Multiple Intracranial Aneurysms Research Articles

There is poor agreement between the subjective and quantitative adjudication of aneurysm wall enhancement.

The determination of Aneurysm wall enhancement (AWE) by human readers on visual inspection alone is subjective and prone to error. A three-dimensional (3D) method for quantifying the aneurysm wall's signal intensity (SI) enables objective determination of AWE. Inter-reader agreement and agreement between subjective and objective determination of AWE were assessed in this study. Patients with saccular intracranial aneurysms (IAs) were imaged with high-resolution MRI. Subjective assessment: Two internal adjudicators visually determined AWE if the degree of enhancement was equal to or higher than the pituitary stalk. An experienced internal neuroradiologist resolved disagreements. This internal adjudication was compared with an external adjudication to assess inter-rater agreement among centers. Objective assessment: The distribution of SI across the aneurysm wall after normalizing the SI to the corpus callosum was determined with an in-house code. The normalized mean SI on post-contrast T1 MRI was defined as 3D-circumferential AWE (3D-CAWE). If the 3D-CAWE value was higher than one, an IA was defined as objectively "enhancing." Inter-rater agreement was analyzed with kappa coefficients. Inter-technique agreement between subjective and objective assessment was performed using kappa statistics. Univariate regressions were performed to identify which morphological characteristics influenced subjective adjudication of enhancement. A total of 113 IAs were analyzed. The agreement of the internal assessment was moderate (k = 0.63), 49.5% of IAs (56) were classified as "enhancing" and 50.5% (57) as "non-enhancing" after consensus. Inter-rater agreement between internal and external adjudication was weak (k = 0.52) for the presence of AWE. There was no agreement between the subjective assessment of AWE and objective 3D-CAWE (k = 0.16, p 0.02). Subjective assessment was less likely to reliably adjudicate enhancement when assessing multiple aneurysms (OR 0.4, 95% CI 0.16 -0.97, p 0.04) and IAs larger than > 7 mm (OR 0.22, 95% CI 0.09 -0.55, p 0.002) despite being objectively "non-enhancing". Subjective adjudication of AWE has poor inter-rater agreement, and no agreement with an objective 3D method of determining AWE. It is also less likely than objective quantification to identify enhancement in aneurysms larger than 7 mm or when multiple aneurysms are present. Objective 3D quantification, such as the technique used in this study, should therefore be considered when assessing AWE, especially in patients with multiple aneurysms and aneurysms larger than 7 mm in size. 3D, three-dimensional; 3D-CAWE, three-dimensional circumferential aneurysm wall enhancement; AWE, aneurysm wall enhancement; Gd, gadolinium; HR-MRI, high resolution MRI; HR 3D T1 VWI, high-resolution 3D T1 weighted black blood vessel wall imaging; IA, intracranial aneurysm; SI, signal intensity.

Myxomatous cause of multiple intracranial aneurysms and cognitive decline: a case report

BackgroundThe occurrence of cerebral aneurysm in a case of cardiac myxoma is rare with less than 60 cases reported worldwide. The course of management is still debatable given its rarity. We present a case of multiple intracranial aneurysms secondary to atrial myxoma in a young lady with a brief review of the literature.Case presentationA young lady in her late 30s with a history of right middle cerebral artery territory stroke eight years ago presented with gradually progressive symptoms in the form of holocranial headache, inattention and forgetfulness for the last few years. On neuroimaging, she was found to have multi-territorial lacunar infarcts and multiple intracranial artery aneurysms which was confirmed with a digital subtraction angiogram. A cardiac evaluation revealed a left atrial myxoma. The aetiology of subcortical cognitive decline and intracranial aneurysms was attributed to the myxoma with secondary myxomatous embolism. Other secondary causes were ruled out. She is being followed up medically after resection of the myxoma.ConclusionIntracranial aneurysms are rare complications of cardiac myxoma which may present before, concurrent or many years after diagnosis of the myxoma. Nonspecific neurological complaints occasionally are the ominous signs of intracranial aneurysms which mandate a low threshold for neuroimaging in a case of cardiac myxoma. Given the absence of definitive risk factors and unclear natural history, clinical and radiological follow-ups are critical.Learning PointsIntracranial aneurysms are rare complications of cardiac myxoma that may present before, concurrent or many years after diagnosis of the myxoma.Special attention must be given to nonspecific neurological complaints with a low threshold for neuroimaging in those with a prior history of cardiac myxoma.Given the absence of definitive risk factors and unclear natural history, clinical and radiological follow-up including conventional angiography and/or magnetic resonance imaging is critical.

Unruptured intracranial aneurysms in pediatric sickle cell disease: clinical and MR imaging follow-up of 296 patients.

Currently available data regarding unruptured intracranial aneurysms (UIAs) in sickle cell disease (SCD) are largely based on adult patients; this has made it challenging to reach a consensus on treatment decisions and follow-up strategies for pediatric SCD patients with UIAs. A retrospective review of 296 SCD patients (aged 18 years or younger) who underwent MRA from January 2008 to September 2022 was performed. The vessel of origin and characteristics of the UIAs, including maximum diameter, laterality, and number, were evaluated. Demographic data, as well as history of vaso-occlusive crisis and moyamoya syndrome, were recorded. Interval change in size or morphology, as well as a new aneurysm development, were reviewed on follow-up MRA. Forty-nine aneurysms were identified in 32/296 (10.81%) patients, and they all had saccular morphology. In total, 30/49 (61.22%) aneurysms were in the anterior circulation. The ophthalmic segment of the internal carotid artery and the posterior cerebral artery were the most common locations (n = 12 [24.49%] each). Multiple aneurysms were seen in 11/32 patients (34.37%). Most of the African American patients had multiple aneurysms (n = 25/28 [89.3%]). Most aneurysms (n = 43 [87.75%]) were 3 mm or less in diameter. No significant difference in aneurysm size was noticed between aneurysms located in anterior or posterior circulation (p = 0.22). Similarly, age, sex, ethnicity, genotype, or aneurysm multiplicity were not associated with size. Follow-up MRA was available for 24/32 patients (75%). All except 2 aneurysms (n = 2/38 [5.3%]) were stable in size and morphology on follow-up. Interval progression in aneurysm size was noticed in 2 patients with multiple intracranial aneurysms (n = 2/11 [18.2%]). In pediatric SCD patients, the incidence of UIAs was higher than previously reported. Those aneurysms demonstrated a tendency for multiplicity, an atypical anatomical distribution compared with that of adult brain aneurysms, bilateral involvement, and higher prevalence in African Americans. Although most of the aneurysms were stable, some showed interval growth in size.

Flow diverter braid deformation following treatment of cerebral aneurysms: incidence, clinical relevance, and potential risk factors

BackgroundAlthough flow diverters (FDs) have benefited from several technical improvements, recently concerns have arisen regarding the braid stability after implantation. Thus, we investigated frequency, predictive factors, and clinical impact of...

Combined Microsurgical and Endovascular Intracranial Aneurysm Treatment: Interdisciplinary Experience Using a True Hybrid Approach and a Systematic Review of the Literature.

(1) Background: Most intracranial aneurysms (IAs) can be treated either with microsurgical clipping or endovascular techniques. In a few cases, simultaneous treatment utilizing both modalities in a hybrid operation room may be favorable. This study analyzes the indication and benefits of a true hybrid approach (tHA) that combines simultaneous endovascular and microsurgical procedures for treatment of IAs in one session. (2) Methods: All patients receiving a true hybrid procedure between 2010 and 2022 in our institution were included. Demographic characteristics, neurological symptoms, pre-interventional treatments, angiographic findings, and postoperative clinical and radiological outcomes were analyzed. Results are discussed in the light of a systematic literature review on reported true hybrid procedures for IA treatment. (3) Results: In total, 10 tHAs were performed. Of these, coiling and concomitant decompressive craniectomy or hematoma evacuation was performed on six occasions. In two patients, multiple IAs were treated with different modalities during the same procedure. In two patients, intraoperative conditions did not allow for complete IA clipping, and the remnant was coiled in the same session. The review of the literature revealed nine papers comprising 58 IAs treated with a tHA. (4) Conclusions: The need for a tHA for IA treatment is rare and limited to highly selective cases. In our experience, tHAs have been most valuable in an emergency setting concerning ruptured IAs. Furthermore, tHAs may also be considered in patients with multiple aneurysms in different vascular territories.

T Cells Immune Imbalance Present in Patients With Multiple Intracranial Aneurysms.

Growing evidence suggests that systemic immune and inflammatory responses may play a critical role in the formation and development of aneurysms. Exploring the differences between single intracranial aneurysm (SIA) and multiple IAs (MIAs) could provide insights for targeted therapies. However, there is a lack of comprehensive and detailed characterization of changes in circulating immune cells in MIAs. Peripheral blood mononuclear cell (PBMC) samples from patients with SIA (n = 16) or MIAs (n = 6) were analyzed using high-dimensional mass cytometry to evaluate the frequency and phenotype of immune cell subtypes. A total of 25 cell clusters were identified, revealing that the immune signature of MIAs included cluster changes. Compared to patients with SIA, patients with MIAs exhibited immune dysfunction and regulatory imbalance in T-cell clusters. They also had reduced numbers of CD8+ T cells and their subgroups CD8+ Te and CD8+ Tem cells, as well as reduced numbers of the CD4+ T-cell subgroup CD27-CD4+ Tem cells. Furthermore, compared to SIA, MIAs were associated with enhanced T-cell immune activation, with elevated expression levels of CD3, CD25, CD27, CCR7, GP130, and interleukin 10. This study provides insights into the circulating immune cell profiles in patients with MIAs, highlighting the similarities and differences between patients with SIA and those with MIAs. Furthermore, the study suggests that circulating immune dysfunction may contribute to development of MIAs.

Sex‐Dependent Manifestations of Intracranial Aneurysms

Background Intracranial aneurysms (IAs) are more common in women than in men; however, there is still limited knowledge on sex‐dependent differences regarding aneurysm location, multiplicity, rupture risk, risk factors, and histopathology. Methods This cross‐sectional, consecutive cohort study examined whether IAs differ in multiplicity, location, geometry, rupture risk, risk factors, and histology between sexes. Results We included 982 patients (714 women, 268 men) totaling 1484 IAs (1056 unruptured, 397 ruptured). A total of 363 patients (36.97%) had multiple IAs, the proportion of which was significantly higher in women. In women, the internal carotid artery (40.79%) was the most frequent location for IAs, whereas in men most were found along the anterior carotid artery territory (32.86%). Men were significantly more often diagnosed with ruptured aneurysms. Aneurysm geometry did not differ between sexes; however, ruptured aneurysms in men presented with a significantly larger neck diameter than unruptured ones. Regarding risk factors for aneurysm rupture, blood pressure control was more effective in women, whereas the effect of smoking status did not show clear sex‐dependent differences. Histologically, wall‐type classification analysis showed significantly more severe aneurysm wall types in men. Conclusion IA prevalence in women is significantly higher than in men. Women more often present with multiple IAs, whereas men were more often diagnosed with ruptured IAs. Sex‐specific differences in IA location were identified, whereas geometry of IAs did not differ between sexes. IAs in men showed a more severe histological wall type. Further research is needed to unravel the molecular mechanisms underlying these important sex‐dependent manifestations in IAs.

A model with multiple intracranial aneurysms: possible hemodynamic mechanisms of aneurysmal initiation, rupture and recurrence

BackgroundHemodynamic factors play an important role in aneurysm initiation, growth, rupture, and recurrence, while the mechanism of the hemodynamic characteristics is still controversial. A unique model of multiple aneurysms (initiation, growth, rupture, and recurrence) is helpful to avoids the confounders and further explore the possible hemodynamic mechanisms of aneurysm in different states.MethodsWe present a model with multiple aneurysms, and including the states of initiation, growth, rupture, and recurrence, discuss the proposed mechanisms, and describe computational fluid dynamic model that was used to evaluate the likely hemodynamic effect of different states of the aneurysms.ResultsThe hemodynamic analysis suggests that high flow impingement and high WSS distribution at normal parent artery was found before aneurysmal initiation. The WSS distribution and flow velocity were decreased in the new sac after aneurysmal growth. Low WSS was the risk hemodynamic factor for aneurysmal rupture. High flow concentration region on the neck plane after coil embolization still marked in recanalized aneurysm.ConclusionsAssociations have been identified between high flow impingement and aneurysm recanalization, while low WSS is linked to the rupture of aneurysms. High flow concentration and high WSS distribution at normal artery associated with aneurysm initiation and growth, while after growth, the high-risk hemodynamics of aneurysm rupture was occurred, which is low WSS at aneurysm dome.

Microsurgical Clipping of Multiple Intracranial Aneurysms via the Keyhole Approach

BackgroundKeyhole surgery has been widely used to clip various intracranial aneurysms. Here, the feasibility of microsurgical clipping of multiple intracranial aneurysms via the keyhole approach was further investigated. MethodsThe clinical data of 80 patients with multiple intracranial aneurysms treated with keyhole surgery were retrospectively analyzed. The patients included 25 males and 55 females, with an average age of 57.5 years. There were 13 patients with unruptured aneurysms, 67 patients with ruptured aneurysms (small aneurysms accounted for 52.2% of ruptured aneurysms), and a total of 198 aneurysms. A 4 cm incision and a bone hole of approximately 2.5 cm were used, per craniotomy standards. Forty-eight cases were treated via the supraorbital keyhole approach, 45 cases via the pterional keyhole approach, and three cases via the interhemispheric keyhole approach. ResultsA bilateral and unilateral keyhole approach was applied in 18 and 62 cases, respectively. A total of 170 ipsilateral and 7 contralateral aneurysms were clipped. The complete clipping rate was 98.9%. During the follow-up period of 6-12 months after surgery, the Glasgow outcome scale score was 5 points in 74 cases, 4 points in five cases, and 3 points in one case. The prognosis was associated with the preoperative Hunt–Hess classification but not with the number of operative sides, the operation opportunity, or the number of clipped aneurysms. ConclusionEarly keyhole surgical clipping of multiple intracranial aneurysms is an effective treatment. Among ruptured aneurysms, small aneurysms are common and need attention and timely treatment.

Unexpected Bilateral Emergence of the Ophthalmic Arteries from the Cavernous Segment of the ICA in a Patient with Multiple Intracranial Aneurysms

Unexpected Bilateral Emergence of the Ophthalmic Arteries from the Cavernous Segment of the ICA in a Patient with Multiple Intracranial Aneurysms

Risk of unruptured aneurysms in subarachnoid hemorrhage patients with multiple intracranial aneurysms: a multicenter, longitudinal, comparative study from China

BackgroundIn aneurysmal subarachnoid hemorrhage patients with multiple intracranial aneurysms (aSAH-MIA patients), the risk of secondary unruptured intracranial aneurysms is inconsistent. This study aimed to explore the risk of unruptured aneurysms...

Multiple Small, Medium and Large Intracranial Aneurysms in a Single Patient

Multiple Small, Medium and Large Intracranial Aneurysms in a Single Patient

Endovascular treatment of multiple intracranial aneurysms.

Multiple intracranial aneurysms are difficult to treat. In order to investigate the effect and safety of endovascular treatment for multiple intracranial aneurysms, 54 consecutive patients with 116 multiple intracranial aneurysms treated with endovascular embolization were retrospectively enrolled. Angiography was performed immediately after embolization and at each follow-up. All clinical data were analyzed. Of the 116 aneurysms, 56 (48.3%) were embolized with coiling alone, 19 (16.4%) with stent-assisted coiling, 31 (26.7%) with stenting alone, and 10 (8.6%) with flow diverters plus coiling. After embolization, 31 (27.6%) aneurysms with stenting alone had no apparent change in size, and in the remaining 84 aneurysms, complete occlusion was achieved in 50 aneurysms (59.5%), near-complete occlusion in 26 (31.0%), and incomplete occlusion in 8 (9.5%). Thrombus formation at the aneurysm neck occurred in 3 patients (5.6%), coil protrusion in 2 (3.7%), and intraprocedural rupture in 1 (1.9%), resulting in a total complication rate of 11.1%. Follow-up angiography was performed in 44 (81.5%) patients 6 to 90 months (mean 49) later. Among 50 completely occluded aneurysms, 38 (76%) aneurysms remained completely occluded, and 4 (8%) aneurysms recurred. Among 26 aneurysms with initial near-complete occlusion, 12 (46.2%) aneurysms with neck remnant had progressive thrombosis to complete occlusion, 2 (7.7%) had no change compared with immediate occlusion, and 5 (19.2%) regrew. In conclusion, endovascular embolization with intracranial stenting and coiling is safe and effective and may play an increasingly important role in the management of multiple intracranial aneurysms.

Evaluation of unruptured aneurysm scoring systems and ratios in subarachnoid hemorrhage patients with multiple intracranial aneurysms.

This study aims to appraise aneurysm scores and ratios' ability to discriminate between ruptured aneurysms and unruptured intracranial aneurysms (UIAs) in subarachnoid hemorrhage (SAH) patients harboring multiple intracranial aneurysms (MICAs). We, then, investigate the most frequent risk factors associated with MICAs. We retrospectively applied unruptured intracranial aneurysm treatment score (UIATS) and population hypertension age size of aneurysm earlier SAH from another aneurysm site of aneurysm (PHASES) score, aspect, and dome-to-neck ratio to the 59 consecutive spontaneous SAH patients with MICAs admitted between January 2000 and December 2015 to the Department of Neurosurgery of the University Hospital Center "Hôpital des Spécialités" of Rabat (Morocco). Patients with at least two intracranial aneurysms (IAs) confirmed on angiography were included in the study. Fifty-nine patients were harboring 128 IAs. The most frequent patient-level risk factors were arterial hypertension (AHT) 30.5 % (n = 18) and smoking status 22.0 % (n = 13). A PHASES score recommended treatment in 52 of 60 ruptured aneurysms and in six of 68 UIAs with a sensitivity of 31.67% and a specificity of 76.47%. UIATS recommended treatment in 26 of 62 ruptured aneurysms and in 35 of 55 UIAs with a sensitivity of 41.9% and a specificity of 63.6%. Aspect ratio recommended treatment in 60 of 60 ruptured aneurysms and in 63 of 68 UIAs with a sensitivity of 100% and a specificity of 88.24%. Dome-to-neck ratio recommended treatment in 45 of 60 ruptured aneurysms and in 48 of 68 UIAs with a sensitivity of 80% and a specificity of 63.24%. The aspect ratio (area under the curve [AUC] = 0.953) AUC > 0.8 has a higher discriminatory power between ruptured aneurysms and UIAs. AHT and smoking status were the most common risk factors for intracranial multiple aneurysms and the aspect ratio and PHASES score were the most powerful discrimination tools between ruptured aneurysms and the UIAs.

Single-stage endovascular treatment in aneurysmal subarachnoid haemorrhage with multiple intracranial aneurysms: Systematic review of the literature and multicentric retrospective experience.

The presence of multiple intracranial aneurysms in patients with acute subarachnoid haemorrhage is a condition with no evidence of optimal treatment strategy, especially in case of uncertain haemorrhage patterns on cumputed tomography. The aim of this study was to analyse the safety and efficacy profile of single-stage endovascular treatment of multiple intracranial aneurysms with aneurysmal subarachnoid haemorrhage in the literature and in a retrospective case series. A systematic review of the present literature was conducted to identify studies related to single-stage endovascular treatment for ≥2 aneurysms; in addition, a retrospective multicentric review was performed. Data on clinical presentation, aneurysm size and location, occlusion rates, intracranial complications and clinical outcome were recorded. Thirteen articles were identified (all little case series) reporting 189 patients harbouring 389 aneurysms. And 85.6% presented with a Hunt-Hess scale 1-3, and 14.4% 4-5. Intracranial complications rate was 11.5%. Baseline and follow-up (20.5 months) occlusion rates were adequate (Raymond-Roy occlusion scale I-II) in 93% and 96.2%, respectively. 81% of patients had favourable clinical outcomes (modified Rankin Scale (mRS) ≤2; Glasgow outcome scale (GOS) 5-4) and 19% poor (mRS 3-6; GOS 3-1). The retrospective database identified 53 patients with 115 aneurysms. Clinical presentation was Hunt-Hess (HH) 1-3/WNFS 1-2 75% and HH 4-5/WNFS 3-5 25%. Intracranial complication rate was 24.5%. Occlusion rate RROC I-II was 78.7% at baseline and 15 months and 90.2% at follow up. Clinical outcome at 3 months was mRS ≤2 68.6% and mRS 3-6 31.4%. Single-staged endovascular treatment can be feasible, although a higher risk of intraprocedural complications, with clinical presentation being the major factor to influence the outcome.

Prognostic Risk Factors of One-stage Surgical Clipping in aSAH Elderly Patients with MIAs.

To discuss the prognostic factors affecting the prognosis of 1-stage surgical clipping in aneurysmal subarachnoid hemorrhage (aSAH) elderly patients with multiple intracranial aneurysms (MIAs). A total of 84 elderly patients with aSAH who had MIAs and underwent 1-stage surgical clipping were retrospectively analyzed. Follow-up was conducted with patients 30 days after discharge using the Glasgow Outcome Scale (GOS). A GOS score of 1 to 3 was defined as a poor outcome, and a GOS score of 4 to 5 was defined as a good outcome. General information (gender, age, size of aneurysm, location of rupture of the responsible aneurysm, H-H grade, CT characteristics of aSAH, number of subarachnoid hemorrhages, operation opportunity, postoperative complications, and intraoperative rupture) and complications（cerebral infarction, hydrocephalus, electrolyte disturbance, and encephaledema）were recorded. Univariate analysis and multivariate regression analysis were used to analyze factors that may affect outcomes. Univariate analysis showed that the number of SAH events ( P =0.005), intraoperative rupture ( P =0.048) and postoperative complications ( P =0.002) were associated with the prognosis of aSAH elderly patients with MIAs undergoing 1-stage surgery. Multivariate analysis showed that the number of SAH events (odds ratio [OR] 4.740, 95% confidence interval [CI] 1.056 to 21.282, P =0.042) and postoperative complications (OR 4.531, 95% CI 1.266 to 16.220, P =0.020) were independently associated with the prognosis of aSAH elderly patients with MIAs undergoing 1-stage surgery. The number of SAH events and postoperative complications are independent risk factors for the prognosis of aSAH elderly patients with MIAs undergoing 1-stage surgery. These factors contribute to the timely treatment of potentially related patients.

Endovascular treatment of multiple intracranial aneurysms in patients with subarachnoid hemorrhage: one or multiple sessions?

This study aimed to compare the safety and efficacy of single- and multiple-stage endovascular treatment in aneurysmal subarachnoid hemorrhage (SAH) patients with multiple intracranial aneurysms. We retrospectively analyzed the clinical and imaging data of 61 patients who harbored multiple aneurysms and presented to our institution with aneurysmal subarachnoid hemorrhage. Patients were grouped according to endovascular treatment strategy: one-stage or multiple-stage. The 61 study patients harbored 136 aneurysms. One aneurysm in each patient had ruptured. In the one-stage treatment group, all 66 aneurysms in 31 patients were treated in one session. The mean follow-up was 25.8 months (range, 12-47). At the last follow-up, the modified Rankin scale was ≤2 in 27 patients. In total, 10 complications occurred (cerebral vasospasm, six patients; cerebral hemorrhage, two patients; and thromboembolism, two patients). In the multiple-stage treatment group, only the ruptured aneurysm (30 in total) was treated at the time of presentation, and the remaining aneurysms (40 in total) were treated later. The mean follow-up was 26.3 months (range, 7-49). At the last follow-up, the modified Rankin scale score was ≤2 in 28 patients. In total, five complications occurred (cerebral vasospasm, four patients; and subarachnoid hemorrhage, one patient). During the follow-up period, there was one recurrence of aneurysm with subarachnoid hemorrhage in the single-stage treatment group and four recurrences in the multiple-stage treatment group. Both single- and multiple-stage endovascular treatment is safe and effective in aneurysmal subarachnoid hemorrhage patients who harbor multiple aneurysms. However, multiple-stage treatment is associated with a lower rate of hemorrhagic and ischemic complications.

Sellar hematoma as a new potential radiological clue for superior hypophyseal artery aneurysm rupture

Background. In cases of spontaneous subarachnoid haemorrhage (SAH) with multiple intracranial aneurysms (MIAs) detected on angiography, some radiological clues assist in determining the site of a ruptured aneurysm which is bleeding is quite beneficial for the selection of the best treatment strategy. Case description. We report a case of a 60 years old patient who presented with spontaneous SAH, sellar hematoma, and three different aneurysms detected in angiography. Although the right Posterior communicating artery (PcomA) aneurysms showed Murphy’s teat on angiography intraoperatively, we discovered that the right superior hypophyseal aneurysm (SHA) was the source of the index bleeding. Both aneurysms were clipped successfully. Conclusion. From the preoperative radiological and intraoperative surgical findings, we propose that sellar hematoma on a non-contrast CT scan is a new potential sign to be correlated with superior hypophyseal artery aneurysm rupture.

Reconstructive endovascular treatment of distal cerebral aneurysm associated with cardiac myxoma

Introduction. The etiology and pathogenesis of cerebral aneurysms are diverse. The rare cause of cerebral aneurysms occurrence is cardioembolism in cases of heart tumors, in particular in myxoma. Cardiac myxoma (from Latin muxa, mucus) is the most common (about 50 %) benign tumor of heart. With untimely diagnosis and absence of the disease treatment, embolisms in cerebral vessels may occur with typical symptoms of ischemic stroke as well as in some cases the myxomal aneurysms may develop. There are several theories of their origin. The myxomal aneurysms of cerebral vessels are more common in women and in the vast majority of cases they develop in carotid basins. In a quarter of cases, the disease onsets as intracranial hemorrhage caused by rupture of an oncotic (myxomal) aneurysm, that significantly exceeds the frequency of ruptures (1–3 % per year) in cases of “normal” bifurcation‑hemodynamic intracranial aneurysms. The mortality rate is 3.4 %. The majority (80 %) of ruptures were observed within 2 years after the diagnosis of cardiac myxoma, and in half (48.6 %) of cases clinically significant episodes of embolism were noted. Timely treatment can prevent the hemor rhagic type of course of these aneurysms. Various methods of treatment are described in the literature: different options for surgical eradication as well as the possibilities of chemotherapy and radiation exposure.Aim. To present a case of successful radical reconstructive endovascular treatment of patient with distal cerebral aneurysm associated with cardiac myxoma, combined with presence of multiple cavernous malformations and also to highlight issues of diagnosis, differential diagnosis and existing treatment options for these diseases.Clinical observation. The article presents a clinical observation of multiple aneurysms associated with myxoma of the heart in combination with multiple cavernous angiomas of the brain. The possibility of reconstructive eradication of distal aneurysm after its transformation from fusiform to saccular is demonstrated. The etiology and pathogenesis of occurrence, the nuances of differential diagnosis, possible methods and the algorithm for choosing a method for treating brain aneurysms associated with myxomas are reflected. The patient underwent reconstructive aneurysm shutdown by embolization with microspirals, which became possible due to the anatomical shape that favored this type of treatment. Conversion to destructive intervention was not required. Due to the natural course of the disease, the patient remains at risk of progression of a distal aneurysm in the basin of the same artery, and therefore it will be observed in dynamics.Conclusion. All patients with cardiac myxomas, both before and in dynamics after their removal, are recommended to perform noninvasive visualization of brain vessels for verification of such complication as metastatic (myxomal) aneurysms. The prognosis in most patients with multiple intracranial aneurysms associated with myxoma is favorable and most aneurysms associated with myxoma are stable. However, in cases with progressive or ruptured aneurysms, surgical treatment options should be considered including microsurgical or endovascular eradication. Radiation and chemotherapy methods may have a certain therapeutic value.

Why She? A Retrospective Study on Sex Inequality Related to Subarachnoid Haemorrhage

Subarachnoid haemorrhage (SAH) is the only type of stroke with female predominance. We conducted a retrospective analysis of SAH patients throughout a decade and tried to establish any reason for such remarkable sex difference. We conducted a retrospective analysis of subarachnoid haemorrhages treated in Istria County between 2010 and 2021. Some of those patients were referred to a comprehensive stroke centre and we collected those data too. We also collected data regarding the outcome recorded at follow up exams of patients treated for SAH in that period. A total of 193 patients with subarachnoid haemorrhage were found in observed period. We found a lower incidence regarding general population but with a tendency to increase, compared with data from other studies. Among all SAH, 113 were female, which makes a Risk Ratio (RR) of 1.44. The highest RR in females was in aneurysmal subarachnoid haemorrhages, 2.06. We obtained a similar high RR of 2.03 in the case of female ruptured multiple intracranial aneurysms (IA), clearly with a worse outcome. Conversely, the RR in non-aneurysmal subarachnoid haemorrhages and perimesencephalic subarachnoid haemorrhages was lower in the case of female sex and amounted 0.67. We noticed similar sex inequality as shown in other studies, so we can also state that women are at higher risk of IA rupture than men. The reason has to be multifactorial. As found in this study, women have different predilection sites of IA rupture compared with men so we strongly believe that certain hemodynamic forces may lead to aneurysm growth and rupture. As we also confirmed IA rupture is age dependent more in women than in men. As shown in other studies, oestrogen level might be the reason for that. Future studies should further establish and prove these risk factors for IA aneurysm rupture and improve preventive measures.