Middle Cerebral Artery Aneurysm Research Articles

A Case of Brachial Artery Infected Aneurysm Secondary to Infective Endocarditis from Intramuscular Steroid Use

Infected aneurysms are a subset of aneurysms associated with infection. Approximately 10% of infected aneurysms involve the upper extremity. Infected aneurysms present a management challenge as patients are often unwell with concomitant infective endocarditis or septicemia. We present a case of a brachial artery infected aneurysm secondary to mitral valve infective endocarditis likely due to intramuscular anabolic steroid use. A 52-year-old male presented with a 24-h history of lethargy, blurred vision, and ataxia. He had a background history of intramuscular anabolic steroid use for the past 5 years. Swelling of his left arm localized to his cubital fossa was noted. Blood cultures were positive for Cardiobacterium hominis. Transthoracic echocardiography demonstrated a large vegetation on the mitral valve. Magnetic resonance imaging angiography demonstrated a right middle cerebral artery aneurysm. Computed tomography angiography of the left arm demonstrated an abrupt filling defect of the distal 2 cm of the brachial artery, with surrounding fat stranding and aneurysmal degeneration of the artery. Following successful aneurysm coiling, the patient underwent excision and debridement of the infected aneurysm. Histopathology was consistent with infected thromboembolism with aneurysmal degeneration of the artery. The patient underwent mitral valve replacement 10 days later. The brachial artery is the most common site of upper extremity infected aneurysms. Open surgical resection of the infected tissue is accepted as the gold standard. The rich collateral supply of the upper extremity permits ligation and debridement without needing simultaneous revascularization. We present this case to draw attention to an interesting manifestation of a rare pathology.

Intracranial stents in the management of wide-neck intracranial aneurysms

Intracranial aneurysms are bulges in vessels that are prone to rupture with attendant morbidity and mortality. Early detection and treatment can avoid rupture and its associated consequences. Endovascular treatment of aneurysms with wide neck can be challenging due to potential coil migration or protrusion. The use of intracranial stents and balloons can help overcome some of these management challenges. We present 3 cases of endovascular treatment of wide-neck intracranial aneurysms. The first patient presented with a wide-neck left middle cerebral artery aneurysm that was successfully treated with stent-assisted coiling with complete obliteration of the aneurysmal sac. The second patient presented with a large, cavernous internal carotid artery aneurysm that was successfully treated with a flow diverter stent with complete obliteration of the aneurysm while the third case presented with a wide-neck left posterior communicating artery aneurysm and was also successfully treated with stent-assisted coiling. Even though endovascular treatment of wide-neck intracranial aneurysms is technically challenging, the evolution of new treatment techniques such as the use of stents and stent-assisted coiling make these treatments safe.

Endovascular management of middle cerebral artery aneurysms (single-center case series study)

BackgroundMiddle cerebral artery (MCA) aneurysms were usually subjected to treatment by surgery, while endovascular treatment (EVT) was performed only in chosen patients. We assessed the efficacy, safety, and durability in addition to the clinical outcome of EVT when it is regarded as the first-line treatment modality for MCA aneurysms.ResultsWe recruited 30 patients with MCA aneurysms who underwent definitive management from July 2017 to July 2018. All those patients were treated endovascularly; 22 patients (73.3%) presented with subarachnoid hemorrhage, and 8 patients (26.7%) had different presentations, including isolated headaches and seizures. EVT was performed for all patients and required the use of a balloon, stent, or double catheter techniques in 13 cases and flow diverter stents alone in two cases. Clinical outcome was assessed by the modified Rankin Scale (mRS) at 3 months. Angiographic follow-up was done by a conventional angiography at 6 months and after 1 year. EVT was efficiently conducted, leading to an outstanding accomplishment (mRS = 1–2) in 29 patients. However, one patient had a thromboembolic complication, followed by death after severe chest infection that was not related to the procedure. Immediate anatomical results included complete aneurysmal occlusion with the establishment of normal cerebral circulation. Angiographic follow-up revealed 24 unchanged occlusions and 5 cases with recanalization that required further treatment.ConclusionEVT of MCA aneurysms is a viable treatment option with positive outcomes in most cases. Nevertheless, the employment of long-term imaging follow-up is compulsory for validating such early results, often with respect to anatomical and functional stability.

The Effects of Temporary Clipping as an Expression of Circulatory Individuality: Online Measurement of Temporal Lobe Oxygen Levels During Surgery for Middle Cerebral Artery Aneurysms

Despite its widespread use, much is left to understand about the repercussions of parent artery temporary clipping in neurosurgery. This study seeks a better comprehension of the subject by aiming at the online measurement of brain tissue oxygen pressure (PbtO2) during such events. This was a prospective observational study. Patients submitted to surgery for middle cerebral artery aneurysms (both ruptured and unruptured) were continuously monitored under Intensive Care Monitoring+ software, in order to obtain temporal (downstream) PbtO2 levels while temporary clips were applied. Separate PbtO2 curve events were identified, extracted, and processed. These were studied for assessing intraindividual and interindividual variability and the potential impact of repeated clipping and previous aneurysmal rupture. Eighty-six temporary clippings (from 20 patients) were recorded with a mean duration of 140.8 (41- 238) seconds. Temporary arterial occlusion at the M1 segment of the middle cerebral artery produced specifically shaped trajectories, characterized by a preclipping PbtO2 level, rapid downward sigmoid-shaped curve, succession of progressively angled slopes, and lower plateau. The steepest slope of the curve correlated strongly with PbtO2 range (P < 0.001, r= 0.944). These features were highly reproducible only intraindividually and did not vary significantly with repeated clippings. The effects of temporary arterial occlusion on temporal lobe oxygenation demonstrate a high degree of singularity, highlighting the potential benefits of assessing individual available collateral circulation intraoperatively. The "PbtO2 steepest slope" predicted the severity of PbtO2 decrease and was available within the first minute.

Third Nerve Palsy Due to Intracranial Aneurysms and Recovery after Endovascular Coiling.

The modality of treatment of third nerve palsy (TNP) associated with intracranial aneurysms remains controversial. While treatment varies with the location of the aneurysm, microsurgical clipping of PComm aneurysms has generally been the traditional choice, with endovascular coiling emerging as a reasonable alternative. Patients with TNP due to an intracranial aneurysm who subsequently underwent treatment at a mid-sized Canadian neurosurgical center over a 15-year period (2003-2018) were examined. A total of 616 intracranial aneurysms in 538 patients were treated; the majority underwent endovascular coiling with only 24 patients treated with surgical clipping. Only 37 patients (6.9%) presented with either a partial or complete TNP and underwent endovascular embolization; of these, 17 presented with a SAH secondary to intracranial aneurysm rupture. Aneurysms associated with TNP included PComm (64.9%), terminal ICA (29.7%), proximal MCA (2.7%), and basilar tip (2.7%) aneurysms. In general, smaller aneurysms and earlier treatment were provided for patients for ruptured aneurysms with a shorter mean interval to TNP recovery. In the endovascularly treated cohort initially presenting with TNP, seven presented with a complete TNP and the remaining were partial TNPs. TNP resolved completely in 20 patients (55.1%) and partially in 10 patients (27.0%). Neither time to coiling nor SAH at presentation were significantly associated with the recovery status of TNP. Endovascular coil embolization is a viable treatment modality for patients presenting with an associated cranial nerve palsy.

The stent-assisted coil-jailing technique for very small intracranial aneurysm treatment

The stent-assisted coil-jailing technique was initially introduced as an effective and secure method in the treatment of large wide-necked intracranial aneurysms. Later on, this technique has proved its efficiency in the safety and optimal treatment of very small aneurysms. In this article, we will present the successful treatment of a very small middle cerebral artery aneurysm using the stent-assisted coil-jailing technique and review the current trends in this type of treatment.

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.

Microsurgical treatment of distal aneurysms of the middle cerebral artery

The study objective is to investigate the features of distal aneurysms of the middle cerebral artery and to evaluate the results of their surgical treatment.Materials and methods. From 01/01/2000 to 12/31/2019 at the N.V. Sklifosovsky Research Institute of Emergency Medicine, 37 patients with distal SMA aneurysms were operated (21 women, 16 men, the average age of 48 y. o). SMA aneurysms were classified by their localization according to the classification of H. Gibo. The aneurysms of the M2 segment of the MCA were encountered more often (56.8 %). 28 aneurysms had a saccular structure, 9 (24.3 %) had a fusiform. The size of the saccular aneurysms ranged from 1.4 to 34.0 mm. More than 65 % of patients had aneurysms of 7 mm or less.Results. The surgical access was selected depending on the location of the MCA aneurysm. The pterional transsylvian access is used more often, less often - with aneurysms of the M4-segment, convexital trepanation. The reconstructive clipping of the distal SMA aneurysm was performed in 22 (59.4 %) cases, trapping and/or excision in 15 (40.5 %) cases. After the deconstructive intervention, revascularization was performed on 6 (16 %) patients.Conclusion. Distal aneurysms of the middle cerebral artery are a rare pathology that requires an individual approach -contact Doppler ultrasound or intraoperative angiography, intraoperative neuromonitoring, as well as, if necessary, the use of revascularization methods. To optimize surgical access, it is preferable to use neuronavigation.

脳内血腫・脳血管攣縮を伴う破裂左中大脳動脈脳動脈瘤の1 例

脳内血腫・脳血管攣縮を伴う破裂左中大脳動脈脳動脈瘤の1 例

The Silk Vista Baby - The UK experience.

The Silk Vista Baby (SVB) flow diverter (FDS) is the only FDS deliverable via a 0.017 inch microcatheter and is specifically designed for the distal vasculature. We sought to evaluate the safety and efficacy of the SVB. We performed a retrospective review to identify SVB cases at 4 tertiary neurosurgical centres within the U.K. Clinical, procedural, angiographic and follow-up data were collected. We identified 60 patients (35 female, 58%) of average age 54 ± 10.5 (range 30-72) with 61 aneurysms, 50 (81.9%) located in the anterior circulation. The majority of the aneurysms treated were unruptured (46, 75.4%) and saccular (46, 75.4%). Dome size was 6.2 ± 6.2 mm (range 1-36mm) and parent vessel diameter was 2.3 ± 0.4 mm (range 1.2-3.3 mm).An average number of 1.07 devices were implanted. Coils or other devices were implanted in 14 aneurysms (23.3%). At last angiographic follow-up (n = 55), 7.5 ± 4.2 months post-procedure, 32 aneurysms (57.1%) were graded as RRC I, 7 (12.5%) RRC II, and 17 RRC III (30.4%).Clinical complications, excluding death, were seen in 4 patients (6.8%) including 1 delayed aneurysm rupture and 3 symptomatic ischaemic events. Only one patient had permanent morbidity (mRS 1). 3 patients died during follow-up (5.1%); 2 deaths were related to the aneurysms (3.4%) - one ruptured dissecting MCA aneurysm, and one giant partially thrombosed posterior circulation aneurysm. 93% of patients were mRS ≤ 2 at last follow-up. The SVB has high rates of technical success and an acceptable safety profile. Distal aneurysms may occlude slower due to relative oversizing of the devices.

The Value of C-Reactive Protein as a Predictor of Vasospasm and Poor Outcome in Spontaneous Subarachnoid Hemorrhage

Abstract Background: Rupture of an intracranial aneurysm carries a high risk of disability or death. Cerebral vasospasm remains the most troublesome complication of acute Subarachinoid-haemorraghe (SAH). Activation of the systemic immune response, manifested by increased levels of circulating cy-tokines, is believed to have a significant role in the pathogenesis of cerebrovascular vasospasm. Aim of Study: The aim of this study is to correlatebetween level of CRP and incidence of vasospasm in spontaneous S.A.H, and being an independent predictor for prognosis. Patients and Methods: Cross sectional study with stratified random sample of 30 patients who admitted in Intensive Care Unit, Neurosurgery Department, Emergency and Trauma Unit at Kasr Al-Ainy, Cairo University Hospitals, from September 2018 till April 2019 diagnosed with spontaneous Subarachnoid hemorrhage and screened for CRP. Results: Out of the 30 included in the study 10 patients (33.3%) diagnosed to have anterior communicating artery aneurysm; 2 patients (6.7%) have basilar tip aneurysm, 2 patients (6.7%) have posterior communicating artery aneurysm, 2 patients (6.7%) have posterior cerebral aneurysm, and 1 patient (1.9%) have middle cerebral artery aneurysm, 2 patient have AVM, 11 patient have no underlying pathology in the conventional 4 vessels angiography. Overall age ranged from 21 years to 80 years with a mean age 53.19 patients (63.3%) were males and 11 patients (36.7%) were females. Out from 30 patients, 14 patients (46.7%) had vasospasm, and 16 (53.3%) patients didn't have vasospasm, out of 14 patients who developed vasospasm, 13 patients (92%) initially had high serum CRP level above 50mg/L, and all patient who had rising CRP level (double to triple folds) had poor outcome. Conclusion: Vasospasm is a serious event complicating spontaneous aneurysmal subarachnoid hemorrhage, it could be diagnosed clinically or radiologically, serum CRP level is an indicator of cerebral vasospasm following aneurysmal subarachnoid hemorrhage and rising serum CRP level is an independent predictor for poor outcome.

Pipeline embolization of proximal middle cerebral artery aneurysms: A multicenter cohort study.

Flow diversion of aneurysms located in the M1 segment and middle cerebral artery bifurcation with Pipeline embolization device is sometimes performed, but further study is needed to support its regular use in aneurysm treatment. Here, we report measures of safety and efficacy for Pipeline embolization in the proximal middle cerebral artery in a multi-center cohort. Clinical and angiographic data of eligible patients were retrospectively obtained from participating centers and assessed for key clinical and angiographic outcomes. Additional details were extracted for patients with complications. In our multi-center cohort, complete aneurysm occlusion was achieved in 71% (17/24) of treated aneurysms. There were no deaths or disabling strokes, but non-disabling ischemic strokes occurred in 8% (2/24) of patients. For aneurysms in the M1 segment, complete aneurysm occlusion was observed in 75% (12/16) of aneurysms, aneurysm volume reduction was observed in 100% (16/16) of aneurysms, and non-disabling ischemic strokes occurred in 13% (2/16) of patients. For aneurysms at the middle cerebral artery bifurcation, complete aneurysm occlusion was observed in 63% (5/8) of aneurysms, aneurysm volume reduction occurred in 88% (7/8) of aneurysms, and ischemic or hemorrhagic complications occurred in 0% (0/8) of patients. Pipeline embolization of cerebral aneurysms in the M1 segment and middle cerebral artery bifurcation demonstrated a 71% rate of complete aneurysm occlusion. There were no deaths or disabling strokes, but there was an 8% rate of non-disabling ischemic strokes.

Incidence of Neo-Intimal Hyperplasia in Anterior Circulation Aneurysms Following Pipeline Flow Diversion

IntroductionFlow diversion of the distal anterior circulation cerebral vasculature may be used for management of wide necked aneurysms not amenable to other endovascular approaches. Follow-up angiography sometimes demonstrates neo-intimal hyperplasia within or adjacent to the stent, however there is limited evidence in the literature examining the incidence in MCA and ACA aneurysms. We present our experience with flow diversion of the distal vasculature and evaluate the incidence of neo-intimal hyperplasia. Materials and methodsRetrospective review of patients who underwent Pipeline embolization device (PED) treatment for ruptured and unruptured anterior circulation aneurysms. ResultsA total of 251 anterior circulation aneurysms were treated by pipeline flow diversion, of which 175 were ICA aneurysms, 14 were ACA aneurysms and 18 were MCA aneurysms. 6-month follow-up angiography was available in 207 patients. The incidence of neo-intimal hyperplasia was 15.9%, 21.4%, and 61.1% in ICA, ACA, and MCA aneurysms, respectively. MCA-territory aneurysms developed neo-intimal hyperplasia at a significantly higher rate than aneurysms in other vessel territories. Rates of aneurysmal occlusion did not significantly differ from those patients who did not exhibit intimal hyperplasia on follow-up angiography. ConclusionIn our experience, flow diversion of distal wide-necked MCA and ACA aneurysms is a safe and effective treatment strategy. The presence of neo-intimal hyperplasia at 6-month angiography is typically clinically asymptomatic. Given the statistically higher rate of neo-intimal hyperplasia in MCA aneurysms at 6-month angiography, we propose delaying initial follow-up angiography to 12-months and maintaining dual antiplatelet therapy during that time.

Stroke due to middle cerebral artery aneurysm clipping when the intraoperative angiogram was normal

ObjectiveAn intraoperative angiogram (IOA) may be used to check the clipping of middle cerebral artery (MCA) aneurysms. This study analyzes the occurrence of a stroke when the IOA was normal as this has not been looked into before. MethodsThe records of all patients with a normal IOA after MCA aneurysm clipping were reviewed. Patients who woke up with a stroke were selected for this study and analyzed in detail. ResultsThirty-one patients with 34 aneurysms had a normal IOA. Of those, 7 woke up with a new deficit from perforator or small artery ischemia resulting in a stroke rate of 22.6%. Five out of the 7 strokes were potentially avoidable. ConclusionAn IOA is still an important tool to check the adequacy of clip placement. However, our experience has taught us that the intent to use it should not lessen the amount of time spent dissecting and exposing the aneurysm as completely as possible. The urge to clip the neck and hope that the IOA will be favorable, when the aneurysm is not maximally exposed, should be resisted. Ideally, a full 360 degrees dissection of the aneurysm should be done to identify perforators and small arteries en passage before clipping. If this had been done, it is likely that the stroke rate would have dropped towards 6.5%.

A nomogram to predict rupture risk of middle cerebral artery aneurysm.

Determining the rupture risk of unruptured intracranial aneurysm is crucial for treatment strategy. The purpose of this study was to predict the rupture risk of middle cerebral artery (MCA) aneurysms using a machine learning technique. We retrospectively reviewed 403 MCA aneurysms and randomly partitioned them into the training and testing datasets with a ratio of 8:2. A generalized linear model with logit link was developed using training dataset to predict the aneurysm rupture risk based on the clinical variables and morphological features manually measured from computed tomography angiography. To facilitate the clinical application, we further constructed an easy-to-use nomogram based on the developed model. Ruptured MCA aneurysm had larger aneurysm size, aneurysm height, perpendicular height, aspect ratio, size ratio, bottleneck factor, and height-width ratio. Presence of a daughter-sac was more common in ruptured than in unruptured MCA aneurysms. Six features, including aneurysm multiplicity, lobulations, size ratio, bottleneck factor, height-width ratio, and aneurysm angle, were adopted in the model after feature selection. The model achieved a relatively good performance with areas under the receiver operating characteristic curves of 0.77 in the training dataset and 0.76 in the testing dataset. The nomogram provided a visual interpretation of our model, and the rupture risk probability of MCA aneurysms can be directly read from it. Our model can be used to predict the rupture risk of MCA aneurysm.

Placement of interlocking fenestrated clips for a large broad-based middle cerebral artery aneurysm with atherosclerosis: Technical case report

IntroductionClip ligation of a large or giant middle cerebral artery (MCA) aneurysm is sometimes challenging, since these aneurysms commonly involve the efferent arteries and often show atherosclerotic changes in the aneurysm wall. We present herein a surgical case of large MCA aneurysm with atherosclerosis, and demonstrate a technique that enables adjustment of the patency of efferent arteries and the dog-eared remnant of the complex bifurcation aneurysm by placement of interlocking fenestrated clips. Case illustrationA 63-year-old woman was referred to our hospital for treatment of a relatively large unruptured left MCA saccular aneurysm (dome height × neck width: 9.5 mm × 7.6 mm). She underwent microsurgical clip ligation of the aneurysm. Due to the atherosclerotic changes in the aneurysm neck and efferent arteries, a large amount of dog-eared remnant of the aneurysm neck or clip slippage was likely to occur following single clip ligation. The interlocking clip application technique was thus considered using fenestrated clips with high closure force at the tips, resulting in successful aneurysm obliteration without complicated replacement of the clips. ConclusionAlthough complex clip application techniques for large MCA aneurysms with atherosclerosis have been reported, the present technique could provide an alternative.

External Carotid Artery-to-Middle Cerebral Artery Bypass Using a Saphenous Vein Graft With 3-Vessel Anastomosis for the Treatment of a Large, Ruptured Middle Cerebral Artery Aneurysm: 2-Dimensional Operative Video.

Cerebral revascularization is the treatment of choice for select complex intracranial aneurysms unamenable to traditional approaches.1 Complex middle cerebral artery (MCA) bifurcation aneurysms can include the origins of 1 or both M2 branches and may benefit from a revascularization strategy.2,3 A novel 3-vessel anastomosis technique combining side-to-side and end-to-side anastomoses, allowing for bihemispheric anterior cerebral artery revascularization, was recently reported.4 This 2-dimensional operative video presents the case of a 73-yr-old woman who presented as a Hunt-Hess grade 4 subarachnoid hemorrhage due to the rupture of a large right MCA bifurcation aneurysm. The aneurysm incorporated the origins of the frontal and temporal M2 branches and was deemed unfavorable for endovascular treatment. A strategy using a high-flow bypass from the external carotid artery to the MCA with a saphenous vein (SV) graft was planned to revascularize both M2 branches simultaneously, followed by clip-trapping of the aneurysm. Intraoperatively, the back walls of both M2 segments distal to the aneurysm were connected with a standard running suture, and the SV graft was then attached to the side-to-side construct in an end-to-side fashion. Catheter angiograms on postoperative days 1 and 6 demonstrated sustained patency of the anastomosis and good filling through the bypass. The patient's clinical course was complicated by vasospasm-related right MCA territory strokes, resulting in left-sided weakness, which significantly improved upon 3-mo follow-up with no new ischemia. The patient consented for inclusion in a prospective Institutional Review Board (IRB)-approved database from which this IRB-approved retrospective report was created.

Relationship of the vascular territory affected by delayed cerebral ischemia and the location of the ruptured aneurysm in patients with aneurysmal subarachnoid hemorrhage

ObjectiveTo determine the area most at risk of delayed cerebral ischemia (DCI) in relation to the location of the ruptured aneurysm in patients with aneurysmal subarachnoid hemorrhage (aSAH) and, therefore, help to choose the site for focal multimodal neuromonitoring.MethodsWe retrospectively analyzed angiographic findings, CCT scans, and patient charts of patients who were admitted with aSAH to our neurosurgical intensive care unit between 2009 and 2017. DCI was defined as infarction on CCT 2–6 weeks after aSAH.ResultsDCI occurred in 17.9% out of 357 included patients. A DCI occurring in the vascular territory of the artery carrying the ruptured aneurysm was found in 81.0% of patients with anterior circulation aneurysms but only in 16.7% with posterior circulation aneurysms (Fisher’s exact, p=0.003). The vascular territory most frequently showing a DCI was the ipsilateral MCA territory (86.7%) in ICA aneurysms, the contra- (71.4%) and the ipsilateral (64.3%) ACA territory in ACA aneurysms, the right (93.8%) and the left (81.3%) ACA territory in AcomA aneurysms, and the ipsilateral MCA territory in MCA aneurysms (69.2%) as well as in VA/PICA/SCA aneurysms (100.0%). DCI after the rupture of a BA aneurysm occurred with 33.3% in 6 out of 8 vascular territories, respectively. DCI of multiple vascular territories occurred in 100.0% of BA aneurysms, 87.5% of AcomA aneurysms, 71.4% of ACA aneurysms, 40.0% of ICA aneurysms, 38.5% of MCA aneurysms, and 33.3% of VA/PICA/SCA aneurysms.DiscussionFew studies exist that could determine the area most at risk of a DCI after an aSAH. Our data could identify the territory most at risk for DCI with a probability of > 60% except for BA aneurysms, which showed DCI in various areas and patients suffering from multiple DCIs. Either the ipsilateral ACA or MCA were affected by the DCI in about 80% of ACA and more than 90% of AcomA, ICA, MCA, and VA/PICA/SCA aneurysms. Therefore, local intraparenchymal neuromonitoring in the ACA/MCA watershed area might detect the vast majority of DCIs for all aneurysm locations, except for BA aneurysms. In ACA and AcomA aneurysms, bilateral DCI of the ACA territory was common, and bilateral probe positioning might be considered for monitoring high-risk patients. Non-focal monitoring methods might be preferably used after BA aneurysm rupture.

Brain ischemia due to direct vascular compression associate with rapid enlargement of unruptured middle cerebral artery aneurysm: A case report

Background: Acute cerebral infarction is a rare complication resulting from an unruptured cerebral aneurysm (UCA). There is presently no consensus on the optimal strategy for the management of UCAs with cerebral infarctions.Case Description: A 53-year-old man presented with transient dysarthria and left hemiparesis. Magnetic resonance imaging (MRI) demonstrated the presence of a 7 mm UCA originating from the middle cerebral artery bifurcation, and diffusion-weighted imaging showed no evidence of cerebral infarction. One month later, his transient left hemiparesis recurred, and the patient was admitted to our hospital. Computed tomography angiography showed enlargement of the aneurysm. His left hemiparesis worsened 3 days later. MRI showed cerebral infarction in the area of perforating arteries and further enlargement of the aneurysm with surrounding parenchymal edema. Therefore, the rupture risk was considered to be rarely high and dome clipping was performed immediately. Postoperatively, his neurological status improved without any recurrent brain ischemia.Conclusion: We report a rare case of a rapidly enlarging aneurysm that presented with cerebral infarction. This is the first report describing aneurysmal sac enlargement that can lead to perforating artery obstruction and brain ischemia. The case illustrates the importance of performing close follow-up examinations to confirm findings that suggest a high rupture risk.

Management of intracranial aneurysms in France: Place of microsurgery and demography of vascular neurosurgeons

Study designObservational retrospective survey-based study. IntroductionIntracranial aneurysms (IA) can be treated with microsurgery or by endovascular treatments (EVT). EVT have taken an increasingly important part in IA management; the ability of neurosurgical teams to perform such surgery as well as the quality of their training is being questioned. We therefore wanted to assess the proportion of IA treated by microsurgery in France, the demography and caseload of surgeons trained in vascular neurosurgery. MethodologyA 60-question survey was sent to the 34 French neurosurgical centers treating IA. Twenty-seven questions dealt with the demography of neurovascular surgeons and caseload. Descriptive data are reported here. ResultsTwenty-seven centers answered, giving us a response rate of 79.4%. A total of 209 neurosurgeons worked in these centers. Forty-six neurosurgeons were designated as referents in vascular neurosurgery, 47% of them were under 45 years old. Among the centers, 96.3% had at least one surgeon that was a referent in neurovascular surgery. A total of 88 surgeons performed IA surgery, but only 11 operated more than 20 IA per year. Two thousand four hundred and thirty seven unruptured IA were treated every year in these centers, 25% of which by microsurgery. A total of 2727 ruptured IA were treated in these centers, of which 15% were treated by microsurgery. The most common indications for microsurgical treatment of IA were: middle cerebral artery aneurysms, wide-neck intracranial aneurysms, and giant intracranial aneurysms, as well as aneurysms associated with a hematoma for the ruptured ones. ConclusionDemography of vascular neurosurgeons remains favorable, with a referent neurosurgeon in most centers, who, in half of the cases, is a young practitioner. The percentage of microsurgery in the treatment of IA is low, especially for ruptured ones. The most frequently operated types of intracranial aneurysm correspond to good practice recommendations.