Parent Artery Research Articles

Flow Diversion for Intracranial Aneurysms With Incorporated Branch: A Subanalysis From the SEASE International Registry

BACKGROUND The presence of an incorporated branch as well as its anatomical relationship to the intracranial aneurysms (IAs) and the parent artery may affect the occlusion outcome following flow diversion. This study evaluated the safety and effectiveness of the cobalt‐chromium Surpass Evolve (Stryker), a 64‐wire flow diversion device for the treatment of IAs with incorporated branches. METHODS This subanalysis uses data from the SEASE (Safety and Effectiveness Assessment of Surpass Evolve) registry to retrieve data related to IAs with incorporated branches. Those IAs were classified by a core lab into 4 categories based on their anatomical relationship to the parent artery and branch: (A) sidewall anatomic, (B) sidewall hemodynamic, (C) neck branch, and (D) dome branch. We compared the outcomes based on their incorporated branch's relation to the dome (A–C versus D). RESULTS This study included 67 patients and IAs. Most IAs were in the posterior communicating artery (46.3%), with a median size of 4.35 mm. Age, sex, comorbidities, baseline functional‐status, and IA features were similar between the 2 groups. Among those, 53 (79.1%) had branches emerging from the dome, and 14 (20.9%) had branches originating from other locations (A = 7, B = 2, and C = 5). At a median imaging follow‐up of 10.5 months, complete occlusion was lower in IAs with a branch from the sac compared with those with the neck (60.8% versus 92.9%; P = 0.026), with an overall occlusion of 67.7%. Thromboembolic and hemorrhagic complications, as well as retreatment, were reported in 1.6% and 3.1% of cases, respectively, with no significant differences between groups. CONCLUSION Our analysis underscores the influence of branch origin on occlusion rates, with the neck‐originating branch demonstrating higher occlusion rates. These insights emphasize the role of anatomical considerations in treatment strategies, follow‐up timelines, and designing future clinical trials. Further studies are warranted to explore these variations across different flow diversion technologies.

Application of computational fluid dynamic simulation of parent blood flow in the embolization of unruptured A1 aneurysms

To investigate the effect of microcatheter shaping based on the parent artery mainstream line of blood flow simulated using the computational fluid dynamics (CFD) technique on embolization of unruptured aneurysms on the posterior wall of the anterior cerebral artery (ACA) A1 segment. Patients with unruptured cerebral aneurysms on the posterior wall of the ACA A1 segment were retrospectively enrolled and treated with endovascular embolization after microcatheter shaping. The clinical, embolization and follow-up data were analyzed. Eight patients were enrolled and treated with endovascular embolization. Eight microcatheters were steam shaped in vitro and were all successfully navigated to the right location in the in vitro experiment. During the embolization procedure, seven microcatheters were successfully navigated to the right location for embolization. In the remaining one patient who had tortuous cerebral arteries, reshaping of the microcatheter based on the parent artery mainstream of blood flow made successful navigation of the microcatheter to the right place. Complete occlusion was obtained in seven (87.5%) aneurysms and residual aneurysm neck in the remaining one (12.5%). At angiographic follow-up in 6 (75%) patients, the Raymond grade was I in 5 (83.3%) and II in the rest one (16.7%). Use of CFD simulation of parent artery blood flow for microcatheter shaping in the embolization of unruptured aneurysms on the posterior wall of the ACA A1 segment is safe and effective in navigating the microcatheter to the right location for embolization, resulting in good stability and support for the embolization.

Efficacy of endovascular therapy in short-term two-stage operation for thrombosed giant cerebral aneurysm

Background: Giant cerebral aneurysms have a high rupture rate, are often difficult to treat, and have a poor prognosis. We report two cases in which good results were achieved with a short, two-stage operation using a combination of endovascular treatment (EVT) and direct surgery. Case Description: Case 1 - A 50-year-old man had become immobile due to truncal ataxia after nausea. Magnetic resonance imaging, computed tomography (CT), and angiography revealed a giant thrombosed aneurysm of the right vertebral artery 30 mm in diameter, which compressed medulla oblongata. He underwent endovascular parent artery occlusion (PAO) followed by direct surgical thrombectomy 3 days later.The patient’s outcome was modified Rankin score (mRS) 1 at 7 days after the operation and mRS 0 at 1 year. Case 2 - A 40-year-old man developed a progressive visual disturbance. CT showed a giant thrombosed aneurysm of 50 mm diameter in the C2 portion of the left internal carotid artery. A balloon test occlusion (BTO) and cerebral blood flow single-photon emission computed tomography under BTO suggested partial ischemic tolerance due to PAO. PAO followed by low flow bypass and thrombectomy of the aneurysm by direct surgery was performed on the same day.The patient’s vision was improved with the outcome of mRS 1. Conclusion: EVT in a short-term two-stage operation for a thrombosed giant cerebral aneurysm is effective for the purpose of hemostasis in the thrombectomy designed to decompress the suffered brain or nerve. Complete PAO and meticulous perioperative use of antithrombotic agents are necessary to avoid perforator failure and hemorrhagic complications in this technique.

Risk Factors for In-Stent Stenosis After Flow Diverter Treatment of Intracranial Aneurysms: A Systematic Review and Meta-Analysis of 2350 Patients.

Recent advances in flow diverter (FD) therapy for intracranial aneurysms have highlighted the need to evaluate risk factors for in-stent stenosis (ISS), a potentially serious complication. This meta-analysis aims to identify risk factors associated with an increased risk of ISS after FD treatment. PubMed, Web of Science, Embase, and SCOPUS databases were systematically searched for studies reporting ISS rates and risk factors after FD therapy for intracranial aneurysms. Odds ratios were calculated using random-effects models to assess potential risk factors associated with ISS. Ten studies involving 2350 patients with 2441 aneurysms were included. Younger age (P = .006) and male sex (P = .003) were associated with higher ISS risk. Smoking also increased the risk (P = .02). Aneurysm location in the posterior circulation (P < .00001) and fusiform morphology (P < .00001) were significant risk factors for ISS, as were ruptured aneurysms (P = .05). Hypertension, hyperlipidemia, diabetes, allergies, and alcohol abuse, as well as aneurysm size, neck width, and parent artery diameter, did not affect ISS risk. Procedural factors like balloon angioplasty, multiple FDs, or FD/coil combinations were not significantly associated with ISS. This meta-analysis identified both nonmodifiable (younger age, male sex) and modifiable (smoking) patient factors, as well as high-risk aneurysm characteristics (posterior circulation, fusiform, ruptured), associated with an increased risk of ISS after FD treatment. These findings highlight the importance of tailored monitoring and management approaches for optimizing outcomes in FD therapy.

Zygomatic Anterolateral Temporal Approach for P1/P2 segment complex posterior cerebral aneurysm: a single-center retrospective study.

Treating complex posterior cerebral artery (PCA) aneurysms, such as fusiform, giant, and dissecting aneurysms, poses significant challenges. Parent artery occlusion carries a risk of ischemic stroke and fails to alleviate mass effects. This study aims to analyze the technical nuances and patient outcomes of treating complex PCA aneurysms, ranging from the P1 to P2P segments, using a Zygomatic Anterolateral Temporal Approach(ZATA) combined with flow reconstruction. This study was a retrospective study. Surgical treatment was performed on twelve patients with complex PCA aneurysms located in the P1 to P2P segments. Ten patients underwent flow reconstruction including Superficial Temporal Artery(STA)-Middle Cerebral Artery(MCA),Internal Maxillary Artery(IMA)-Radial Artery(RA)-MCA,STA-PCA(P2), and IMA-RA-PCA(P2). The aneurysm occlusion rate, surgical complications, and patient prognosis, including stroke occurrence/ modified Rankin Scale(mRS), were recorded and analyzed. Using the ZATA, all twelve complex PCA aneurysms were successfully clipped/resected/trapped. This included two high-position aneurysms (> 3mm above the posterior clinoid process) at the P1/P2 junction and three P2P aneurysms. The mass effects of six large or giant aneurysms were resolved or alleviated. Postoperative and follow-up CTA/DSA confirmed the patency of the bypass vessels. Four patients experienced strokes in the perioperative period, with three ischemic and one hemorrhagic. The median follow-up period was 28.5months. At the last follow-up, the good prognosis rate (mRS ≤ 2) was 83.3%, and one patient had died. Clipping/resection/trapping of aneurysms via the ZATA, combined with flow reconstruction, is a feasible option for treating complex PCA aneurysms from the P1 to P2P segments. This approach helps maintain or improve cerebral perfusion in the affected vascular territory.

Endovascular Treatment of Mycotic Intracranial Aneurysms: A Series of Three Cases with Institutional Treatment Algorithm

AbstractMycotic intracranial aneurysms (MIAs) are rare but can cause significant morbidity and mortality due to rupture. Most patients have additional systemic medical comorbidities making endovascular treatment a vital modality in the treatment of these aneurysms. We aimed to share our institutional experience with the role of endovascular therapy in the treatment of mycotic aneurysms with a literature review. We conducted a retrospective review of our patient database to identify individuals diagnosed with MIAs who underwent endovascular intervention at our institution between January 2002 and December 2021. We have found three patients with ruptured MIAs. All three patients had a heart disease with infective endocarditis. Two patients presented with subarachnoid hemorrhage (SAH) in which, one had a rebleed resulting in intracerebral hemorrhage (ICH), the third patient initially presented with ICH. Distal anterior cerebral artery (ACA) was the site of MIA in two cases and distal middle cerebral artery (MCA) in one patient. Two patients were treated with simple coiling and one patient was treated by glue (n-butyl cyanoacrylate [NBCAs]) injection within the aneurysm. There was no periprocedural complication with complete obliteration of the aneurysm and preservation of the parent artery. All the patients had good outcomes on follow-up. Two patients had a modified Rankin scale (mRS) score of 0 at 6 months and one patient had an mRS score of 3 at the end of 3 months whose preprocedure mRS score was 5. Endovascular embolization of MIAs with coils or liquid embolic agents can be performed in critically ill patients and is an excellent treatment modality with high occlusion rates and low procedural complications.

Treatment of Acute Iatrogenic Cerebrovascular Injury Using Flow Diverter Stents

BACKGROUND AND OBJECTIVES: Iatrogenic cerebrovascular injury can cause intracranial hemorrhage and pseudoaneurysm formation, putting patients at high risk for postoperative bleeding. No consensus for management exists. This study describes endovascular treatment of these acute injuries with flow diverter stents. METHODS: Electronic medical records were retrospectively reviewed for injury type and etiology, timing of diagnosis, and endovascular management, including antiplatelet regimens, embolization results, and clinical outcome. RESULTS: Six patients were included. Three suffered an injury to the internal carotid artery, 1 suffered an injury to the left anterior cerebral artery, 1 suffered an injury to the right posterior cerebral artery, and 1 suffered an injury to the basilar artery. Four of the 6 injuries occurred during attempted tumor resection, 1 occurred during cerebrospinal fluid leak repair, and 1 occurred during an ophthalmic artery aneurysm clipping. All injuries resulted in pseudoaneurysm formation. Four were immediately detected on angiography; 2 were initially negative on imaging. Five were treated with a pipeline embolization device, and 1 was treated with a Silk Vista Baby. Two were treated with 2 pipeline embolization devices telescopically overlapped across the pseudoaneurysm. All devices deployed successfully. No pseudoaneurysm recurrence or rebleeding occurred. No parent artery occlusion or stenosis was observed, and complete pseudoaneurysm occlusion was observed in 4 patients (in 2 patients, follow-up imaging could not be obtained). CONCLUSION: With proper antiplatelet regimens, flow diverter stents can be used safely to successfully treat complex acute iatrogenic injuries. Early repeat angiogram is needed when immediate postinjury imaging does not discover the point of vessel injury.

Intracranial bypass for giant aneurysms treatment assessed by computational fluid dynamics (CFD) analysis

Unruptured giant intracranial aneurysms (GIA) are those with diameters of 25 mm or greater. As aneurysm size is correlated with rupture risk, GIA natural history is poor. Parent artery occlusion or trapping plus bypass revascularization should be considered to encourage intra-aneurysmal thrombosis when other treatment options are contraindicated. The mechanistic background of these methods is poorly studied. Thus, we assessed the potential of computational fluid dynamics (CFD) and fluid–structure interaction (FSI) analyses for clinical use in the preoperative stage. A CFD investigation in three patient-specific flexible models of whole arterial brain circulation was performed. A C6 ICA segment GIA model was created based on CT angiography. Two models were then constructed that simulated a virtual bypass in combination with proximal GIA occlusion, but with differing middle cerebral artery (MCA) recipient vessels for the anastomosis. FSI and CFD investigations were performed in three models to assess changes in flow pattern and haemodynamic parameters alternations (wall shear stress (WSS), oscillatory shear index (OSI), maximal time averaged WSS (TAWSS), and pressure). General flow splitting across the entire domain was affected by virtual bypass procedures, and any deficiency was partially compensated by a specific configuration of the circle of Willis. Following the implementation of bypass procedures, a reduction in haemodynamic parameters was observed within the aneurysm in both cases under analysis. In the case of the temporal MCA branch bypass, the decreases in the studied parameters were slightly greater than in the frontal MCA branch bypass. The reduction in the magnitude of the chosen area-averaged parameters (averaged over the aneurysm wall surface) was as follows: WSS 35.7%, OSI 19.0%, TAWSS 94.7%, and pressure 24.2%. FSI CFD investigation based on patient-specific anatomy models with subsequent stimulation of virtual proximal aneurysm occlusion in conjunction with bypass showed that this method creates a pro-thrombotic favourable environment whilst reducing intra-aneurysmal pressure leading to shrinking. MCA branch recipient selection for optimum haemodynamic conditions should be evaluated individually in the preoperative stage.

A Combination Technique of N-butyl-2-cyanoacrylate and Minimal Coils with Flow Control for Parent Artery Occlusion of a Giant Internal Carotid Artery Aneurysm: A Technical Note.

Parent artery occlusion for large or giant internal carotid artery aneurysms remains a necessary procedure in the era of flow diverters. Endovascular parent artery occlusion is currently performed using detachable balloons or coils, which are difficult to obtain or costly. At our institution, we have devised a technique for combining n-butyl-2-cyanoacrylate and coils with flow control to solve this problem. Patients who underwent parent artery occlusion for large or giant internal carotid artery aneurysms with a follow-up period of more than 12 months were included. Imaging outcomes were evaluated for complete or incomplete aneurysmal occlusion and with or without aneurysmal shrinkage. The clinical outcome was based on changes in the modified Rankin Scale. Ten patients (ten aneurysms) were included. Their average age and average follow-up period were 68.4 years and 36 months, respectively. Complete occlusion and favorable clinical outcome were observed in all cases. The parent artery occlusion using a combination of coils and n-butyl-2-cyanoacrylate with flow control technique is effective for both imaging and clinical outcomes.

Combined Treatment of Ruptured Intracranial Infectious Aneurysm Accompanied by Intracerebral Hemorrhage: Endovascular Treatment and Neuroendoscopy

Intracranial infectious aneurysms (IIAs) are very rare. Most IIAs are associated with infective endocarditis (IE). The treatment of ruptured IIAs with intracerebral hemorrhage (ICH) remains challenging. Here, the authors aimed to describe a minimally invasive approach, combining endovascular treatment (EVT) with endoscopic techniques, for this complex issue. From January 2019 to December 2021, 3 cases of ruptured IIAs with intracerebral hemorrhage treated with EVT and neuroendoscopic hematoma evacuation at Guangdong Provincial People’s Hospital were included in this study. We retrospectively reviewed the clinical and imaging data and postoperative follow-up. All the IIAs were located in the middle cerebral arteries. The IIAs were secured by embolizing the aneurysms and occluding the parent artery. The ICH was evacuated using neuroendoscopy without postoperative rebleeding. After IIAs treatment, 2 patients underwent cardiac surgery, one at 10 days postoperatively and the other at 1 month postoperatively. At the 1-year follow-up, all patients resumed their normal lives. EVT and neuroendoscopic therapy for ruptured IIAs with ICH in patients is a useful complement to current treatment strategies.

Value of difference in diameters between Pipeline embolization device and parent artery in assessing aneurysm outcome

OBJECTIVE In vitro trials have demonstrated that oversized stents are associated with reduced metal coverage and increased porosity. However, the relationship between stent selection and aneurysm outcome is inconclusive, and determination of this was the authors’ purpose in conducting this study. METHODS This was a single-center retrospective study. Patients who underwent Pipeline embolization device treatment at the authors’ center between January 1, 2018, and June 15, 2023, were enrolled. The authors constructed multiple logistic regression models and restricted cubic spline plots to examine the effect of the difference in diameters between the stent and parent artery (Dd) on aneurysm outcome. The authors also performed stratified analyses. Then, Dd was included in the logistic regression analysis as a categorical variable. The cutoff value for Dd was determined according to the principle of the maximum Youden’s index. RESULTS In total, 302 patients were included in this study. The median Dd was 0.52 mm. With a median follow-up time of 7 months, the aneurysm occlusion rate was 80.1%. The restricted cubic spline plots showed a decreasing aneurysm occlusion rate as Dd increased. After stratification by age and adjunctive embolization, the restricted cubic splines aligned with the results of the main analysis. Compared with the group with a smaller Dd (Dd &lt; 0.3625 mm), the group with a larger Dd showed an OR of 0.439 (p = 0.026). Additionally, patients with diabetes mellitus (OR 0.306, p = 0.018), age ≥ 65 years (OR 0.968, p = 0.03), aneurysm incorporation with a branch (OR 0.253, p &lt; 0.001), and aneurysm neck ≥ 4 mm (OR 0.872, p = 0.003) were independent predictors of aneurysm persistence, whereas Pipeline embolization device plus coiling (OR 4.949, p &lt; 0.001) and smoking history (OR 5.86, p = 0.025) were predictors of aneurysm occlusion. CONCLUSIONS The authors’ retrospective analysis demonstrated that the aneurysm occlusion rate declined when Dd increased within a certain range. The authors suggested that Dd with an interval of −0.25 to 0.5 mm may be proper in clinical practice.

Basic Setup and Coil Embolization Technique for Ruptured Cerebral Aneurysms

For treating ruptured cerebral aneurysms, it is important to understand the setup and basic technique of coil embolization. Safe and effective embolization relies on preoperative considerations that determine the treatment strategy, guide the optimization of the therapeutic environment, and help in the selection of appropriate device systems. Moreover, during aneurysmal embolization, basic techniques for microcatheter shaping and navigation, safe coil introduction, and precise use of occlusion balloons are indispensable. Microcatheter shaping should be based on three-dimensional digital subtraction angiography findings as well as the axes of the parent artery and aneurysm. The operator must understand the advantages and disadvantages of the two methods for navigating the microcatheter into the aneurysm. Furthermore, it is essential to preoperatively simulate and understand the approaches for managing aneurysmal embolization-related complications, such as intraoperative aneurysmal rupture and thromboembolism. Mastery of these steps is mandatory before undertaking embolization of ruptured cerebral aneurysms.

Erratum. Intracranial Aneurysms Managed by Parent Artery Reconstruction Using Tubridge Flow Diverter study: 1-year outcomes.

Erratum. Intracranial Aneurysms Managed by Parent Artery Reconstruction Using Tubridge Flow Diverter study: 1-year outcomes.

Endovascular Treatment of Unruptured Pancreatic Arcade Aneurysms.

This study aimed to assess the safety and efficacy of endovascular treatment of unruptured pancreatic arcade aneurysms in a single-center series. The electronic medical records of patients who underwent endovascular treatment for unruptured pancreatic arcade aneurysms between 2011 and 2022 at our tertiary center were retrospectively reviewed. The presence of celiac artery stenosis/occlusion; aneurysm number, location, and size; endovascular technique; procedure-related complication incidence; and clinical outcomes were assessed. Twenty-three patients (12 men and 11 women; mean [range] age, 63.8 [45-84] years) with 33 unruptured pancreatic arcade aneurysms were identified. Celiac artery stenosis/occlusion coexisted in 17 (74%) patients. Five (21%) patients had multiple aneurysms. The median aneurysm size was 9.3mm (range, 4-18mm). Seven, 6, 6, 5, 4, 3, and 2 aneurysms were located in the gastroduodenal, dorsal pancreatic, anterior superior pancreaticoduodenal, inferior pancreaticoduodenal, posterior inferior pancreaticoduodenal, posterior superior pancreaticoduodenal, and anterior inferior pancreaticoduodenal arteries, respectively. Four (15%) and 22 (85%) aneurysms were treated with endosaccular packing alone and coil embolization with endosaccular packing and parent artery occlusion, respectively, with resulting exclusion from arterial circulation. The remaining 7 aneurysms coexisting with larger aneurysms in other peripancreatic arteries were observed without embolization because they were small and for preserving collateral blood flow to the celiac artery. The treated aneurysms did not rupture or recur during the follow-up period (median, 40months). Endovascular treatment is a safe and effective treatment for unruptured pancreatic arcade aneurysms. 3, non-controlled retrospective cohort study.

Computational fluid dynamics; a new diagnostic tool in giant intracerebral aneurysm treatment

Giant intracerebral aneurysms (GIA) comprise up to 5 % of all intracranial aneurysms. The indirect surgical strategy, which leaves the GIA untouched but reverses the blood flow by performing a bypass in combination with proximal parent artery occlusion is a useful method to achieve spontaneous aneurysm occlusion. The goal of this study was to assess the utility of computational fluid dynamics (CFD) in preoperative GIA treatment planning. We hypothesise that CFD simulations will predict treatment results.A fluid-structure interaction (FSI) CFD investigation was performed for the entire arterial brain circulation. The analyses were performed in three patient-specific CT angiogram models. The first served as the reference geometry with a C6 internal carotid artery (ICA) GIA, the second a proximal parent artery occlusion (PAO) and virtual bypass to the frontal M2 branch of the middle cerebral artery (MCA), and the third a proximal PAO in combination with a temporal M2 branch bypass. The volume of “old blood”, flow residence time (FRT), dynamic viscosity and haemodynamic changes were also analysed.The “old blood” within the aneurysm in the bypass models reached 41 % after 20 cardiac cycles while in the reference model it was fully washed out. In Bypass 2 “old blood” was also observed in the main trunk of the MCA after 20 cardiac cycles. Extrapolation of the results yielded a duration of 4 years required to replace the “old blood” inside the aneurysm after bypass revascularization. In both bypass models a 7-fold increase in mean blood viscosity in the aneurysm region was noted.Bypass revascularization combined with proximal PAO favours thrombosis. Areas prone to thrombus formation, and subsequently the treatment outcomes, were accurately identified in the preoperative model. Virtual surgical operations can give a remarkable insight into haemodynamics that could support operative decision-making.

Anatomical Flow Diversion by Hybrid Strategy for Intractable Large Cerebral Aneurysms.

Flow diverters (FDs) provide curative endovascular treatment for wide-necked sidewall aneurysms. The efficacy of FDs for bifurcation or branching sidewall aneurysms is probably limited. We used anatomical flow diversion (AFD) for intractable large cerebral aneurysms. We report our experiences with AFD. The concept of AFD is the transformation from the bifurcation or branching sidewall type to the nonbranching sidewall type. Linearization of the parent artery by stenting, intentional branch occlusion, and aneurysmal coil embolization were performed. Furthermore, bypass surgery is performed for patients intolerant to branch occlusions. We evaluated the clinical outcomes of intractable aneurysms treated with AFD. AFD was performed in seven unruptured large aneurysms. Aneurysmal locations were the top of the basilar artery (BA), BA-superior cerebellar artery (SCA), internal carotid artery (IC)-posterior communicating artery (PcomA), and IC terminal. The mean dome diameter was 17.0 ± 4.6 mm. Six patients underwent bypass surgery. The occluded branches were the PCA + SCA, PcomA, and anterior cerebral artery (ACA) A1. An FD was used in three patients and a neck bridge stent in four patients. No intraprocedural complications occurred. Two postprocedural ischemic complications occurred in one patient. Six (86%) patients demonstrated a modified Rankin Scale (mRS) 0 at the 3-month follow-up, and one with an ischemic complication showed an mRS 5. Complete occlusion of all aneurysms was maintained with a median follow-up duration of 60 months. AFD is useful for intractable large cerebral aneurysms with high curability, although safety verification is required.

Hemodynamic characteristics in ruptured and unruptured intracranial aneurysms: a prospective cohort study utilizing the AneurysmFlow™ tool.

Hemodynamic factors significantly influence the onset, progression, and rupture of intracranial aneurysms (IAs). Current rupture risk prediction scores focus primarily on the clinical, anatomical and morphological aspects. This study aimed to investigate the hemodynamic characteristics differences between ruptured and unruptured IAs. Conducted from July 2021 to July 2022, this prospective cohort study involved patients with ruptured and unruptured IAs undergoing digital subtraction angiography (DSA). Hemodynamic characteristics were assessed using the AneurysmFlow™ tool. Hemodynamic, clinical, anatomical and morphological parameters were compared between ruptured and unruptured IA groups. The study included 127 patients with 135 aneurysms (67 ruptured, 68 unruptured). Complex flow patterns (type 3 and 4) were observed more frequently in ruptured aneurysms compared to unruptured aneurysms (odds ratio [OR], 5.57; 95% confidence interval [CI], 2.49-12.45; P < 0.001) in univariate analysis, and were also more common in unruptured aneurysms associated with daughter sacs features (P = 0.015). The mean aneurysm flow amplitude (MAFA) was lower in ruptured aneurysms, and associated with lower flow velocity in the parent artery related to vasospasm. MAFA in the aneurysmal dome or any additional daughter sacs was lowest compared to other regions inside the aneurysms. The technical failure rate of AneurysmFlow™ measurements was 8.5% (12 out of 139 patients). Additionally, hypertension (OR, 0.42; 95% CI, 0.30-0.54; P < 0.001), bifurcation location (AcomA/ACA/MCA/PcomA/posterior circulation) (OR, 0.17; 95% CI, 0.05-0.29; P = 0.005), and irregular shape (OR, 0.19; 95% CI, 0.05-0.35; P = 0.012) were identified as independently associated with rupture. Complex flow patterns identified on the AneurysmFlow™ tool are significantly more common in ruptured and unruptured aneurysms associated with daughter sac features. The lowest MAFA in the aneurysmal dome and daughter sacs likely indicates specific pathophysiological changes within the aneurysm wall associated with rupture incidence. Hypertension, bifurcation location, and an irregular shape are independently associated with the risk of rupture. Further multicenter studies with larger sample sizes are needed to validate these findings. ACA = anterior cerebral artery; AcomA = anterior communicating artery; IAs = intracranial aneurysms; ICA = internal carotid artery; MAFA = mean aneurysm flow amplitude; MCA = middle cerebral artery; PcomA = posterior communicating artery; RIAs = ruptured intracranial aneurysms; SAH = subarachnoid hemorrhage; UIAs = unruptured intracranial aneurysms.

Small vessel disease burden and prognosis of recent subcortical ischaemic stroke differ by parent artery atherosclerosis.

Parent artery atherosclerosis is an important aetiology of recent subcortical ischaemic stroke (RSIS). However, comparisons of RSIS with different degrees of parent artery atherosclerosis are lacking. Prospectively collected data from our multicentre cohort (all were tertiary centres) of the Stroke Imaging Package Study between 2015 and 2017 were retrospectively reviewed. The patients with RSIS defined as a single clinically relevant diffusion-weighted imaging positive lesion in the territory of lenticulostriate arteries were categorized into three subgroups: (1) normal middle cerebral artery (MCA) on magnetic resonance angiography and high-resolution magnetic resonance imaging (HR-MRI); (2) low-grade MCA atherosclerosis (normal or <50% stenosis on magnetic resonance angiography and with MCA plaques on HR-MRI); (3) steno-occlusive MCA atherosclerosis (stenosis ≥50% or occlusion). The primary outcome was 90-day functional dependence (modified Rankin Scale score >2). The clinical and imaging findings were compared between subgroups. A total of 239 patients (median age 60.0 [52.0-67.0] years, 72% male) were enrolled, including 140 with normal MCA, 64 with low-grade MCA atherosclerosis and 35 with steno-occlusive MCA atherosclerosis. Patients with steno-occlusive MCA atherosclerosis had the largest infarct volume. Low-grade MCA atherosclerosis was independently associated with cerebral microbleeding, more severe perivascular spaces in basal ganglia and higher total cerebral small vessel disease burden. Low-grade MCA atherosclerosis was an independent determinant of 90-day functional dependence (odds ratio 3.897; 95% confidence interval 1.309-11.604). Our study suggested RSIS with varying severity of parent artery atherosclerosis exhibits distinctive clinical and neuroimaging characteristics, with low-grade MCA atherosclerosis associating with higher cerebral small vessel disease burden and worse prognosis.

Endovascular treatment of unruptured intracranial aneurysms: Rate of thromboembolic events depicted by diffusion-weighted imaging in relation to different techniques

BackgroundThe rate of thromboembolic events (TEEs) associated with endovascular treatment (EVT) of intracranial aneurysms is not reported uniformly in the literature due to the various ways that are used to...

Early vs Delayed Antihypertensive Treatment in Acute Single Subcortical Infarction

The China Antihypertensive Trial in Acute Ischemic Stroke II (CATIS-2) suggests that early antihypertensive treatment did not reduce the risk of dependency or death in acute ischemic stroke (AIS), compared with delayed treatment. Single subcortical infarction (SSI) is an important stroke subtype, and the association of antihypertensive timing with clinical outcomes is unclear. To investigate the association of early vs delayed antihypertensive treatment with clinical outcomes in patients with SSI, stratified by the presence of parent artery disease (PAD) stenosis. This secondary analysis of the CATIS-2 randomized clinical trial included 106 hospitals in China between June 2018 and July 2022. In CATIS-2, patients with AIS within 24 to 48 hours of symptoms onset and elevated systolic blood pressure were eligible. Patients with SSI detected in diffusion-weighted imaging were included in the current post hoc subgroup analysis. Patients were grouped into (1) SSI with PAD stenosis and (2) SSI without PAD stenosis. Statistical analysis was performed from July 2023 to May 2024. Early (immediate) vs delayed (starting on day 8) antihypertensive therapy. Primary outcome was the combination of functional dependency or death (modified Rankin Scale score ≥3) at 90 days. Among 997 patients with SSI in CATIS-2 (mean [SD] age, 62.4 [9.8] years; 612 [61.4%] men), 116 (11.6%) had SSI with PAD and 881 (88.4%) had SSI without PAD. There was no significant difference in the primary outcome between early and delayed antihypertensive treatment groups among all patients with SSI (8.8% vs 7.1%; OR, 1.25 [95% CI, 0.79-1.99]; P = .34). Among patients with SSI with PAD, early antihypertensive treatment was associated with increased risk of the primary outcome compared with delayed treatment (23.4% vs 7.7%; OR, 3.67 [95% CI, 1.14-11.86]; P = .03); this finding was not observed in patients with SSI without PAD (6.6% vs 7.1%; OR, 0.93 [95% CI, 0.55-1.57]; P = .77). Significant interaction with treatment and presence of PAD stenosis was detected for the primary outcome (P for interaction = .04). In this secondary analysis of a randomized clinical trial, early antihypertensive treatment was associated with an increased risk of functional dependency or death at 90 days among patients with SSI and coexisting PAD stenosis, compared with delayed antihypertensive treatment. Further studies are warranted for individualized BP management in patients with SSI by the presence of PAD. ClinicalTrials.gov Identifier: NCT03479554.