Artery Aneurysm with Secondary Lobule Using Combination Woven EndoBridge and Coil Embolization (P5-5.010)

155 Safety and Efficacy of Endovascular Versus Microsurgical Treatment of Unruptured Wide-necked Middle Cerebral Artery Aneurysms: A Propensity-Matched Analysis of the Neurovascular Quality Initiative-Quality Outcomes Database (NVQI-QOD)

INTRODUCTION: There is clinical equipoise regarding the best treatment for unruptured wide-necked middle cerebral artery (WN-MCA) aneurysms. METHODS: The NVQI-QOD registry was queried for patients with unruptured WN-MCA aneurysms. Wide-neck was defined as aneurysm neck = 4 mm or dome:neck ratio = 2. Demographics, aneurysm characteristics, and safety data were queried. Aneurysm occlusion status and modified Rankin score (mRS) at discharge and last follow up were evaluated. Propensity score matching was utilized to match aneurysm size, number of aneurysms treated, patient age and aneurysm status (asymptomatic or symptomatic). RESULTS: Of 670 unruptured MCA aneurysms, 319 were wide-necked. Thirty operations were excluded as the aneurysm was previously treated. 289 operations in 282 patients were assessed (203 EVT, 86 MS). After propensity score matching, there were 86 operations in each group. The median aneurysm size was 5.6 mm (EVT) versus 5.3 mm (MS), p = 0.243. Patients who underwent MS were more likely to have complete occlusion at discharge (90.4% vs. 58.8%, p < 0.001). The median follow up was 404 days in the EVT group versus 157.5 days in the MS group (p = 0.241). Patients who underwent EVT were more likely to have a mRS of zero at discharge (50/59 (84.8%) versus 29/54 (53.7%), p < 0.0003) and last follow up (36/55 (65.5%) versus 13/36 (36.1%), p = 0.006). Safety data showed similar intra-operative (7% EVT vs. 3.5% MS, p = 0.496) and post-operative (4.7% EVT vs. 7% MS, p = 0.750) complication rates. CONCLUSIONS: This report describes the largest-to-date, modern cohort of propensity matched patients undergoing treatment of unruptured WN-MCA aneurysms. Patients undergoing EVT had better functional outcomes at discharge and last follow up though there was significant loss to follow up. Patients undergoing MS were more likely to have complete aneurysm occlusion. Safety data was similar in both groups.

One-Stage Combined Open and Endovascular Treatment Using a Hybrid Operating Room is Safe and Effective for Distal Middle Cerebral Artery Aneurysms

BackgroundAneurysms located in the distal middle cerebral artery (MCA) are relatively rare and lack an established treatment strategy. For distal MCA (DMCA) aneurysms, we performed a one-stage combined procedure of endovascular parent artery occlusion (PAO) with coils and superficial temporal artery to middle cerebral artery (STA-MCA) bypass in a hybrid operating room (HOR). The aim of this study was to evaluate the safety and efficacy of this procedure. MethodsCases of unruptured DMCA aneurysms treated with the one-stage combined PAO and STA-MCA bypass in HOR were retrospectively examined, and patients’ and aneurysmal backgrounds, surgical procedures, and treatment outcomes were analyzed. ResultsSix patients were included in the study. The average maximum diameter of the aneurysms was 14.4 mm. One aneurysm was located at M2 and five at M3. All aneurysms had a fusiform shape. No cases were associated with infection, trauma, or malignant tumors. In all six cases, the combined PAO and STA-MCA bypass was successfully completed. No postoperative hemorrhagic complications occurred. A symptomatic ischemic complication occurred in one case whose symptom disappeared in a week. Three months after surgery, complete obliteration of the aneurysm and patency of the bypass were confirmed in all cases. ConclusionsThe one-stage combined PAO and STA-MCA bypass in the HOR is safe and effective for DMCA aneurysms, potentially serving as a treatment option for this complex aneurysm.

319 A Case Series of Direct Multi-territory Cerebral Revascularizations Using a Three-Vessel Anastomosis

INTRODUCTION: The ability to perform simultaneous, multi-territory cerebral bypass using a single interposition graft has significant utility for the revascularization of multiple cerebral territories that would otherwise require multiple constructs, serial anastomoses, or a combination of direct and indirect approaches. METHODS: Peri-operative data and outcomes were collected retrospectively for patients undergoing multi-territory cerebral revascularization using a three-vessel anastomosis over a 4-year period (2019-2023). RESULTS: Five patients underwent triple vessel bypass (median age 53 years [range 12-73]). Three patients with complex middle cerebral artery (MCA) aneurysms (one ruptured) were treated multi-territory external carotid artery (ECA)-M2-M2 revascularization using a saphenous vein interposition graft, followed by either proximal ligation or partial/complete aneurysm clip trapping. Two patients with predominately bilateral anterior cerebral artery (ACA) territory moyamoya disease were treated with proximal superficial temporal artery (STA)-A3-A3 revascularization using a radial artery or radial artery fascial flow-through free flap (RAFF) graft. Bypass patency was 100% and zero patients experienced surgery-related ischemia. One patient had new strokes from vasospasm after subarachnoid hemorrhage. One patient required a revision surgery for a post-operative hematoma and RAFF debridement that did not affect bypass patency or neurologic outcome. Median Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS) scores on discharge were 4 (range 3-5) and 2 (range 0-5), respectively. GOS and mRS scores were stable or improved on follow up in 4/5 patients; one patient died from medical complications of their original stroke. CONCLUSIONS: In experienced hands, three-vessel anastomosis can be a viable option for the safe, simultaneous revascularization of multiple ACA and MCA territories.

A novel predictor of ischemic complications in the treatment of ruptured middle cerebral artery aneurysms: Neck-branching angle

ObjectiveThe risk factors of procedural cerebral ischemia (CI) in ruptured middle cerebral artery (MCA) aneurysms are unclear. This study proposed the neck-branching angle (NBA), a simple quantitative indicator of the aneurysm neck and branch vessels, and analyzed its usefulness as a predictor of procedural CI in ruptured MCA aneurysms. MethodsWe retrospectively analyzed 128 patients with ruptured saccular MCA aneurysms who underwent surgical or endovascular treatment between January 2014 and June 2021. We defined the NBA as the angle formed by the MCA aneurysm neck and M2 superior or inferior branch vessel line. The superior and inferior NBA were measured on admission via three-dimensional computed tomography angiography on admission. We divided the patients into clipping (106 patients) and coiling (22 patients) groups according to the treatment. Risk factors associated with procedural CI were analyzed in each group. ResultsBoth groups showed that an enlarged superior NBA was a significant risk factor for procedural CI (clipping, P < 0.0005; coiling group, P = 0.007). The receiver operating characteristic curve showed the closed thresholds of the superior NBA with procedural CI in both groups (clipping group, 128.5°, sensitivity and specificity of 0.667 and 0.848, respectively; coiling group, 130.9°, sensitivity and specificity of 1 and 0.889, respectively). ConclusionThe NBA can estimate the procedural risk of ruptured MCA aneurysms. In addition, an enlarged superior NBA is a risk factor for procedural CI in both clipping and coiling techniques.

The impact of an approach incorporating myofunctional therapy of the masticatory system movement on the motor efficiency of a patient after a subarachnoid hemorrhage to the left hemisphere of the brain – A case study

This paper analyzes the case of a 46-year-old woman who suffered a subarachnoid hemorrhage to the left hemisphere of the brain with penetration into the ventricular system from a ruptured aneurysm of the left middle cerebral artery (cardiac arrest, critical condition, GCS 4), followed by subsequent paralysis of the lower and upper right limbs and aphasia. Data collected during a 2-year therapy process were analyzed, including examinations of the stomatognathic system, analysis of the axes and planes of the facial cranium in relation to the joint structures of the movement system, observations of the interactions of tissue structures as well as mandibular-hyoid and lingual structures, analysis of Angle’s classifications, analysis of imaging studies of the orofacial zone and neck muscle tension, results of periodic functional tests, including manual functional analysis of the masticatory system movement. A vision analysis of the material was performed using ShapeCare.Physio equipment with Blaze Pose software based on a model for detecting the skeleton of a moving person. It was found that treatment including myofunctional therapy of the masticatory system movement contributed to the improvement of the patient's motor efficiency after suffering a subarachnoid hemorrhage to the left hemisphere of the brain and after a frontotemporo-parietal craniotomy.

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.

Rapid presentation of a de novo intracranial aneurysm: illustrative case.

Intracranial aneurysms are prevalent, particularly with advancing age. De novo aneurysms, occurring independently from the initial lesion, pose a unique challenge because of their unpredictable nature. Although risk factors such as female sex, smoking history, and hypertension have been proposed, the mechanisms underlying de novo aneurysm development remain unclear. A 79-year-old female developed a de novo saccular aneurysm within a year after management of a ruptured vertebral artery dissecting aneurysm. Her complex clinical course involved subarachnoid hemorrhage with diffuse vasospasm, stent occlusion of a dissecting aneurysm, discovery of a right 7- to 8-mm de novo middle cerebral artery aneurysm at the 1-year magnetic resonance angiography follow-up, and successful coil embolization. This rare occurrence challenges established timelines, as most de novo aneurysms manifest over a longer interval. Studies have attempted to identify risk factors, yet consensus remains elusive, particularly regarding the influence of treatment modality on de novo formation rates. This unique case urges reconsideration of posttreatment surveillance protocols, proposing shorter intervals for imaging and more vigilant follow-up strategies to detect asymptomatic de novo aneurysms. Timelier identification could significantly impact patient outcomes by averting potential ruptures. This emphasizes the need for further research to delineate effective monitoring and preventive measures for these enigmatic lesions.

Navigating Complexity: A Comprehensive Approach to Middle Cerebral Artery Aneurysms.

Background: The concept of aneurysm "complexity" has undergone significant changes in recent years, with advancements in endovascular treatments. However, surgical clipping remains a relevant option for middle cerebral artery (MCA) aneurysms. Hence, the classical criteria used to define surgically complex MCA aneurysms require updating. Our objective is to review our institutional series, considering the impacts of various complexity features, and provide a treatment strategy algorithm. Methods: We conducted a retrospective review of our institutional experience with "complex MCA" aneurysms and analyzed single aneurysmal-related factors influencing treatment decisions. Results: We identified 14 complex cases, each exhibiting at least two complexity criteria, including fusiform shape (57%), large size (35%), giant size (21%), vessel branching from the sac (50%), intrasaccular thrombi (35%), and previous clipping/coiling (14%). In 92% of cases, the aneurysm had a wide neck, and 28% exhibited tortuosity or stenosis of proximal vessels. Conclusions: The optimal management of complex MCA aneurysms depends on a decision-making algorithm that considers various complexity criteria. In a modern medical setting, this process helps clarify the choice of treatment strategy, which should be tailored to factors such as aneurysm morphology and patient characteristics, including a combination of endovascular and surgical techniques.

Predictors of In-Stent Stenosis Following the Implantation of Pipeline Embolization Devices for the Treatment of Aneurysms Located at or beyond the Circle of Willis in the Anterior Circulation.

In-stent stenosis is commonly observed after stent implantation. There is no consensus on the contributing factors for in-stent stenosis, especially for aneurysms located at or beyond the circle of Willis in the anterior circulation. This study aimed to investigate the morbidity and determinants of in-stent stenosis in distal anterior circulation aneurysms following the implantation of Pipeline Embolization Devices. Patients who underwent Pipeline Embolization Device treatment at our center between January 1, 2018, and June 15, 2023, were enrolled. Distal anterior circulation aneurysms were defined as those occurring at or beyond the circle of Willis, including anterior communicating artery aneurysms, anterior cerebral artery aneurysms, and MCA aneurysms. Baseline information, aneurysm characteristics, and follow-up data of patients were analyzed. Patients were divided into 2 groups: the in-stent stenosis group (patients with a loss of >25% of the lumen diameter of the parent artery) and the non-in-stent stenosis group. Binary logistic regression and restricted cubic spline curves were used to explore risk factors. We included 85 cases of 1213 patients treated with flow-diverter devices at our hospital. During an average follow-up period of 9.07 months, the complete occlusion rate was 77.64%. The overall incidence of in-stent stenosis was 36.47% (31/85), of which moderate stenosis accounted for 9.41% (8/85), and severe stenosis, 5.88% (5/85) (triglyceride-glucose index ≥ 8.95; OR = 6.883, P = .006). The difference in diameters between the stent and parent artery of ≥0.09 mm (OR = 6.534, P = .015) and 55 years of age or older (OR = 3.507, P = .036) were risk factors for in-stent stenosis. The restricted cubic spline curves indicated that the risk of in-stent stenosis increased as the difference in diameter between stent and parent artery and the triglyceride-glucose index increased. Compared with the on-label use of Pipeline Embolization Devices, the rate of in-stent stenosis did not obviously increase when treating distal anterior circulation aneurysms with these devices. The incidence of in-stent stenosis was 36.47% when defined as a lumen diameter loss of >25%, and 15.2% when defined as a lumen diameter loss of >50%. Stent-size selection and biochemical indicators can potentially impact the incidence of in-stent stenosis.

Fourteen intracranial aneurysms in a single patient—the largest number ever reported in the literature

A 52-year-old female came with complaints of intense headaches for the past 10 days. The CT brain revealed SAH in the bilateral Sylvain fissure (left more than right) with Hunt and Hess Grade 1. An urgent CT cerebral angiogram was done, which revealed multiple bilateral MCA, ACA, and basilar top aneurysms. DSA was done the next day, which revealed multiple aneurysms, a total of fourteen in number. Such multiple aneurysms in a single patient were never reported in the literature until now, according to the present author's knowledge.

Open Surgical Treatment of Middle Cerebral Artery Aneurysms: A Single-Center Series in the Endovascular Era

ObjectiveWe review the outcomes of open surgical treatment of MCAAs at a single center, focusing on aneurysm obliteration rates and functional outcomes at the most recent follow-up. These findings can be used for future comparisons of surgical outcomes with MCAAs. MethodsWe retrospectively reviewed cases from a prospectively maintained database of patients receiving open surgical treatment for ruptured or unruptured MCAAs between July 2014 and December 2022. We utilized patients’ mRS score and GOS score as functional outcome measures. Means, standard deviations, medians, and interquartile ranges were calculated, and a student’s t-test or its non-parametric equivalent was used to compare subgroups. Results150 patients (114 women, 76%; mean age 55.0±14.7 years) with a total of 156 MCAAs comprised 152 cases; 85 (56%) ruptured and 71 (46%) unruptured. Bypass was performed in 34 cases (22.4%); 18 ruptured (51.4%) and 16 unruptured (48.6%). Intraoperative rupture occurred in 5 (5%) ruptured and 1 (2%) unruptured cases. 145 patients (95.4%) had aneurysm obliteration with initial surgery, with 98.4% of patients having complete occlusion at 40.2±65.5 weeks of follow-up. Intra-hospital mortality occurred in seven (6.9%) ruptured versus one (2.0%) unruptured case. 52 (51.5%) of the ruptured compared to 43 (86%) unruptured patients were discharged home, with the remaining patients requiring inpatient rehabilitation or long-term hospitalization. The ruptured group had a mean hospital stay of 18.4±10.5 days vs 5.7±6.0 days for unruptured. Length of stay, discharge mRS/GOS, and mRS at 4-6 weeks favored unruptured cases (p<0.0001-0.0336). Mean change in mRS from presentation to last follow-up favored ruptured cases (-0.7±1.2 vs. -0.04±1.2, p=0.0215). ConclusionOpen surgery remains a safe and definitive treatment option for MCAAs in the endovascular era.

Abstract 113: Treatment of Tiny (≤ 3mm) Unruptured Middle Cerebral Artery Aneurysms Are Associated With High Risk of Procedural Complications: An Analysis of the Neurovascular Quality Initiative-Quality Outcomes Database

Introduction: Improved imaging modalities have led to an increased detection of intracranial aneurysms, many of which are small. While studies have shown that many ruptured intracranial aneurysms are small (≤7 mm), the natural history of tiny (≤3 mm) aneurysms, particularly in certain locations such as the middle cerebral artery (MCA) is thought to be relatively benign with a reported rupture rate of less than 0.5% per year. The objective of this study is to evaluate the safety and efficacy of treatment of tiny unruptured MCA aneurysms. Methods: The NVQI-QOD registry was queried for patients with tiny unruptured MCA aneurysms who underwent either microsurgical or endovascular repair. Tiny size was defined as an aneurysm with a maximum dimension of ≤3 mm. Demographics, aneurysm characteristics and treatment safety were queried. Safety data included intra-operative and post-operative complications. Outcomes included modified Rankin Score (mRS) at discharge and last follow up as well as aneurysm occlusion status at discharge. Results: Of 670 treated, unruptured MCA aneurysms, 43 were tiny (6.4%). The mean aneurysm width was 1.9 mm with a mean patient age of 56.3 years. The median pre-operative mRS was 0 (range 0-4). The majority of patients underwent microsurgery (27/43). The overall intra-operative complication rate was 7% (3/43) with an intra-operative rupture rate of 4.7% (2/43). The post-operative complication rate was 9.3% (4/43). New intracerebral hemorrhage occurred in 7% of patients (3/43) and unplanned return to OR occurred in 14.8% of patients who underwent microsurgery (4/27). There were no mortalities. 16.3% (7/43) of patients were discharged to inpatient rehabilitation or a skilled nursing facility. At discharge, 37 (88.1%) patients had complete aneurysm occlusion. In the subgroup of patients with recorded follow up data, only 40% (10/25) had a mRS of 0 at discharge and 40% (6/15) had an mRS of 0 at last follow up (median follow up: 165 days). Conclusions: Our analysis showed that treatment of tiny unruptured MCA aneurysms is associated with a high rate of complications. We suggest that many tiny, unruptured MCA aneurysms should be observed given that the morbidity associated with treatment is likely significantly higher than the risk of rupture.

Spectrum of Intracerebral Hemorrhage in a Tertiary Hospital

Introduction: Intracerebral hemorrhage is a devastating type of stroke that leads to profound morbidity and carries high mortality. Survivors of hemorrhagic stroke suffer not only from physical and social decline but also results in loss of productivity and financial burden.&#x0D; Causes of hemorrhagic stroke are hypertension, coagulopathic condition, diabetes mellitus and cardiovascular diseases. lesional hemorrhagic stroke can be due to subarachnoid hemorrhage from intracranial aneurysm, arteriovenous malformation, dural arteriovenous fistula etc.&#x0D; Methods: A retrospective cross sectional study carried out at KISTMCTH. Data from six years duration was analysed from hospital records, outpatient department records. Patients that presented with intracranial hemorrhage were included. Post operative patients and traumatic intracerebral hemorrhage cases were not included.&#x0D; &#x0D; Results: Total of 112 patients was included in the study. 73 (65.1%) of them were male and 39 (34.8%) were female. putamen and caudate region were most common 47 (41.9%) followed by subarachnoid region 27 (24.1%), thalamus 19 (16.9%), cerebellum 9 (8.04%) , lobar region 8 (7.1%) and brainstem 2 (1.7%). Intracranial hemorrhage was more common in age group of 41-60 years 59 (52.6%) followed by age group 61- 100 years 42 (37.5%). 14 (51.8%) female had subarachnoid hemorrage in comparision to 13 male (48.1%). Anterior communicating artery aneurysm had highest occurrence 10 (37%) followed by middle cerebral artery aneurysm 6 (22.2%) , paraclinnoidal / anterior choroidal/posterior communicating artery aneurysm 5 (18.5%), vertebral artery aneurysm 3 (11.1%), distal anterior cerebral artery aneurysm 1 (3.7%).&#x0D; Intracranial hemorrhage had highest occurrence on the month of January (15%) and lowest on the month of November (3.57%). 29 (25.8%) of total intracranial hemorrhage patient had intraventricular extension of hemorrhage. Intraventricular extension was more common in thalamic hematoma 15 (13.39%) followed by caudate/putaminal hematoma 10 (8.9%), cerebellum 3 (2.6%).Modified Rankin Scale ( MRS) outcome score was found to be highest as MRS 6 for 34 (30.6%) patients . while good outcome in terms of MRS 1 , MRS 2 and MRS 3 were observed for 7 (6.2%), 26 (23.2%), 25 (22.3%) patients respectively.&#x0D; Conclusion: Hypertension remains one of the major risk factor that results in various location specific hemorrhage and it shows specific peak seasonal variation. Proper blood pressure control is recommended for prevention of intracranial hemorrhages.

Clipping of a persistent middle cerebral artery aneurysm after previous flow diverter placement: An illustrative case and review of the literature.

Flow diverter (FD) is increasingly used in the management of wide necked cerebral aneurysms. Despite a reported lower efficacy in middle cerebral artery (MCA) aneurysms, they are still being utilised. Microsurgery is best considered as an index treatment, but can also be a safe and effective treatment when encountering a persistent MCA aneurysm after prior FD. As there is a paucity in literature and more cases of failed FD are expected to appear, we want to add our experience to the existing literature. The microsurgical management of a persistent MCA bifurcation aneurysm, 3 years after a p48 MW HPC Flow Diverter (phenox GmbH, Bochum Germany) insertion is reported and the relevant literature discussed.