Aneurysm Location Research Articles

Endovascular versus neurosurgical aneurysm treatment: study protocol for the development and validation of a clinical prediction tool for individualised decision making

IntroductionTreatment decisions for aneurysmal subarachnoid haemorrhage patients should be supported by individualised predictions of the effects of aneurysm treatment. We present a study protocol and analysis plan for the development...

Acute Development of a Traumatic Pseudoaneurysm of the Posterior Inferior Cerebellar Artery Due to a Fracture of the Clivus

BACKGROUND AND IMPORTANCE: Traumatic intracranial aneurysms are uncommon and are mostly located in the anterior circulation. Aneurysms involving the posterior circulation are extremely rare and account for less than 10% of traumatic aneurysms. In this study, we describe an extremely rare case of a traumatic pseudoaneurysm of the posterior inferior cerebellar artery due to a fracture of the clivus that ruptured in the acute stage after blunt brain injury and that was successfully cured endovascularly. CLINICAL PRESENTATION: A 68-year-old man presented with loss of consciousness because of a severe subarachnoid hemorrhage and multiple contusions after blunt brain injury. Angiography the day after trauma revealed a traumatic pseudoaneurysm near the clivus fracture that had not been identified on the first day of trauma. The aneurysm's location was consistent with the location of the increased thick subarachnoid hemorrhage. The aneurysm was successfully occluded endovascularly through posterior inferior cerebellar artery parent artery occlusion. The patient survived the acute stage because of management that included endovascular treatment followed by decompressive craniectomy. CONCLUSION: A traumatic pseudoaneurysm that is likely to rupture due to the fragility of the aneurysm wall can be identified within 1 day after trauma. Neurosurgeons should pay careful attention to the aneurysm formation and perform early treatment to prevent its rupture, which could lead to a fatal hemorrhage.

Incidence and Prediction of Chronic Depression Following Aneurysmal Subarachnoid Hemorrhage: A Single-Center 17-Year Experience

The incidence and risk factors for chronic depression after aneurysmal subarachnoid hemorrhage (aSAH) are described. Patients with aSAH treated at a single institution (January 1, 2003-December 31, 2019) and a modified Rankin Scale score ≤3 at follow-up who were evaluated for chronic depression were analyzed. Chronic depression was defined using a depression screening questionnaire as ≥5 positive answers for symptoms lasting >2weeks. A predictive model was designed for the primary outcome of depression. Among 1419 patients with aSAH, 460 patients were analyzed; 130 (28%) had major depressive disorder. Mean follow-up was >6years. Higher depression rates were associated with tobacco smoking (odds ratio [OR]= 2.64, P< 0.001), illicit drug use (OR= 2.35, P= 0.007), alcohol use disorder (1.92, P= 0.04), chronic obstructive pulmonary disease (COPD) (OR=2.68, P= 0.03), and vasospasm requiring angioplasty (OR=2.09, P= 0.048). The predictive model included tobacco smoking, illicit drug use, liver disease, COPD, diabetes, nonsaccular aneurysm type, anterior communicating artery or anterior cerebral artery aneurysm location, refractory spasm requiring angioplasty, and a modified Rankin Scale score at discharge of >1 (P ≤ 0.03). The model performed with appropriate goodness of fit and an area under the receiver operator curve of 0.70 for depression. Individual independent predictors of depression were tobacco smoking, COPD, diabetes, and nonsaccular aneurysm. A substantial percentage of patients had symptoms of depression on follow-up. The proposed predictive model for depression may be a useful clinical tool to identify patients at high risk for developing depression who warrant early screening and evaluation.

Predictive factors associated with outcome in patients six months after mild to moderate aneurysmal subarachnoid hemorrhage: Focus on neuropsychological tests conducted one month after the event

ObjectiveThe study aimed to investigate predictive factors associated with outcome six months after mild to moderate aneurysmal subarachnoid hemorrhage (SAH). MethodsWe divided 136 patients (51 men and 85 women) after SAH (Hunt & Kosnik [H&K] grade I to III) into groups with good and poor outcome according to scores on the modified Rankin Scale (mRS) at six months after SAH onset: good outcome (mRS score, 0–1; n = 105) and poor outcome (mRS score, 2–6; n = 31). At admission, we assessed age, sex, H&K grade, and Fisher grade, and one month after aneurysmal SAH, we evaluated aneurysm location, treatment modality (coil embolization, clipping, or no surgical treatment), proportion of patients who underwent shunt placement, proportion of patients with delayed cerebral ischemia, and scores on neuropsychological tests (Mini-Mental State Examination, Raven’s Colored Progressive Matrices, Kana-hiroi Test, Trail Making Test, and Rey-Osterrieth Complex Figure Test, immediate recall). ResultsH&K grade was associated with outcome (χ2 = 6.220, P = 0.005), and a significantly higher proportion of the good outcome group had an H&K grade II (P = 0.025). The good outcome group had significantly better scores on the Mini-Mental State Examination (U = 1251, P = 0.045), Raven’s Colored Progressive Matrices (U = 1224, P = 0.036), and Trail Making Test parts A (U = 1238, P = 0.043) and B (U = 1247, P = 0.048). However, we found no significant intergroup differences in the other patient demographic and disease characteristics, including age, treatment modality, and delayed cerebral ischemia, or in the other neuropsychological assessments. Binary logistic regression analysis identified H&K grade I and II as predictive factors associated with good outcome. ConclusionBesides severity at admission as indicated by H&K grade, neuropsychological tests explicitly performed one month after mild to moderate aneurysmal SAH may help nursing staff to predict patient outcome, including possible symptoms after discharge.

Radiation dose and fluoroscopy time of aneurysm coiling in patients with unruptured and ruptured intracranial aneurysms as a function of aneurysm size, location, and patient age

PurposeEndovascular treatment of unruptured intracranial aneurysms (UIAs) requires a risk–benefit analysis and adherence to diagnostic reference levels (DRLs). The national DRL (250 Gy·cm2) is only determined for intracranial aneurysm coiling in general, including ruptured intracranial aneurysms (RIAs). This study aims to investigate the dose in the treatment of UIAs and RIAs separately.MethodsIn a retrospective study design, dose area product (DAP) and fluoroscopy time (FT) were assessed for all patients undergoing intracranial aneurysm coiling between 2010 and 2021. DRL was set as the 75th percentile of the dose distribution. A multivariable linear regression analysis was performed to investigate DAP and FT for the two groups, UIA and RIA adjusted for patient age, aneurysm size, and location.Results583 (414 females, mean age 56.5 years, 311 UIAs) are included. In the overall population, DAP (median (IQR)) is 157 Gy·cm2 (108–217) with a median FT of 32.7 min (IQR 24.0–47.0). Local DRL is 183 Gy·cm2 for UIAs and 246 Gy·cm2 for RIAs. After adjustment for the other variables, the UIA and RIA groups have a significant effect on both DAP (p < 0.001; 95% CI − 68.432 – − 38.040) and FT (p < 0.001; 95% CI − 628.279 – − 291.254). In general, both DAP and FT increase significantly with patient age and aneurysm size, whereas the location of the aneurysm did not significantly change neither DAP (p = 0.171; 95% CI − 5.537–31.065) nor FT (p = 0.136; 95% CI − 357.391–48.508).ConclusionBoth aneurysm size and patient age were associated with increased DAP, whereas aneurysm location did not significantly change DAP or FT. The increased dose in patients with RIAs is likely equivalent to additional diagnostic cerebral four-vessel angiography performed in this group.

In Reply: Cost Comparison of Microsurgery vs Endovascular Treatment for Ruptured Intracranial Aneurysms: A Propensity-Adjusted Analysis.

To the Editor: We thank Dr Wang1 for providing a thoughtful critique of our article “Cost comparison of microsurgery vs endovascular treatment for ruptured intracranial aneurysms: a propensity-adjusted analysis.”2 Wang raises concerns that variables may potentially confound the results of our comparisons between the endovascular and microsurgical cohorts. First, Wang noted that the patients who received endovascular treatment were older than those who received microsurgical treatment and were thus at higher risk for complications associated with older age. However, there was no significant difference between the cohorts with respect to the number of complications (including deep vein thrombosis or pulmonary embolism, external ventricular drain placement, infection, vasospasm, and stroke). Second, Wang noted that the mean aneurysm size was greater in the endovascular cohort than in the microsurgical cohort. Greater aneurysm size is associated with a greater risk of recurrence, possibly necessitating multiple procedures and increased costs. However, the difference in mean aneurysm size, although statistically significant, was only 0.6 mm. Furthermore, endovascular treatment of small intracranial aneurysms tends to be more difficult (possibly involving perioperative complications, recurrence, and other challenges); therefore, more small aneurysms were treated surgically at our institutions during the study period, and this likely contributed to the larger mean aneurysm size found in the endovascular cohort.3 Third, Wang pointed out that the Hunt and Hess scores were lower and the aneurysm sizes were smaller among patients with follow-up cost data, possibly because patients with good outcomes have greater enthusiasm for and adherence to follow-up. Although this and the aforementioned concerns may have merit, a propensity score adjustment was performed to mitigate baseline differences between the cohorts. Propensity score adjustment was performed for age; sex; comorbidities; Glasgow Coma Scale score; Hunt and Hess grade; Fischer grade; aneurysm size, type, and location; and follow-up duration. Because of the observational, nonrandomized design of our study, we cannot exclude the possibility of unmeasured differences in the cohort contributing to confounding biases. However, the propensity score–adjusted analysis theoretically controlled for these potentially confounding factors. Finally, we agree that the costs of endovascular treatment are expected to continue to decrease. This trend will hopefully mitigate the differences in cost between endovascular coiling and microsurgical clipping for aneurysmal subarachnoid hemorrhage.

Flow Diverter Devices in the Treatment of Anterior Communicating Artery Region Aneurysms: Would the Regional Anatomy and the Aneurysm Location Affect the Outcomes?

In this study, the authors evaluated the efficacy and the safety of flow diverter devices (FDD) in anterior communicating artery (ACoA) region aneurysms, focusing on anatomical factors that could affect the outcome, such as the location of the aneurysm along the ACoA (centered on ACoA or decentered on the A1-A2 junction) and the anatomy of the ACoA region. Clinical, procedural and follow-up data were analyzed. Aneurysms were classified according to the location along the ACoA (centered or decentered on the A1-A2 junction) and on the basis of the anatomical configuration of the ACoA region. Safety was assessed by recording intraprocedural, periprocedural and delayed complications to determine the morbidity and mortality rates. The functional outcome was evaluated with the modified Rankin scale (mRS) prior to and after the endovascular procedure. To assess the efficacy, midterm and long-term clinical, angiographic and cross-sectional imaging follow-ups were recorded. Subgroup analysis according to the different ACoA regional anatomical configurations and the ACoA aneurysm locations were performed. 33 patients (17 males; 16 females) with ACoA region aneurysms were treated with FDDs. 27 aneurysms were located at the A1-A2 junction (82%) while the remaining six aneurysms were centered on the ACoA. No mortality was recorded. The overall morbidity rate was 6% (2/33 procedures). Major complications occurred in 33% (2/6) of ACoA aneurysms and in the 0% of A1-A2 junction aneurysms. Mid-term and long-term neuroimaging follow-ups showed the occlusion of the aneurysm in 28/33 cases (85%). Complete occlusion rates were 93% in the A1-A2 junction aneurysms and 50% in ACoA aneurysms. The FDD is a safe and effective tool that can be used in the treatment of selected cases of ACoA region aneurysms. The location of the aneurysm along the ACoA and the regional anatomy of the ACoA complex could affect the efficacy and safety.

The Intersection Between the Oculomotor Nerve and the Internal Carotid Artery to Distinguish Extracavernous and Intracavernous Paraclinoid Aneurysms Using Anatomic Dissections-A New 3T Magnetic Resonance Imaging Protocol Confirmed by Three-Dimensionally Printed Biomodels.

To evaluate the relationship between the oculomotor nerve (CNIII) and the internal carotid artery (ICA) as a new anatomic-radiologic landmark for distinguishing the exact location of a paraclinoid intracranial aneurysm (IA). Microanatomic dissections were performed in 20 cavernous sinuses to evaluate the ICA paraclinoid region. Based on anatomic observations, a new magnetic resonance (MRI) protocol to classify paraclinoid aneurysms was proposed. MRI of 42 IAs from 34 patients was independently analyzed and classified as intracavernous, extracavernous, or transitional by 2 neuroradiologists. To validate the proposed MRI protocol, each IA was classified by a three-dimensionally (3D) printed biomodel and agreement with the radiologic classifications was evaluated. Of 42 IAs, 23 undergoing microsurgeries were also classified by direct visualization. We observed that the true cavernous sinus roof is defined by the carotid-oculomotor membrane, which has an intimate relationship with the intersection between the superior limit of the CNIII and the ICA. Based on this intersection, all 42 IAs were radiologically classified and agreement with the 3D printed biomodels was observed in 95% IAs. Concordance tests showed a statistically significant (P < 0.05) agreement between the classifications. All 23 IAs treated had the radiologic and 3D biomodel classification confirmed. The intersection between the ICA and the CNIII, which crosses it transversely in its entire diameter, is a reliable anatomic-radiologic landmark to correctly classify paraclinoid aneurysms. Through a new MRI protocol, it is possible to radiologically identify this intersection and to easily distinguish the intracavernous and extracavernous ICA paraclinoid aneurysms.

Evaluation of Radiation Dose according to Aneurysm Size and Location during Cerebral Aneurysm Coil Embolization

Evaluation of Radiation Dose according to Aneurysm Size and Location during Cerebral Aneurysm Coil Embolization

A 12-year experience of endovascular repair for ruptured abdominal aortic aneurysms in all patients

ObjectiveEndovascular aneurysm repair (EVAR) has been increasingly performed for ruptured abdominal aortic aneurysms (rAAAs). However, multiple randomized trials have failed to demonstrate a survival benefit compared with open aortic surgery. During a 12-year period, 100% of patients without a history of aneurysm surgery had undergone EVAR for a rAAA at Örebro University Hospital, with no emergent open aortic surgery performed. In the present study, we evaluated the mortality and technical success during this “EVAR-only” period. MethodsA single-center, retrospective observational study was conducted. We identified all patients who had presented to Örebro University Hospital with a rAAA between October 2009 and September 2021. Patients with isolated iliac artery, thoracic, and thoracoabdominal aortic ruptures were not included. Patients who had received previous aortic interventions (open or endovascular) and patients who had received palliative treatment instead of surgical intervention were also excluded. The patient characteristics, perioperative and postoperative data, and mortality rate were investigated. ResultsEVAR had been performed in 100 patients. Preoperative hemodynamic instability had been present in 54 patients (54%), and 18 (18%) had undergone aortic balloon occlusion. The aneurysm location was infrarenal in 89 patients (89%). Bifurcated stent grafts had been used in 97 patients (97%), and adjunct endovascular techniques had been used for 27 patients (27%). Of 98 patients, EVAR had been performed with the patient under local anesthesia for 62 patients (63%). Peri- and postoperative complications at 30 days had occurred in 20 of 100 patients (20%) and 22 of 79 patients (28%), respectively. The overall mortality at 30 days was 27% (27 of 100 patients), and the mortality for those with an isolated infrarenal rAAA was 24% (21 of 89 patients). The overall mortality at 1 year was 39% (39 of 100 patients) and for those with an isolated infrarenal rAAA was 37% (33 of 89 patients). The presence of preoperative hemodynamic instability and the use of ABO were statistically significantly and independently associated with increased 30-day mortality on multivariate logistic regression analysis. ConclusionsAll 100 patients who had undergone surgery for a rAAA had been treated using EVAR and endovascular adjuncts, with a relatively low mortality rate, thus continuing the “EVAR-only” approach. A low proportion of rAAA patients were considered surgically unsuitable. These findings support the applicability of EVAR for the treatment of all rAAAs at suitable centers.

Treatment of giant intracranial aneurysms: long-term outcomes in surgical versus endovascular management

Aneurysms with a major diameter > 25 mm are defined as giant intracranial aneurysms (GIAs). Different clinical, pathological, and radiological factors were revealed as playing a role in choosing the best strategy between surgical and endovascular approaches. Despite the improvement of both techniques, the efficacy and safety of these different management are still debated. We evaluated the differences in clinical and radiological outcomes of GIAs treated with surgical and endovascular techniques in a large retrospective mono-centric study. We compared aneurysm location, clinical, morphological features, treatment outcome, and complications on the ground of treatment technique. The final cohort consisted of 162 patients. All the patients were assigned on the ground of the type of eligible treatment: surgical (118 patients) and endovascular procedure (44 patients). The different treatment strategies were made through a multidisciplinary selection whereas clinical parameters, location, and morphologic features of the aneurysm were considered. The surgical group manifested a greater reduction in performance levels and neurological status in the post-operative phases than the endovascular group (p < 0.01) with a higher incidence of complications (p = 0.012) in contrast to a lower recurrence rate (p > 0.01). There is no significant difference in post-operative mortality and survival between surgical and endovascular groups. The surgical group manifested a higher incidence of complications after treatment. The endovascular group has a better post-operative outcome, but a higher risk of recurrence and the necessity of further treatment.

Treatment outcome of coil embolization for distal anterior cerebral artery aneurysms: A single-center experience

ObjectiveIn recent years, endovascular treatment has become the treatment of choice for distal anterior cerebral artery (DACA) aneurysms. In this study, we report the outcomes of coil embolization for DACA aneurysms. MethodsEighteen DACA aneurysms in 16 patients treated with endovascular treatment between January 2010 and December 2020 were included in this study. We retrospectively analyzed patient characteristics, data on aneurysms, the reason for the selection of endovascular treatment, treatment technique, and treatment outcomes. ResultsThere were 18 procedures in 16 patients. The average age was 65.7 years and 56% of patients were male. The average diameter of the dome was 5.5 mm, and the location of aneurysm was A3 in 83% and A4 in 17%. We mainly selected endovascular treatment for patients with a past history of craniotomy and head trauma, or with systemic comorbidities. The technical success rate was 94%, and adequate obliteration immediately after treatment was achieved in 72%. There were no symptomatic periprocedural complications. The retreatment rate was 11.1%. ConclusionCoil embolization for DACA aneurysms yielded good treatment outcomes. Endovascular treatment for DACA aneurysms will become more common with advances in endovascular devices and the establishment of stable perioperative antiplatelet therapy.

Devastating delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage.

BackgroundWe investigated the proportion of patients in an initial good clinical condition who developed devastating DCI, and aimed to characterize these patients by aneurysm location, blood pressure instability prior to DCI, and the extent of cerebral ischemia.MethodsWe included aSAH patients admitted between 2010 and 2021 with a Glasgow Coma Scale of 11 or higher 24 h after aneurysm treatment, who developed devastating DCI, defined as DCI leading to coma for at least 48 h with cerebral infarction on the subsequent scan. Blood pressure instability was defined as nimodipine-induced blood pressure drops, dosage adjustments, or the use of blood pressure drugs before onset of DCI. Descriptive statistics were used to summarize the data.ResultsOut of 1,211 consecutive aSAH patients, 617 patients had a good clinical condition after aneurysm treatment of whom 16 (3%) patients [14 (88%) women] were included in this study. Thirteen (81%) patients had an aneurysm in the anterior circulation. Thirteen patients (81%) had blood pressure instability: twelve (75%) had nimodipine-induced blood pressure drops, eleven (69%) received antihypertensive drugs, and 7 (44%) received hypertension induction before onset of DCI. Thirteen (81%) patients had bilateral ischemia, mainly in the anterior circulation (56%).ConclusionsThe proportion of aSAH patients with a good clinical condition after aneurysm treatment who develop devastating DCI is small. The vast majority of these patients had blood pressure instability. Future studies are needed to investigate if a reduction in the number and extent of blood pressure fluctuations decreases the incidence of devastating DCI.

Surgical treatment of distal cerebral aneurysms

Background. Distal cerebral aneurysms are very rare. To date, there are very few publications on distal cerebral aneurysms and they are mostly limited to clinical case series.Aim. To analyze anatomical characteristics of distal cerebral aneurysms and surgical outcomes, as well as to identify risk factors for a poor outcome and develop a treatment algorithm on this basis; to determine the role of neuronavigation and revascularization in the surgical treatment of distal cerebral aneurysms.Materials and methods. We performed a retrospective analysis of surgical outcomes of 153 patients with distal cerebral aneurysms treated in N.V. Sklifosovsky Research Institute for Emergency Medicine (Moscow Healthcare Department) between January 1, 2000 and December 31, 2019.Results. Distal cerebral aneurysms were identified in 4.5 % cases of all cerebral aneurysms; 81.7 % of patients with distal cerebral aneurysms were admitted to the hospital with ruptured aneurysms. The most frequent locations of distal cerebral aneurysms were pericallosal and middle cerebral arteries. Distal cerebral aneurysms were usually small (77.5 %), had a wide neck (31.8 %), and fusiform structure (15.7 %). Aneurysm clipping was performed in 74.5 % cases; parent artery trapping, in 23.5 % of patients; revascularization, in 5.9 % of patients. The main risk factors for a poor outcome included aneurysm size and location, patient grade on the modified scale of the World Federation of Neurosurgical Societies (mWFNS), and presence of severe vasospasm.Conclusion. The developed surgical algorithm for distal cerebral aneurysms (based on the assessment of a poor outcome risk factors, the use of neuronavigation, arterial patency control, and revascularization) could improve surgical outcomes of patients with distal cerebral aneurysms.

Transradial versus transfemoral access for embolization of intracranial aneurysms with the Woven EndoBridge device: a propensity score-matched study.

Transradial access (TRA) is commonly utilized in neurointerventional procedures. This study compared the technical and clinical outcomes of the use of TRA versus those of transfemoral access (TFA) for intracranial aneurysm embolization with the Woven EndoBridge (WEB) device. This is a secondary analysis of the Worldwide WEB Consortium, which comprises multicenter data related to adult patients with intracranial aneurysms who were managed with the WEB device. These aneurysms were categorized into two groups: those who were treated with TRA or TFA. Patient and aneurysm characteristics and technical and clinical outcomes were compared between groups. Propensity score matching (PSM) was used to match groups according to the following baseline characteristics: age, sex, subarachnoid hemorrhage, aneurysm location, bifurcation aneurysm, aneurysm with incorporated branch, neck width, aspect ratio, dome width, and elapsed time since the last follow-up imaging evaluation. This study included 682 intracranial aneurysms (median [interquartile range] age 61.3 [53.0-68.0] years), of which 561 were treated with TFA and 121 with TRA. PSM resulted in 65 matched pairs. After PSM, both groups had similar characteristics, angiographic and functional outcomes, and rates of retreatment, thromboembolic and hemorrhagic complications, and death. TFA was associated with longer procedure length (median 96.5 minutes vs 72.0 minutes, p = 0.006) and fluoroscopy time (28.2 minutes vs 24.8 minutes, p = 0.037) as compared with TRA. On the other hand, deployment issues were more common in those treated with TRA, but none resulted in permanent complications. TRA has comparable outcomes, with shorter procedure and fluoroscopy time, to TFA for aneurysm embolization with the WEB device.

A Predictive Model for Chronic Hydrocephalus After Clipping Aneurysmal Subarachnoid Hemorrhage.

Chronic hydrocephalus after clipping aneurysmal subarachnoid hemorrhage (aSAH) often results in poor outcomes. This study was to establish and validate model to predict chronic hydrocephalus after aSAH by least absolute shrinkage and selection operator logistic regression. The model was constructed from a retrospectively analyzed. Two hundred forty-eight patients of aSAH were analyzed retrospectively in our hospital from January 2019 to December 2021, and the patients were divided into chronic hydrocephalus (CH) group (n=55) and non-CH group (n=193) according to whether occurred CH within 3 months. In summary, 16 candidate risk factors related to chronic hydrocephalus after aSAH were analyzed. Univariate analysis was performed to judging the risk factors for CH. The least absolute shrinkage and selection operator regression was used to filter risk factors. Subsequently, the nomogram was designed by the above variables. And area under the curve and calibration chart were used to detect the discrimination and goodness of fit of the nomogram, respectively. Finally, decision curve analysis was constructed to assess the practicability of the risk of chronic hydrocephalus by calculating the net benefits. Univariate analysis showed that age (60y or older), aneurysm location, modified Fisher grade, Hunt-Hess grade, and the method for cerebrospinal fluid drainage, intracranial infections, and decompressive craniectomy were significantly related to CH ( P <0.05). Whereas 5 variables [age (60y or older), posterior aneurysm, modified Fisher grade, Hunt-Hess grade, decompression craniectomy] from 16 candidate factors were filtered by LASSO logistic regression for further research. Area under the curve of this model was 0.892 (95% confidence interval: 0.799-0.981), indicating a good discrimination ability. Meanwhile, the result of calibration indicated a good fitting between the prediction probability and the actual probability. Finally, decision curve analysis showed a good clinical efficacy. In summary, this model could conveniently predict the occurrence of chronic hydrocephalus after aSAH. Meanwhile, it could help physicians to develop personalized treatment and close follow-up for these patients.

Initial severity of aneurysmal subarachnoid hemorrhage (SAH): Trend over time.

The trend in the initial severity of aneurysmal subarachnoid hemorrhage (SAH) is unclear. This study aimed to evaluate whether there was an improvement in the initial severity of SAH over time. From January 1, 2005, to December 31, 2020, we identified patients who visited the emergency department of our institution with SAH due to intracranial aneurysm rupture. We identified the Hunt Hess (HH) grade and modified Fisher grade of each patient from the medical records, and the Mann-Kendal method was used to estimate the trend of each grade system. A total of 547 patients with SAH were identified. The mean age of the patients was 59.3 years (standard deviation (SD), 14.6). The mean aneurysm size was 6.9 mm (SD, 4.6 mm). The most frequent aneurysm location was the anterior communicating artery (28.7%). In the Mann-Kendal estimates for the analysis of the trend, there was no statistically significant grade throughout the HH and modified Fisher grades. Similarly, there was no improvement throughout all grades in the modified Fisher grade over time. The initial severity of SAH due to cerebral aneurysm rupture did not improve over time.

The impact of residual hematoma after evacuation on the outcomes of patients with ruptured intracranial aneurysms with intracerebral hematoma: A longitudinal single-center observational study.

Intracerebral hematoma (ICH) as a result of ruptured of intracranial aneurysms often arises in patients with subarachnoid hemorrhage. Few studies focused on risk factors for ICH and not the impact of residual hematoma after evacuation on the outcomes of the patients. Therefore, 2 questions need to be answered: does residual hematoma after evacuation have impact on the outcome of patients who present with ICH as a result of ruptured intracranial aneurysms? Is radical pursuit of the hematoma necessary? The study was a single-center longitudinal observational type. Data of 2044 consecutive patients with subarachnoid hemorrhage from January 2009 to December 2019 were reviewed. ICHs were established and the locations of aneurysms as well as hematoma volumes were measured by computed tomographic scan before aneurysm occlusion. Only patients who received aneurysm clipping were included. Patients were stratified into hematoma evacuation without residuals versus residual hematoma after evaluation groups, and outcome was assessed according to the modified Rankin Scale (mRS) at 6 months. Out of the 1365 patients who received clipping, 476 patients presented in poor grade, whereas 889 patients' good grade. Our mRS scores revealed that patients who attained hematoma evacuation without residuals in the good-grade category attained better functional outcome than those with residual hematoma after evacuation. Contrarily, our mRS scores did not establish any significant difference in outcome between the poor-grade patients with hematoma evacuation without residuals and patients with residual hematoma after evacuation. Furthermore, our logistic regression model showed that advance age, poor Hunt-Hess grade, and vascular injury due to surgery were contributing factors for poor outcome of patients with ICH. Our data suggested that aggressive hematoma evacuation may not benefit the poor-grade patients. Majority of poor outcomes were due to surgical complications which were vascular related as a result of excessive pursuit of ICH.

Factors predicting effective aneurysm early obliteration after flow re-direction endoluminal device placement for unruptured intracranial cerebral aneurysms

ObjectiveThere have been few reports of the outcomes of flow re-direction endoluminal device (FRED) treatment for unruptured cerebral aneurysms, and patient factors associated with effective aneurysm obliteration have yet to be determined. Flow diverters also have problems with delayed rupture. The objective of this study was to investigate associations between the cases of early obliteration of aneurysm after FRED treatment and a range of factors. MethodA retrospective analysis of 75 aneurysms in 72 patients whose response to treatment was evaluated by cerebral angiography 6 months after FRED treatment was conducted. The aneurysm obliteration rate was classified according to the O'Kelly-Marotta grading scale (OKM grade). The patients were classified into those assessed as OKM Grade A or Grade B with poor aneurysm obliteration (poor obliteration), and those assessed as Grade C or Grade D with good aneurysm obliteration (good obliteration). The parameters evaluated were age, sex, medical history, immediate postoperative eclipse sign, P2Y12 reaction units (PRU), aspirin reaction units (ARU), operating time, maximum aneurysm diameter measured on cerebral angiography, and aneurysm location. ResultsAt 6 months post-treatment, 19 aneurysms (25.3%) were OKM Grade A, 15 (20%) were Grade B, 10 (13.3%) were Grade C, and 31 (41.3%) were Grade D. Age ≥67.5 years was significantly associated with a poor obliteration [odds ratio (OR): 0.1; 95% confidence interval (95%CI): 0.2-0.4; p=0.002] and intracranial side wall aneurysm [OR: 21.7; 95%CI: 1.6–284.5; p=0.01]. ConclusionsThe results of this study demonstrated that age was associated with aneurysm obliteration after FRED treatment. This finding may be useful for further studies investigating factors predictive of the aneurysm obliteration rate and the residual aneurysm rate after FRED treatment.

Single Center Retrospective Analysis of Cerebral Aneurysms from a Patient Sample Data Collection at a Comprehensive Stroke Center

INTRODUCTION Institutional self-monitoring of cerebral aneurysm data should occur regularly. The objective of this retrospective single center study was to examine the reproducibility of a data collection and analytic method to examine cerebral aneurysm characteristics and trends. METHODS A single center retrospective analysis was performed from 2018 to 2021 of the most recent 100 patient presentations with a newly diagnosed cerebral aneurysm. Data collection included patient demographics, radiographic features, ruptured or unruptured status, location, grading scale, treatment strategy, survival, and length of stay, which were extracted and presented in tabular form and analyzed for overall trends. RESULTS Of the collected 100 patients meeting ICD-10 criteria, 10 (10%) patients were excluded due to having been previously diagnosed at the institution and not meeting the criteria of a new discovery of cerebral aneurysm for inclusion. The remaining 90 sample patients presented with newly diagnosed aneurysms to the authors’ Emergency Department between 2018 and 2021. Most patients were between the ages of 25 and 65 with 55 (61%) patients identifying themselves as female sex. Of the 90 eligible sample patients, 59 (66%) had aneurysms that were not ruptured. Eighty-eight (97.7%) patients had cerebral aneurysms that were &lt; 7mm in size. The most common location for aneurysms was in the anterior cerebral circulation, with identification of 27 middle cerebral artery aneurysms. Length of stay (LOS) ranged from 0-171 days with a mean of 11.97 days (SD = 19.9). Of the seven (7.7%) patients who expired, four (57%) experienced spontaneous subarachnoid hemorrhages, with two (29%) occurring in the anterior communicating artery and one (14%) in the left middle cerebral artery and basilar artery respectively. CONCLUSIONS The typical presentation of a cerebral aneurysm is unruptured with a pre-dominance in middle-aged females. Our findings are congruent with the literature regarding the location of the aneurysm originating in the anterior circulation. However, most aneurysms in our clinical cohort were located on the MCA/ICA in contrast to the literature reported (i.e., most anterior communicating artery). Of those patients who presented unruptured, outpatient follow-up and routine monitoring were appropriate with medical management in the setting of small aneurysms. The risk of progression and subsequent rupture was relatively small in this patient cohort. Multi-year examinations of single institution comprehensive stroke centers regarding cerebral aneurysms would enable researchers to conduct regional analyses and comparisons to national and international trends.