Illustrative Case Research Articles

Intelligent Cyber Defense: Exploring the Role of AI in Safeguarding Digital Assets

Abstract: In a modern digital environment, cyber threats are one of the main problems that pose a serious threat to the attacks on digital assets' security. To handle this problem, the marriage of artificial intelligence (AI) technologies into such cybersecurity plans has been introduced as an innovative solution to reinforce defense capacities. This work discusses how the AI that advocates cyber security can act against malicious acts. The immediate picture begins with describing quickly growing cyber threats and crucial requirements for defense procedures development. This part moves on to a general overview of AITbased cybersecurity methods consisting of machine learning, natural language processing, and anomaly detection. The abstract demonstrates the capabilities of AI-driven solutions through the use of illustrative figures and case studies showing the power of this technology in extracting threats in real time, preventing them proactively, and automating incident response. Besides that, normative and law issues around AI use in cyber security are discussed briefly, with a clear accent on the necessity of clear and accountable governance. The abstract of this paper wraps up by addressing issues of the existing state and possible developments in AI-supported cyber defense, emphasizing the uniqueness of the AI technologies in this field for ensuring necessary security measures against cyber threats, which could change or evolve further in time.

Cyber Diplomacy through Official Public Attribution: Paving the Way for Global Norms

Abstract International discussions on establishing and implementing norms for behavior in cyberspace have spanned over two decades. However, differences in what constitutes ‘acceptable conduct’ have hindered progress in forming these norms. In recent years, Western countries have adopted a strategy to signal what is considered unacceptable behavior by publicly attributing cyberattacks and intrusions. I argue that this act of official public attribution serves as a practice for countries to express their disapproval of inappropriate cyberspace behavior and condemnation and can cumulatively shape international practices, holding the attacking state accountable. I explore this by (1) analyzing new data from the European Repository of Cyber Incidents, which shows patterns of official public attributions for the years 2000–2023, providing exploratory directions and trends, and (2) examining the Iranian cyberattack against Albania in 2022 and its subsequent official public attributions as an illustrative case study. I demonstrate how repeated instances of official public attribution can contribute to the development of a common practice that signals dissatisfaction of a specific behavior. As state-sponsored cyberattacks and intrusions are on the rise, this practice could have an accumulative effect.

Environmental public health research at the U.S. Environmental Protection Agency: A blueprint for exposure science in a connected world.

Exposure science plays an essential role in the U.S. Environmental Protection Agency's (U.S. EPA) mission to protect human health and the environment. The U.S. EPA's Center for Public Health and Environmental Assessment (CPHEA) within the Office of Research and Development (ORD) provides the exposure science needed to characterize the multifaceted relationships between people and their surroundings in support of national, regional, local and individual-level actions. Furthermore, exposure science research must position its enterprise to tackle the most pressing public health challenges in an ever-changing environment. These challenges include understanding and confronting complex human disease etiologies, disparities in the social environment, and system-level changes in the physical environment. Solutions will sustainably balance and optimize the health of people, animals, and ecosystems. Our objectives for this paper are to review the role of CPHEA exposure science research in various recent decision-making contexts, to present current challenges facing U.S. EPA and the larger exposure science field, and to provide illustrative case examples where CPHEA exposure science is demonstrating the latest methodologies at the intersection of these two motivations. This blueprint provides a foundation for applying exposomic tools and approaches to holistically understand real-world exposures so optimal environmental public health protective actions can be realized within the broader context of a One Health framework. IMPACT STATEMENT: The U.S. EPA's Center for Public Health and Environmental Assessment exposure research priorities reside at the intersection of environmental decision contexts and broad public health challenges. The blueprint provides a foundation for advancing the tools and approaches to holistically understand real-world exposures so optimal environmental protection actions can be realized. A One Health lens can help shape exposure research for maximum impact to support solutions that are transdisciplinary and must engage multiple sectors.

Spontaneous Intracranial Hypotension and Dural Ectasia in Marfan Syndrome: An Illustrative Case Successfully Treated with Steroid Therapy and Literature Review

Background: Spontaneous intracranial hypotension (SIH) is a rare and frequently misdiagnosed disorder characterized by a low volume of cerebrospinal fluid (CSF) caused by the leakage of CSF through the spinal dural membrane. Patients with Marfan Syndrome (MS) and other connective tissue disorders are at an increased risk for dural ectasia, which may predispose them to spontaneous CSF leaks due to the structural weakness of their dural membranes. The management of SIH in MS patients is debated. Conservative measures, an epidural blood patch (EBP), and surgical treatments are the options generally provided. Methods: Herein, we report on the case of a 52-year-old female affected by MS, genetically confirmed, with a two-month history of sudden-onset, “thunderclap” headache, worsened in an upright position and horizontal diplopia. A Computed Tomography (CT) scan of the brain showed a bilateral chronic subdural hematoma, slit ventricles, and a caudal descent of the brainstem without overt tonsillar herniation. The Magnetic Resonance Imaging (MRI) scan of the whole spine revealed dural ectasia in the lumbosacral area and presacral perineural cyst without extradural CSF collection. The case was successfully managed with bed rest and high-dose corticosteroid therapy. Then, we discuss the pertinent literature, consisting of 25 papers dealing with the treatment of SIH in patients affected by MS. Results: The literature review yielded 25 papers dealing with SIH management in patients with MS, including 28 patients overall; 21 patients underwent EBP, of whom 7 patients had multiple procedures. Overall, in 23 cases (82%), the symptoms improved. In three cases, the patients were managed conservatively with bed rest. In three of these cases, there was an improvement. In one case, the surgical fenestration of two lumbar intradural spinal meningeal cysts was performed and the patient improved after the procedure. Our patient underwent 15 days of steroid therapy (dexamethasone iv 12 mg/day for 7 days, then reduced to 4 mg/day) and intravenous hydration (Ringer lactate 1500 mL/day). In ten days, the symptoms disappeared. At the 6-month follow-up, the patient was in good clinical condition, and a CT scan showed an almost complete regression of the bilateral subdural hematoma. Conclusions: The management of SIH in MS patients is still challenging. Patients with connective tissue disorders such as MS are at an increased risk for SIH. Few studies have assessed the management of these patients and different strategies. Our case and the available literature provide further data for this type of case.

Tensions, Challenges, and Opportunities: Internal Networks Supporting Gender Equality Policy Processes and Structural Change in Universities

Abstract This article examines the role of internal networks in supporting gender equality (GE) units and GE policy processes within universities, focusing on the tensions, challenges, and opportunities that can be encountered. Using two illustrative cases from Spain and employing a qualitative approach, it explores how these networks, bridging top-down and bottom-up approaches, navigate the balance between centralized and decentralized approaches in managing and implementing GE plans and the impact of institutionalization. Research has examined GE policy networks and women’s academic participation, but within-university GE networks are less studied. Tensions arise between institutionalization and feminist activism, coordinated action and idea generation, and local ownership and change agents’ limited authority. Challenges include obtaining institutional recognition while maintaining feminist sensibility, emphasizing the importance of nurturing networks. We highlight the productive power of resistance and the need to capitalize on context-specific opportunities for driving structural change in universities.

Dorsolateral Transdural Surgical Management of Spontaneous Intracranial Hypotension From Ventral Dural Cerebrospinal Fluid Leaks: Case Series and Technical Report

BACKGROUND and OBJECTIVES: Spontaneous intracranial hypotension is an uncommon but debilitating condition that commonly involves positional headaches and vertigo. One cause is cerebrospinal fluid (CSF) leakage from ventral dural defects from calcified spinal discs. Patients can undergo epidural blood or fibrin glue patches as treatment; however, in cases where the leak does not resolve, surgical repair of the dural tear may be warranted. We aim to describe a case series and technical notes for these patients. METHODS: Patients with spontaneous intracranial hypotension because of myelography-confirmed ventral dural defect from calcified thoracic disc, who were treated surgically between June 2020 and March 2024, were included in the study cohort. Demographic information, clinical course, and postoperative outcomes were collected. The surgical technique was also described based on an illustrative case. RESULTS: Twelve consecutive patients underwent surgery between June 2020 and March 2024 with postoperative records. The median age at the time of surgery was 41.5 years (range: 28-58 years). Male patients comprised 50% of the cohort. Dural defects were spread throughout the thoracic spine in the cohort. While all patients reported positional headaches, other symptoms included vertigo, pulsatile tinnitus, and neck pain. Median length of follow-up time was 6.5 weeks. There were no surgical complications or permanent neurologic deficits. All patients had radiologic cure of their leaks with absence of extradural CSF on postoperative MR imaging. Ten patients (83.3%) had complete resolution of spontaneous intracranial hypotension-related symptoms. Two patients did suffer from rebound headaches postoperatively. CONCLUSION: The dorsolateral transdural surgical approach is a safe and effective method to repair type 1 CSF leaks caused by ventral dural defects. Our case series of 12 patients did not involve any surgical or immediate postoperative complications, and all patients had radiologic resolution of their leaks with relief of positional headaches. Two patients experienced continued headaches after treatment.

Specific road safety issues in LMICs: an overview and some illustrative examples

This paper gives an overview of the work of PIARC Working Group 3.1.1 ‘Specific road safety issues for LMICs’. The working group performed its activities in the period 2019–2023. We prepared two deliverables: (a) a literature review, and (b) an overview of illustrative examples. The review started from the notion that the road safety problem requires a multi-disciplinary approach. The safe system approach is generally considered as the central concept for this purpose and this starting point is also taken in this study. However new directions are needed to make the safe system concept work in LMICs. The period of the first UN Decade of Action for Road Safety has brought us a series of valuable problem analysis and overview articles prepared by a variety of institutions and institutes. As a PIARC working group we did not repeat this effort, but used it as a starting point to indicate which specific issues do require a boost in LMICs for the coming period up to 2030. We concluded that the following 12 issues deserve special attention. Strategical: (i) Sustainable Development Goals integral approach, (ii) safety culture, (iii) road safety management and leadership, (iv) building road safety expertise and science; Tactical: (v) transportation system as a whole, (vi) city design, architecture, land use, rural planning, (vii) cost effectiveness, (viii) legislation and enforcement; Operational: (ix) speed, (x) sustainable safe roads, (xi) vehicles as a safe system component, (xii) post-crash health care. As a result of our discussions and analyses we also concluded that it is worthwhile and necessary to make a distinction between the issues in terms of levels of approach. Making roads and vehicles safe may be considered as operational safety measures on a component level, whereas city design and transport system issues do represent a more tactical approach. On top of that, organisational and cultural aspects do have a more strategical nature. As in many managerial and planning tasks the distinction between strategical, tactical and operational levels of approach is needed in the road safety field. It illustrates that the Safe System concept asks for a multi-level vision, thus preventing a silo approach with a limited focus on human behaviour, safe roads or vehicle safety. A further analysis for each of the selected issues resulted in priority areas, i.e. topics that deserve special attention in the LMIC context. In a similar line of reasoning we also described illustrative examples, i.e. LMIC related before-after studies that show the perspective of certain measures on an evidence basis. Although we found some illustrative cases for each of these issues, our search for evidence based cases confirmed the findings from recent overview articles indicating the lack of LMIC related road safety research. A more widespread implementation of effective road safety measures in LMICs would require a stronger national commitment and leadership from the road safety agencies point of view in the first place. Moreover an evidence based policy asks for a strong national and regional knowledge infrastructure. Ultimately road safety policies and road safety research programs are to be considered as inseparable. A strong local knowledge infrastructure may thus become the basis for an effective national road safety policy.

Goal Setting and the Emergence of the Safety-Efficiency Trade-off in Organizations

This article aims to shed light on the trade-off between safety and efficiency that arises in organizations when management sets overly demanding efficiency goals. To explore the dynamics and relationships between management's goal setting and the safety-efficiency trade-off, we have chosen to analyze the extreme and illustrative case of the Herald of Free Enterprise disaster – a ferry that sank on March 6, 1987, resulting in the deaths of 193 passengers and crew members. The case shows how the management's imposition of very tight schedules for embarkation and disembarkation operations at the port of Zeebrugge promoted the emergence of risky practices, namely the regular violation of procedures by the crew. We argue that these violations, aimed at increasing the speed of operations to meet the time goals, were a central factor, though not the only one, in the etiology of the accident. The case provides evidence that when management sets overly strict performance goals, it directs employees' attention and efforts toward efficiency at the expense of safety. As a result, safety is compromised, leading to an increased risk of incidents, which can harm employees' health and cause economic and legal damage to the organization.

Median intraneural ganglion cyst at the elbow: the first known example of a joint connection and a reflection on the past. Illustrative case.

The articular origin of intraneural ganglion cysts has been previously described and well supported, except for the median nerve at the level of the elbow. The authors present a patient with a median intraneural ganglion cyst at the elbow region and magnetic resonance imaging (MRI) evidence of a joint connection to the proximal radioulnar joint. A 63-year-old man presented with thumb flexion weakness and dysesthesias in the thumb, index, and middle fingers. Electromyography confirmed a median nerve lesion at the elbow. MRI demonstrated a median intraneural cyst as well as an extraneural cyst, both arising from the proximal radioulnar joint. The articular branch between the cyst and the proximal radioulnar joint was identified preoperatively on MRI and intraoperatively using indocyanine green. Following disconnection of the articular branch and pedicle and decompression of the intra- and extraneural cysts, the patient recovered grade M4 motor function after 6 months, with resolution of neuropathic pain immediately after surgery. The authors present the first case of a median intraneural cyst with a joint connection to the proximal radioulnar joint. The authors believe that this report along with other historical data strengthens the articular theory for intraneural ganglion cysts not only at this site but at all sites. https://thejns.org/doi/10.3171/CASE24564.

Clazosentan-induced reversible focal brain edema in basal ganglia following aneurysmal subarachnoid hemorrhage treatment: illustrative case.

Clazosentan, a selective endothelin A receptor antagonist, effectively prevents cerebral vasospasm following aneurysmal subarachnoid hemorrhage. Although various adverse effects have been reported, there have been no specific case reports of clazosentan-associated focal brain edema. This report highlights a rare complication associated with clazosentan treatment. A female in her 70s with a subarachnoid hemorrhage underwent surgical clipping of a ruptured middle cerebral artery aneurysm and received clazosentan postoperatively. Six days after surgery, magnetic resonance imaging revealed high-intensity signals in the left basal ganglia on fluid-attenuated inversion recovery and apparent diffusion coefficient sequences without changes on diffusion-weighted imaging. The patient's right-sided hemiparesis and disturbance of consciousness gradually progressed. On day 9, clazosentan was discontinued because of suspected adverse effects. Within approximately 2 weeks of discontinuation, both imaging findings and neurological symptoms improved. The temporal relationship between clazosentan administration, symptom onset, and improvement after discontinuation strongly suggested clazosentan-induced vasogenic edema. Clazosentan can cause reversible localized vasogenic brain edema in the basal ganglia following subarachnoid hemorrhage treatment. This rare but significant complication underscores the importance of careful neurological monitoring and timely imaging in patients receiving clazosentan. Further research is required to understand the risk factors and mechanisms underlying this phenomenon. https://thejns.org/doi/10.3171/CASE24567.

Use of a percutaneous bone fiducial screw for elevating simple closed depressed skull fractures: illustrative cases.

Depressed skull fractures in infants often present as "ping-pong ball" fractures with inward buckling of the calvarium, secondary to trauma. Management varies widely, and few concrete guidelines exist in the literature to guide decision-making when choosing a methodology for fracture elevation. The authors present two cases of attempted depressed skull fracture elevation with traction on a percutaneously placed bone fiducial screw, followed by a review of the literature, in order to further investigate the factors considered when selecting an intervention. An 8-month-old female and a 10-month-old male presented with a right parietal depressed skull fracture. Both underwent attempted fracture elevation with a self-tapping screw anchored into the skull. The authors directly elevated the fracture with the screw technique in the 8-month-old female patient. The 10-month-old male had persistent depressed skull deformity; thus, the authors extended the incision for a standard craniotomy for depressed skull fracture elevation. Percutaneous screw placement may be considered an option in the spectrum of treatment strategies for select patients with depressed skull fractures. Consideration of patient age, skull thickness, and depth of skull fracture can assist with the choice of treatment strategy and the preoperative prediction of the likelihood of fracture elevation success with this technique. https://thejns.org/doi/10.3171/CASE23742.

Management of internal carotid artery pathology with a covered stent: illustrative cases.

Endovascular treatment of internal carotid artery (ICA) pathology includes reconstructive or deconstructive options. One reconstructive option is covered stent placement, although this is limited by a lack of devices designed specifically for neurointervention. The PK Papyrus is a balloon-mounted covered coronary stent that has a lower profile and is more flexible than other stent grafts, which makes it more suitable for treating ICA lesions. The PK Papyrus was used to treat patients with iatrogenic cavernous ICA injury and symptomatic cervical ICA pseudoaneurysms. In both cases, the stent could be easily delivered without the use of an intermediate catheter or stiff microwire. Stent deployment resulted in immediate angiographic resolution of the pathology, and there were no peri- or postoperative complications. The PK Papyrus covered coronary stent is a good option for treating cervical and cavernous carotid pathology. Its single-layer design makes it more flexible and deliverable than other stent grafts, but additional case series are needed. https://thejns.org/doi/10.3171/CASE24517.

"Picket fence" an alternative clipping technique for wide necked and large aneurysms: technical nuances in a case series.

Complex aneurysms are a therapeutic challenge in contemporary neurosurgery. Several microsurgical and endovascular techniques have been proposed for their treatment. The picket fence clipping technique uses fenestrated clips, that are stacked not to reconstruct the neck of the aneurysm, but to create a duct to normalize the cerebral flow by reconstructing the dome. We present four illustrative cases using the picket fence clipping technique. The aneurysms considered were of different locations (ICA, MCA, AComA), of large or giant size with wide necks, in which clipping attempt with a conventional technique was not possible, so that the use of non-conventional clipping techniques had to be applied with favorable results. In our experience we found this technique useful in large and giant, wide-necked aneurysms by reconstructing the parent vessel according to the concept of the ideal closure line in these previously unreported locations, thereby restoring normal cerebral circulation. The use of non-conventional techniques for clipping complex aneurysms can be used alone or in combination for adequate treatment, preserving cerebral circulation without compromising adequate exclusion of the aneurysm. The Picket fence technique is a feasible clipping technique that can be used as a less morbid option in large and giant aneurysms with wide necks.

The pivot to online teaching: an opportunity to create effective problem-based learning environments for dietetic education.

Dietetics, as an autonomous profession guided by evidence-based practice, requires a dynamic and adaptable workforce to meet evolving challenges in healthcare, public health nutrition and epidemiological research. This study aimed to explore the opportunities presented by the transition to online education of preparing dietetic students for professional demands, particularly, through the lens of problem-based learning (PBL) within the Community of Inquiry (CoI) framework. This paper examines the shift from traditional classroom and practice placement education to online and blended learning accelerated by the COVID-19 pandemic. It focuses on the application of PBL, rooted in constructivist theories and the CoI framework, which includes social, cognitive and teaching presences. PBL encourages active and collaborative learning, aligning with the multifaceted roles of dietetic professionals. The CoI framework guides the development of effective online learning environments, emphasising the importance of social, cognitive and teaching presence. The transition to online education presents significant opportunities for dietetic education. Careful instructional design and effective teaching strategies are crucial for creating successful online learning environments, as demonstrated through an illustrative case study.

Surgical Treatment for Scaphocephaly Using a Modified Melbourne Technique in Mexico: An Illustrative Case and Literature Review

Surgical Treatment for Scaphocephaly Using a Modified Melbourne Technique in Mexico: An Illustrative Case and Literature Review

Dynamics in District–University Partnerships Focused on Leadership for Equity

This paper discusses the development of district–university partnerships at the onset of a multi-year grant-funded initiative focused on leadership for equity. Using three illustrative partnership cases, we investigated district–university collaboration through the lens of mutualism, or the mutually beneficial nature of the relationship. Our data analysis revealed the following dynamics as important for the development of mutualism: shared commitment, shared ownership, new collaborative structures, reciprocal benefits, and boundary spanners. We approached partnerships as learning processes, and used a typology of interorganizational learning to understand better how these dynamics sustained the partnerships. Our study contributes to the field’s knowledge of the development of formal partnerships in general as well as of partnerships explicitly focused on equity specifically.

Global sensitivity analysis of Open Systems Pharmacology Suite physiologically based pharmacokinetic models.

Sensitivity analyses are important components of physiologically based pharmacokinetic (PBPK) model development and are required by regulatory agencies for PBPK submissions. They assess the impact of parametric uncertainty and variability on model estimates, aid model optimization by identifying parameters requiring calibration, and enable the testing of assumptions within PBPK models. One-at-a-time (OAT) sensitivity analyses quantify the impact on a model output in response to changes in a single parameter while holding others fixed. Global sensitivity analysis (GSA) methods provide more comprehensive assessments by accounting for changes in all uncertain or variable parameters, though at a higher computational cost. This tutorial article presents a software package for conducting both OAT and GSA of PBPK models built in the Open Systems Pharmacology (OSP) Suite. The tool is accessible through either an R script or a graphical user interface, and the outputs consist of sensitivity metrics of pharmacokinetic (PK) parameters, such as Cmax and AUC, evaluated with respect to model input parameters. Results are formatted according to regulatory standards. The OAT analysis methods comprise two-way local sensitivity analyses and probabilistic uncertainty analyses, whereas the GSA methods include the Morris, Sobol, and EFAST methods. These analyses can be conducted on single PBPK models or pairs of models for the evaluation of the sensitivity of PK parameter ratiosin drug-drug interaction studies. The practical application of the package is demonstrated through three illustrative case studies.

A unique presentation of trigeminal neuralgia related to a central nervous tissue choristoma along the trigeminal nerve root: illustrative case.

Trigeminal neuralgia (TNa), or tic douloureux, is characterized by severe facial pain triggered by everyday activities. Recurring and intense TNa pain results from localized demyelination within the affected nerve segment. The primary cause of TNa is typically vascular compression, with the superior cerebellar artery being the most common vessel. Tumors, multiple sclerosis, and infectious diseases such as herpes are less frequent causes of TNa. The authors present a unique case in which TNa was caused by an aberrant mass resembling a schwannoma during surgery. However, histological examination revealed heterotopic benign central nervous neurons and myelinated axons, which could represent a choristoma in the cisternal segment of the portio major of the trigeminal nerve. Following surgery, the patient's TNa was completely resolved. To the best of the authors' knowledge, this is the first documented case of a central nervous tissue choristoma causing TNa and responding positively to surgical intervention, aside from one previous report that did not specifically use the term "choristoma" in identifying the lesion. This case highlights the challenges involved in diagnosing and managing a rare TNa presentation, with a particular focus on pathology findings. It underscores the potential role of surgery for patients whose condition is resistant to medical intervention. https://thejns.org/doi/10.3171/CASE24384.

Utility of the turn-back supporting technique using a steerable intermediate catheter: illustrative case.

Selective shunt occlusion (SSO) for intracranial dural arteriovenous fistulas (DAVFs) is a safe and effective method that directly intercepts the shunted pouch from the affected sinus with minimal materials. However, it can be challenging to obliterate the shunted pouch if the microcatheter is not supported adequately. A 68-year-old woman presented with tinnitus and was diagnosed with multiple shunted DAVFs in the right transverse-sigmoid sinus (TSS) and the superior sagittal sinus (SSS). Although the entire sinus packing of the right TSS was performed, a follow-up angiography 7 months later revealed significant cerebral venous reflux due to occlusion of the left TSS and an increasing residual shunt flow in the venous pouch at the confluence of the SSS. A guiding catheter was introduced into the isolated sinus transvenously. Then, a steerable intermediate catheter (SIC) was manually steered into a hairpin shape and hooked on near the pouch prior to navigating a microcatheter into the fistula point. Finally, the fistula pouch was completely obliterated using only two coils under the adequate support of the turned-back intermediate catheter. The turn-back supporting technique using an SIC was useful in achieving SSO for DAVFs, providing both adequate support and guidance for the coaxial microcatheter. https://thejns.org/doi/10.3171/CASE24467.

Branching and nonbranching intracranial aneurysms in the presence of a persistent stapedial artery and an aberrant internal carotid artery assessed with computational hemodynamics: illustrative case.

The mechanisms underlying the initiation and progression of bifurcation versus lateral wall aneurysms are not well understood. Computational fluid dynamics (CFD) can improve the understanding of these mechanisms and can consequently help identify patients at higher risk for developing aneurysms and monitor them more closely. A 36-year-old man presented with a ruptured anterior communicating artery aneurysm, which was successfully treated with microsurgical clipping. Imaging also revealed a persistent stapedial artery with an elongated and tortuous posterior communicating artery (PComA). Fourteen years later, he was readmitted for a ruptured aneurysm on a PComA loop. CFD helped identify considerable collateral circulation due to the aberrant internal carotid artery (ICA). High flow rates trigger both types of aneurysms, but nuances exist in the hemodynamic mechanisms that drive their growth. Berry aneurysms and lateral wall aneurysms initially start due to a high flow rate, a common underlying cause. However, the formation of true sidewall aneurysms is primarily characterized by locally increased wall shear stress, while the development of berry aneurysms is mainly linked to high local blood pressure at arterial bifurcations. An aberrant ICA can lead to supraphysiological compensatory flow in the anterior and posterior circulation, increasing the risk of intracranial aneurysm formation at both branching and nonbranching sites, underscoring the need for lifelong monitoring. https://thejns.org/doi/10.3171/CASE24421.