Including Aneurysm Size Research Articles

Treatment strategies of unruptured intracranial aneurysms: A Literature Review

Introduction and purpose Unruptured intracranial aneurysms (UIAs) are often diagnosed incidentally and become a complex clinical dilemma. The main challenge is to choose between invasive treatment and conservative management, considering the low but difficult to predict risk of rupture. The aim of this review is to present current knowledge and approaches regarding UIA management, highlighting both traditional and emerging strategies. Description of state of knowledge Management of UIAs depends on various factors, including aneurysm size, location, morphology, and patient-specific risks. Surgical clipping remains a reasonable method for long-term durability, but more perioperative complications, while endovascular approaches have an advantage due to their less invasive nature, but lower adequate occlusion rate. In selected low-risk patients, conservative monitoring with regular imaging may be appropriate. Advances in computational modeling, artificial intelligence, and hemodynamic analysis are improving our ability to assess rupture risk and tailor treatment plans. However, the lack of universally accepted guidelines continues to complicate decision-making. Conclusion UIA management should be individualized, weighing the risks and benefits of each treatment option. Despite technological progress and improved diagnostic tools, further research and international consensus are needed to establish standardized protocols for clinical practice.

Enhancing intracranial aneurysm rupture risk prediction with a novel multivariable logistic regression model incorporating high-resolution vessel wall imaging.

This study aimed to develop and validate a multivariate logistic regression model for predicting intracranial aneurysm (IA) rupture by integrating clinical data, aneurysm morphology, and parent artery characteristics using high-resolution vessel wall imaging (HR-VWI). A retrospective analysis was conducted on 298 patients with 386 aneurysms. Patients were randomly divided into training (n = 308) and validation (n = 78) sets. Key predictors, including aneurysm size, shape, aneurysm wall and parent artery wall enhancement, were identified through univariate analysis and then used to build the prediction model using multivariate logistic regression. The model was visualized as a nomogram and compared to PHASES and ELAPSS scores. The logistic regression model demonstrated superior predictive performance with an area under the curve of 0.814, which was significantly higher than PHASES and ELAPSS scores (p < 0.05). The model revealed strong calibration and good agreement between predicted and observed rupture probabilities. The multivariate model based on HR-VWI, which incorporates aneurysm and parent artery features, provides a more accurate prediction of IA rupture risk than conventional scoring systems, offering a valuable tool for clinical decision-making.

Patient Selection Criteria for Endovascular Aortic Aneurysm Repair: Optimizing Outcomes.

Endovascular aortic aneurysm repair (EVAR) has become the preferred treatment for abdominal aortic aneurysms, offering a minimally invasive alternative to open surgery. However, successful outcomes depend on meticulous patient selection. This review explores the key criteria for patient eligibility, including aneurysm size, morphology, and the quality of the proximal and distal aneurysm necks. Additionally, imaging assessment and various device variables, including anatomical suitability, are examined to emphasize their influence on procedural success. As EVAR technology evolves, understanding the nuances of patient selection remains crucial for maximizing technical success and clinical outcomes, while minimizing complications including endoleaks and migration, and extending the benefits of the procedure to a broader range of patients.

Inequalities for women diagnosed with distal arch and descending thoracic aortic aneurysms: results from the Effective Treatments for Thoracic Aortic Aneurysms (ETTAA) cohort study.

Women with thoracic aortic aneurysms within the arch or descending thoracic aorta have poorer survival than men. Sex differences in relative thoracic aortic aneurysm size may account for some of the discrepancy. The aim of this study was to explore whether basing clinical management on aneurysm size index (maximum aneurysm diameter/body surface area) rather than aneurysm size can restore equality of survival by sex. The Effective Treatments for Thoracic Aortic Aneurysms (ETTAA; ISRCTN04044627) study was a prospective, observational cohort study. Adults referred to National Health Service hospitals in England with new/existing arch or descending thoracic aorta aneurysms greater than or equal to 4 cm in diameter were followed from March 2014 to March 2022. Baseline characteristics and survival to intervention and overall were compared for men and women. Survival models were used to assess the association between all-cause survival and sex, with and without adjustment for aneurysm diameter or aneurysm size index. A total of 886 thoracic aortic aneurysm patients were recruited: 321 (36.2%) women and 565 (63.8%) men. The mean(s.d.) aneurysm diameter was the same for women and men (5.7(1.1) versus 5.7(1.2) cm respectively; P = 0.751), but the mean(s.d.) aneurysm size index was greater for women than for men (3.32(0.80) versus 2.83(0.63) respectively; P < 0.001). Women had significantly worse survival without intervention: 110 (34.3%) women and 135 (23.9%) men (log rank test, P < 0.001). All-cause mortality remained greater for women after adjustment for diameter (HR 1.65 (95% c.i. 1.35 to 2.02); P < 0.001), but was attenuated after adjustment for aneurysm size index (HR 1.11 (95% c.i. 0.89 to 1.38); P = 0.359). Similar results were found for all follow-up, with or without intervention, and findings were consistent for descending thoracic aorta aneurysms alone. Guidelines for referral to specialist services should consider including aneurysm size index rather than diameter to reduce inequity due to patient sex.

P.123 Is there an association between geographical location of patients in NS and management of unruptured, incidental intracranial aneurysm?

Background: Managing unruptured cerebral aneurysms involves monitoring or repair, with complex factors influencing decision-making. Geographical distance from treatment centers is an understudied factor. This study explores a potential relationship in Nova Scotia between proximity to the sole neurosurgical center in Halifax and aneurysm management. Methods: A prospectively collected neurosurgery database was used to identify all adults seen for unruptured cerebral aneurysm between Jan 1, 2015 - Dec 31, 2020. Demographic data, aneurysm characteristics, follow-up and treatment information were collected. Univariate and multivariate analyses assessed management differences based on geography, controlling for relevant factors including aneurysm size and location. Results: Among 390 patients, 40% were in Halifax, and 60% were outside. No significant difference existed in elective repair (34% vs. 26%, p=0.143) and imaging follow-up frequency (2.26 vs. 2.22, p=0.858). In-person follow-up was higher within Halifax (1.83 vs. 1.43, p=0.008), while virtual follow-up was significant outside Halifax (1.44 vs. 1.01, p=0.003). Overall, in-person and elective repair frequencies declined with the COVID-19 peak, whereas virtual follow-up increased. Conclusions: No significant association was found between patient location and repair decisions. Patients in closer proximity had more in-person follow-ups, while those farther away had more virtual follow-ups. The COVID-19 pandemic affected follow-up frequencies universally.

Diagnosis of intracranial aneurysms by computed tomography angiography using deep learning-based detection and segmentation

BackgroundDetecting and segmenting intracranial aneurysms (IAs) from angiographic images is a laborious task.ObjectiveTo evaluates a novel deep-learning algorithm, named vessel attention (VA)-Unet, for the efficient detection and segmentation of IAs.MethodsThis...

Clipping of Bilateral Ophthalmic Artery Aneurysms Through a Single Craniotomy.

Bilateral ophthalmic aneurysms are rare and involve two aneurysms in the ophthalmic arteries, one on each, leading to potential symptoms such as vision loss and headaches. The treatment options for aneurysms, ranging from surgery and endovascular embolization to observation, depend on various factors, including aneurysm size and the patient's health.Microsurgery, while presenting complexities due to the intricate anatomy of the anterior clinoid region, offers potential advantages such as enhanced decompression rates and reduced aneurysm recurrence. The presented surgical video illustrates the treatment of bilateral ophthalmic artery aneurysms via a single craniotomy. This method reduces surgical duration and trauma, facilitating quicker patient recovery. However, this method bears potential risks, especially to both optic nerves. As underscored in the video, the utmost anatomical understanding in the anterior clinoid area is pivotal for successful outcomes and reduced complications.

How does the recurrence-related morphology characteristics of the Pcom aneurysms correlated with hemodynamics?

Posterior communicating artery (Pcom) aneurysm has unique morphological characteristics and a high recurrence risk after coil embolization. This study aimed to evaluate the relationship between the recurrence-related morphology characteristics and hemodynamics. A total of 20 patients with 22 Pcom aneurysms from 2019 to 2022 were retrospectively enrolled. The recurrence-related morphology parameters were measured. The hemodynamic parameters were simulated based on finite element analysis and computational fluid dynamics. The hemodynamic differences before and after treatment caused by different morphological features and the correlation between these parameters were analyzed. Significant greater postoperative inflow rate at the neck (Qinflow), relative Qinflow, inflow concentration index (ICI), and residual flow volume (RFV) were reported in the aneurysms with wide neck (>4 mm). Significant greater postoperative RFV were reported in the aneurysms with large size (>7 mm). Significant greater postoperative Qinflow, relative Qinflow, and ICI were reported in the aneurysms located on the larteral side of the curve. The bending angle of the internal carotid artery at the initiation of Pcom (αICA@PCOM) and neck diameter had moderate positive correlations with Qinflow, relative Qinflow, ICI, and RFV. The morphological factors, including aneurysm size, neck diameter, and αICA@PCOM, are correlated with the recurrence-inducing hemodynamic characteristics even after fully packing. This provides a theoretical basis for evaluating the risk of aneurysm recurrence and a reference for selecting a surgical plan.

Comparative Study of the Diagnostic Value of Zero-Echo-Time Magnetic Resonance Angiography With Time-of-Flight Magnetic Resonance Angiography for Intracranial Aneurysm.

Intracranial aneurysm (IAN) is a class of cerebrovascular diseases with a serious threat to patients, and an accurate diagnosis of IAN is very important for both selection of the appropriate therapy and prediction of the prognosis. This study aimed to evaluate the diagnostic values of zero-echo-time magnetic resonance angiography (ZTE-MRA) and time-of-flight magnetic resonance angiography (TOF-MRA) in patients with IAN. Digital subtraction angiography, ZTE-MRA, and TOF-MRA were performed in 18 patients diagnosed with IAN. The images of ZTE-MRA and TOF-MRA were compared for image quality, qualitative diagnosis, detailed diagnosis, number of thrombi, and residual aneurysm lumen, with digital subtraction angiography as the reference. Zero-echo-time MRA and TOF-MRA did not show a significant difference in image quality or detailed information (including aneurysm size, growth direction, and angle with the aneurysm-carrying vessel) ( P > 0.05). However, ZTE-MRA showed advantages over TOF-MRA in terms of qualitative diagnosis (sensitivity and specificity), intra-aneurismal thrombus detection, and residual aneurysm lumen detection after embolization ( P < 0.05). Compared with TOF-MRA, ZTE-MRA showed greater diagnostic value for IAN patients in terms of qualitative diagnosis, as well as the detection of intra-aneurysm thrombi and residual aneurysm lumen after embolization.

3D aneurysm wall enhancement is associated with symptomatic presentation

BackgroundAneurysm wall enhancement (AWE) is a potential surrogate biomarker for aneurysm instability. Previous studies have assessed AWE using 2D multiplanar methods, most of which were conducted qualitatively.ObjectiveTo use a new...

Diagnostic Performance of MRA for UnrupturedAneurysms at the Distal ICA.

Unruptured intracranial aneurysms (UIAs) at the distal internal carotid artery (ICA) (segments C5-C7) are difficult to accurately display on computed tomography angiography (CTA) due to the influences of bone structures and vessel curvature. We investigated the utility of three-dimensional time-of-flight magnetic resonance angiography (3D-TOF-MRA) at 3.0‑T for the detection of morphologic features compared to digital subtraction angiography (DSA). This retrospective study included 2398patients between January 2015 and May 2020 who underwent 3D-TOF-MRA and DSA within 3 months. Morphologic features including aneurysm size, neck width, shape and relation to adjacent arteries and other diagnostic parameters were recorded. Three observers blinded to the clinical and DSA results independently analyzed MRA data sets. The statistical difference of each aneurysm-specific variable was performed using χ2-tests and multivariate logistic regression analysis. A total of 551aneurysms in 514patients were confirmed at the distal ICA by DSA. Patient-based, aneurysm-based and location-based evaluations with 3D-TOF-MRA yielded high diagnostic accuracy in the detection of target UIAs. The accuracy of displayed morphologic features was 94.9% for size, 97.2% for neck width, 92.6% for shape, and 96.4% for relationship to adjacent vessels. Multivariate logistic regression showed that tiny (P < 0.001) or giant (P = 0.039) size and alobulated shape (P = 0.006) significantly affected the morphologic assessment on 3D-TOF-MRA. Three-dimensional TOF-MRA can accurately depict and display morphologic features of distal ICA UIAs. Tiny or giant-sized distal ICA aneurysms and with lobulation tend to carry agreat risk of misdiagnosis in morphologic assessments.

Performance of rupture-related morphological parameters in posterior communicating artery aneurysms with fetal-type variant.

The aim of the study was to investigate the impact of fetal-type posterior cerebral artery (fPCA) variant on morphological parameters of posterior communicating artery (PComA) aneurysms for rupture risk assessment. A total of 98 PComA aneurysms (62 ruptured and 36 unruptured) in 98 consecutive patients were reviewed. Morphological parameters were calculated including aneurysm size, aspect ratio (AR), size ratio (SR), dome-to-neck ratio, bottleneck factor and inflow angle. Performances of morphological parameters to discriminate rupture status were compared between aneurysms with or without fPCA. Fetal-type posterior cerebral artery variant was determined in 39 (39.8%, 25 ruptured and 14 unruptured) lesions. The ruptured group revealed a significantly larger size (p = 0.004), AR (p = 0.003), SR (p = 0.001), and inflow angle (p < 0.001). For the aneurysms without fPCA, all morphological parameters were significantly different between ruptured and unruptured aneurysms (p < 0.05); for the aneurysms with fPCA, only inflow angle (p = 0.001) was significantly related with the rupture status. Multivariate analysis showed that SR (p = 0.035 and p = 0.011) and inflow angle (p = 0.001 and p = 0.028) were independent rupture risk factors for the total cohort and the aneurysms without fPCA; while only inflow angle (p = 0.004) revealed to be independently related with rupture status of aneurysms without fPCA. The performances of morphological parameters to discriminate rupture status were different between PComA aneurysms with and without fPCA variants. Inflow angle might be a reliable predictor for rupture risk of PComA aneurysms.

The Analysis of Morphoradiological Parameters in Predicting Risk of Basilar Artery Tip Aneurysm Rupture: A Retrospective Cohort Study

PurposeBasilar artery tip aneurysms can have fatal consequences and poor prognostic outcomes in case of rupture. We investigated the standard parameters used to evaluate aneurysmal morphology to predict aneurysm rupture.Patients and MethodsWe measured the differences between ruptured and unruptured basilar bifurcation aneurysms in terms of morphological features, including aneurysm size, size ratio, aneurysm height, perpendicular height, aneurysm width, bottleneck ratio, aspect ratio, and present daughter domes, using 3D angiography.ResultsAmong 34 patients, 21 (61.8%) and 13 (38.2%) had ruptured and unruptured basilar tip aneurysms, respectively. In the ruptured group, the mean aneurysm size, and aspect, size, and bottleneck ratios were 6.8 ± 1.9 mm, 3.2 ± 1.0, 2.3 ± 0.5, and 2.2 ± 0.4, respectively, compared to 4.5 ± 1.5 mm, 4.4 ± 2.0, 1.6 ± 0.4, and 2.7 ± 0.7, respectively, in the non-ruptured group. Univariate analysis showed a larger aneurysmal cross-sectional diameter (odds ratio [OR], 0.50; 95% confidence interval [CI], 0.5–5.392; p < 0.05), a larger size ratio (OR, 21.375; 95% CI, 3.283–139.177; p < 0.05), and presence of a daughter dome (OR, 72.0; 95% CI, 6.7–776.5; p < 0.05) with ruptured basilar artery tip aneurysms.ConclusionA larger aneurysm size and size ratio, and the presence of a daughter dome were significantly associated with increased rupture risk in basilar tip aneurysms.

A comparative analysis of the endoscopic endonasal and pterional approaches for clipping anterior communicating artery aneurysms on three-dimensional printed models.

A comparative analysis of the endoscopic endonasal and pterional approaches for clipping anterior communicating artery aneurysms on three-dimensional printed models.

Cerebral revascularization for the management of complex middle cerebral artery aneurysm: A case series.

Complex middle cerebral artery (MCA) aneurysms, including aneurysms that are sizeable (large or giant), fusiform, wide-necked or calcified, remain a significant challenge during microsurgical clipping or endovascular coiling as treatment strategies. In the present study, a retrospective analysis of cases of this type of aneurysm treated between August 2012 and December 2019 was performed. From the hospital's database, a total of 13 patients (7 males and 6 females) with a mean age of 39.0 years (range, 13-65 years) were identified. The mean size of the aneurysms was 17.5 mm (range, 3.9-35.0 mm). A total of four patients (30.8%) had ruptured aneurysms and nine (69.2%) had unruptured aneurysms. All aneurysms were treated by proximal occlusion of the parent artery, trapping or excision combined with cerebral revascularization. The bypasses performed included 10 extracranial-intracranial bypasses and 3 intracranial-intracranial bypasses (1 end-to-end re-anastomosis, 1 interpositional graft and 1 end-to-side reimplantation). Postoperative angiography confirmed that the bypass patency was 92.3% and the clinical outcomes were indicated to be favorable, with a modified Rankin Scale score ≤2 in 12 out of 13 patients (92.3%) at the last follow-up. Taken together, the results of the present analysis suggested that treatment strategies for complex MCA aneurysms should depend on the status and characteristics of the aneurysm, including aneurysm size, location and morphology. For aneurysms that lack perforating arteries in the aneurysm dome, clip trapping or aneurysm excision with or without bypass are preferred as treatment strategies. When there are perforating arteries (particularly the lenticulostriate artery) arising from the aneurysm dome, however, the aneurysms should be treated with bypass followed by proximal occlusion of the parent artery or clip reconstruction.

Significance of aneurysm wall enhancement on high-resolution vessel wall magnetic resonance imaging in clinical management of patients with intracranial aneurysms.

The prevalence of intracranial aneurysms is estimated to be around 3% in the general population. Although these are often incidental findings, they potentially carry the risk of rupture, with all of the devastating consequences of SAH. Several risk factors of aneurysm rupture have been identified, including aneurysm size, irregular shape, and location. Although it is widely accepted that the risk of rupture increases with size, small aneurysms remain the cause of a significant percentage of aneurysmal SAH. Up to 30% of patients with acute aneurysmal SAH have multiple aneurysms. Determining the site of rupture in these patients can be challenging, given that the results of imaging studies and clinical symptoms are sometimes inconclusive. It would be extremely useful to identify new imaging biomarkers of aneurysm instability which could have an impact on patient management and qualification for treatment. High-resolution vessel wall magnetic resonance imaging (HR-VW MRI) opens up new possibilities for improved characterisation of intracranial vasculature. One of the most promising clinical applications of this new imaging tool is the evaluation of intracranial aneurysms. Aneurysm wall enhancement (AWE) on HR-VW MRI is believed to be a marker for wall inflammation and, potentially, for aneurysm instability. In this article, we summarise the published literature on AWE with special emphasis on its use in determining the site of rupture in the setting of acute SAH in patients with multiple aneurysms, as well as its role in identifying unruptured aneurysms which are at the greatest risk of rupture. More and larger studies are needed to definitively establish the role of AWE on HR-VW MRI in the diagnostic workup of patients with intracranial aneurysms.

Abstract WP120: Readmission Trends Related to Unruptured Intracranial Aneurysm Treatment

Introduction: The treatment of choice for Unruptured intracranial aneurysms (UICA) is dependent on assessment of several factors including aneurysm size, location, and morphology, along with patient's life expectancy and comorbid conditions. Although multiple studies have deliberated upon the efficacy of surgical and endovascular aneurysm treatment for UICA, the rate of readmission with either technique has not been specifically studied. Methods: We used the Nationwide Readmission database to assess the readmission trends related to various treatment approaches for UICA. The treatment approaches were subdivided into four groups; surgical clipping group and three endovascular approach groups (coil embolization, stent assisted coil embolization and only stent placement groups). All four groups were compared for the characteristics of index hospitalizations and top causes of readmissions. Results: We identified 3533 patients treated with clipping and 4134 (3865 coil embolization, 192 only stent placement and 76 stent assisted coil embolization) patients treated with endovascular approach. Thirty day readmission rate (30RR) was significantly higher with surgical clipping compared to the three endovascular approach groups (8.37% Vs 4.77%, p&lt;0.01). Lower rates of home discharge disposition were observed during index hospitalization (73.8% Vs. 91.4%, p&lt;0.01) and during readmission (53.3% Vs. 72.56%, p&lt;0.01) amongst the clipping group compared to the endovascular groups. Major causes of readmission amongst clipping groups included intracranial hemorrhage (12.9%) and post operative infections (10.5%), Major causes of readmission amongst endovascular group included ischemic cerebrovascular event (21.3%) and headaches (8.6%). Conclusion: Patients undergoing endovascular treatment for UICA are less likely to be readmitted and more likely to be discharged home compared to surgical clipping. Given the complex decision making with consideration of anatomic and patient factors for UICA treatment, these findings do not necessarily prove the general superiority of the endovascular approach but do suggest that when a UICA can be safely treated with either technique, the endovascular approach might reduce the chances of readmission.

A2, M2, P2 aneurysms and beyond: results of treatment with pipeline embolization device in 65 patients

BackgroundIntracranial aneurysms located in the distal vessels are rare and remain a challenge to treat through surgical or endovascular interventions.ObjectiveTo describe a multicenter approach with flow diversion using the pipeline...

Clinico-radiologic factors in paraclinoid aneurysms associated with aneurysm rupture: A CTA study

Clinico-radiologic factors in paraclinoid aneurysms associated with aneurysm rupture: A CTA study

Morphological Parameters Related to Aneurysm Wall Enhancement in Patients with Multiple Intracranial Aneurysms.

Morphological Parameters Related to Aneurysm Wall Enhancement in Patients with Multiple Intracranial Aneurysms.