Ruptured Brain Aneurysms Research Articles

Outcome of Fourth Ventricular Hemorrhage in Ruptured Brain Aneurysms: Impact of Active Blood Clearance and Delayed Cerebral Ischemia Prevention.

Blood in the fourth ventricle is associated with poor outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). We investigated (1) the prognostic significance of the amount of blood in the fourth ventricle and (2) the influence of active blood clearance and delayed cerebral ischemia prevention (ABCD). We reviewed 817 consecutive aSAH patients admitted between January 1, 2009, and December 31, 2022, assessing blood amount in the fourth ventricle using a fourth ventricular hemorrhage scale (FVH): grade 1 (no or minimal blood), grade 2 (partially filled), grade 3 (completely filled/cast), and grade 4 (ballooning). Incidence of poor outcomes was evaluated using multivariate analysis before and after the introduction of ABCD (October 2015). Subsequently, a 1:1 matched-pairs analysis compared outcomes specifically between patients who underwent ABCD and matched controls receiving standard care. Neurological outcomes were evaluated at 6 months (independent modified Rankin scale). Before ABCD, poor outcomes occurred in 31/41 FVH grade 3 patients (76%; odds ratio (OR) 4.4) and in 38/41 FVH grade 4 patients (93%; OR 29.1). After ABCD, the incidence of poor outcomes decreased to 23/40 in FVH grade 3 patients (58%; P = .043; OR 1.3) and 31/41 in FVH grade 4 patients (76%; P = .017; OR: 3.6). The matched-pairs analysis also showed improvement in poor outcomes for FVH grade 4 patients who underwent ABCD compared with standard care (64% vs 89%, P = .024), but not for FVH grade 1 to 3 patients. No increase in the incidence of ventriculitis was seen in patients receiving ABCD treatment (P = .836). Ballooning fourth ventricular hemorrhage (grade 4 FVH) is a powerful predictor of poor outcomes after aSAH. With the introduction of ABCD, the prognosis of these patients improved considerably and 25% reached functional independence 6 months after aSAH.

Open Microsurgical Versus Endovascular Management of Unruptured and Ruptured Brain Aneurysms.

Open microsurgical and endovascular techniques are the 2 primary strategies for treating intracranial aneurysms. Microsurgical clipping and adjuvant technical maneuvers are well-established techniques with a track record for high occlusion rates and durable repairs. Endovascular, endosaccular, and extrasaccular therapies are associated with lower peri-procedural morbidity but with generally higher rates of retreatment. We discuss key clinical and anatomic considerations in treatment decision-making and compare the risks and benefits of microsurgical vs endovascular treatment within each context.

Clinical management of a ruptured intracranial aneurysm

BackgroundIntracranial hemorrhage due to a ruptured aneurysm is one of the most serious neurosurgical emergencies. The patient mostly presents with severe headaches and neurological deterioration. A rapid diagnosis and an interdisciplinary approach play a major role in the fate of these patients. The treatment can vary from endovascular to surgical and must be carefully and individually planned. Neurovascular expertise and an interdisciplinary approach are of vital importance and obligatory for the best possible outcome.MethodsIn this narrative review, we scrutinize the current literature and discuss the actual data and guidelines in order to emphasize the importance of the interdisciplinary expertise and approach in patients with ruptured intracranial aneurysm.ResultsThe current approach to patients with ruptured aneurysm is inhomogeneous and often ineffective due to internal disputes between different disciplines. Although there is plenty of literature and hard evidence to “show the way,” many still choose to base their decisions on personal experience or opinion.ConclusionsEvery ruptured brain aneurysm should be approached in an interdisciplinary manor and treated according to the current evidence and guidelines.

Intraoperative neuromonitoring as real-time diagnostic for cerebral ischemia in endovascular treatment of ruptured brain aneurysms

ObjectiveTo evaluate the diagnostic accuracy of intraoperative neurophysiological monitoring (IONM) during endovascular treatment (EVT) of ruptured intracranial aneurysms (rIA). MethodsIONM and clinical data from 323 patients who underwent EVT for rIA from 2014-2019 were retrospectively reviewed. Significant IONM changes and outcomes were evaluated based on visual review of data and clinical documentation. ResultsOf the 323 patients undergoing EVT, significant IONM changes were noted in 30 patients (9.29%) and 46 (14.24%) experienced postprocedural neurological deficits (PPND). 22 out of 30 (73.33%) patients who had significant IONM changes experienced PPND. Univariable analysis showed changes in somatosensory evoked potential (SSEP) and electroencephalogram (EEG) were associated with PPND (p-values: <0.001 and <0.001, retrospectively). Multivariable analysis showed that IONM changes were significantly associated with PPND (Odd ratio (OR) 20.18 (95%CI:7.40–55.03, p-value: <0.001)). Simultaneous changes in both IONM modalities had specificity of 98.9% (95% CI: 97.1%–99.7%). While sensitivity when either modality had a change was 47.8% (95% CI: 33.9%–62.0%) to predict PPND. ConclusionsSignificant IONM changes during EVT for rIA are associated with an increased risk of PPND. SignificanceIONM can be used confidently as a real time neurophysiological diagnostic guide for impending neurological deficits during EVT treatment of rIA.

Pioglitazone in spontaneous subarachnoid hemorrhage: study protocol of a multicenter, double-blind, randomized trial (PSSH).

Introduction: Spontaneous subarachnoid hemorrhage (SAH), is a disorder that may be fatal and is primarily caused by a ruptured brain aneurysm. Despite significant leaps forward in the methods to produce aneurysms, the long-term outcomes did not much improve. Pioglitazone is a medication that has been authorized by the FDA as an agonist for the peroxisome proliferator-activated receptor-gamma (PPARγ). Pioglitazone or PPARγ has neuroprotective benefits in animal experiments both during and after traumatic brain injury (TBI) and SAH. Nevertheless, the treatment impact of Pioglitazone on humans is still unknown at this time. As a result, we will conduct a randomized, double-blind, placebo-controlled trial to explore the impact of pioglitazone on SAH. Methods/Design: This trial will recruit 400 patients with SAH from four Chinese hospitals. These patients will be equally and randomly assigned to Pioglitazone and placebo control groups for up to 30 days. Scores on the modified Rankin scale (mRS) are the primary outcomes. The secondary outcomes are a 30-day all-cause mortality rate, 6months of Montreal cognitive assessment (Mo-CA), delayed cerebral ischemia, the requirement for intensive care, the incidence of sepsis, etc. All serious adverse events (SAEs) were recorded during the hospital. Every primary and safety analysis was conducted based on the intention-to-treat technique. The participants were given either a matching placebo or 15mg of pioglitazone, with dose titrated to a target of 45mg daily. Data on the therapeutic use of pioglitazone after SAH will be provided as a consequence of the findings of this experiment. In addition, this pilot trial is the first to prospectively investigate the effectiveness and safety of pioglitazone in patients with SAH. Ethics and dissemination: Ethics approval was obtained from the Medical Ethics Committee of 904th Hospital of Joint Logistic Support Force of PLA (Wuxi Taihu Hospital, approval No. 20220701). The findings of the trial will be presented at conferences, discussed in relevant patient groups, and published in peer-reviewed journals. Clinical Trial Registration: clinicaltrials.gov, identifier ChiCTR2200062954.

Neurosurgical clipping vs spiral management in ruptured brain aneurysm. A systematic review

Introducción: La rotura de aneurismas intracraneales, se pueden tratar mediante clipaje o terapia endovascular con espiral, por lo que, es necesario realizar una investigación sobre, el manejo neurocrítico y neuroquirúrgico, teniendo en consideración que la hemorragia subaracnoidea aneurismática, es una causa importante de muerte y discapacidad a nivel mundial. Objetivos: Comparar la terapia endovascular versus tratamiento quirúrgico con clipaje en pacientes con hemorragia subaracnoidea por aneurisma cerebral roto Materiales y métodos: Mediante la aplicación de criterios de inclusión y exclusión se inició la búsqueda de la revisión sistemática. Se revisaron Bases de datos como Google académico, ScienceDirect, Mendeley, Pubmed, IntechOpen, sitios web de revistas de alto prestigio, para consultar los registros e identificar estudios con el tema de búsqueda terapia endovascular versus tratamiento quirúrgico con clipaje en pacientes con hemorragia subaracnoidea por aneurisma cerebral roto. Resultados: Mayor eficacia con el tratamiento quirúrgico de los pacientes con aneurismas de la cerebral media, Rankin modificada &gt;2 puntos: 18% para clipaje versus 24% tratamiento endovascular. Occlusion completa del aneurisma75% para el tratamiento quirúrgico versus 35% para el manejo endovascular. Oclusión completa del aneurisma. Pacientes asignados al clipaje (85%) pacientes asignados al espiral (67%). En comparación, el clipaje se asoció con una menor tasa de resangrado al alta y una mayor tasa de oclusión aneurismática a 1 año de seguimiento, la espiral redujo la tasa de vasoespasmo al alta y la tasa de resultados a 1 año fue mejor para espiral. Conclusión: La terapia endovascular, es una opción factible en pacientes con aneurismas roto de difícil abordaje quirúrgico como por ejemplo el circuito posterior cerebral, comunicante posterior, cerebelosas superiores e inferiores. El clipaje quirúrgico en el tratamiento del aneurisma cerebral roto, es la mejor opción cuando el abordaje es posible tanto por cirugía abierta, así como cirugía mínimamente invasiva, presentando altos porcentajes de oclusión completa del aneurisma. Ambas terapias representan una posibilidad en el manejo del aneurisma roto, según la localización y valorados por la escala de Rankin modificada.

Morphological Characteristics of Ruptured Brain Aneurysms: A Systematic Literature Review and Meta‐Analysis

Background It is unclear what morphological features of brain aneurysms are better at predicting risk of rupture. We conducted a meta‐analysis to analyze the best morphological determinants of rupture status. Methods The Nested Knowledge platform was used to perform a search of articles reporting on aneurysm size, aspect ratio (AR), size ratio (SR), ellipticity index, nonsphericity index, and undulation index. The mean differences between ruptured and unruptured aneurysms were used to calculate effect sizes. Results A total of 63 studies with 13 025 aneurysms were included: 6966 ruptured aneurysms and 6059 unruptured aneurysms. Ruptured aneurysms had a larger size ( P &lt;0.001), AR ( P &lt;0.001), SR ( P &lt;0.001), ellipticity index ( P =0.049), and nonsphericity index ( P =0.049) compared with unruptured aneurysms. The mean size of ruptured aneurysms was 6.1 mm (95% CI, 5.6–6.5). The size of ruptured and unruptured aneurysms was similar in the anterior cerebral artery ( P =0.28), anterior communicating artery ( P =0.31), and basilar artery ( P =0.51). The mean AR of ruptured aneurysms was 1.5 (95% CI, 1.4–1.6), and the mean SR was 2.3 (95% CI, 2.1–2.5). For mirror aneurysms, the mean AR was 1.2 (95% CI, 1.2–1.5), and the mean SR was 2.2 (95% CI, 2.1–2.5). Conclusions Size is not significantly different between ruptured and unruptured aneurysms located in the anterior cerebral artery, anterior communicating artery, and basilar artery. SR is significantly different between ruptured and unruptured aneurysms in all locations. A mean AR of 1.5 and SR of 2.3 are the thresholds associated with ruptured aneurysm status.

Study of an ocular ptosis in a 13th century illuminated manuscript

The finding of an eyelid ptosis in a manuscript of the xiii century raises the differential diagnosis of injury to the third cranial nerve. This nerve was not differentiated from the other oculomotors until the xvi century and only in the xix century a clinicopathological correlation was established for its paralysis. Describe the characteristics and differential diagnoses of an eyelid ptosis illustrated in the Book of Divine Works (1173) by Hildegard of Bingen. In the mentioned work the nun Richardis of Stade is portrayed with her left eyelid drooping. Two conspicuous signs are described, ptosis and corresponding raising of the eyebrow. The deviation of the eye downward and outward is inferred from the shape that adopts the eyelid by the position of the eye and the curvature of the cornea. The picture is consistent with an isolated paralysis of the oculomotor nerve. The causes of ptosis are discussed: aponeurotic due to levator palpebrae dehiscence; myogenic, congenital and acquired; of the neuromuscular junction, and neuropathic, the latter being the most probable in this case and of a compressive mechanism. The nun's unexpected natural death suggests a ruptured brain aneurysm. Richardis of Stade's portrait shows an oculomotor paralysis centuries before its anatomy, function, and clinicopathological expression were known. Credit for this original description must go to Hildegard, whose medical vocation has long been recognized.

Initial experience in the microsurgical treatment of ruptured brain aneurysms in the endovascular era: characteristics and safety of the learning curve in the first 300 consecutively treated patients.

Currently, there is an increasing tendency to refer only complex aneurysms for microsurgery. The formation of new neurosurgeons dedicated to open vascular neurosurgery becomes challenging in a situation in which complex aneurysms must be dealt with early in the career, raising questions about the safety of the learning curve. We analyzed the characteristics and surgical results of the first 300 consecutively treated patients after subarachnoid hemorrhage by a single neurosurgeon. The incidence of surgical complications and clinical outcomes during the learning curve were analyzed, looking for critical periods regarding patient safety. Microsurgical operative times were also studied. A high frequency of wide-necked aneurysms was observed (70.3%), and, as a result, large (> 10mm), MCA and paraclinoid aneurysms were overrepresented. A statistically significant correlation between surgical experience and clinical outcomes was observed, with progressive surgical experience resulting in a lower incidence of unfavorable outcomes. We also observed a higher frequency of major surgical complications, unfavorable clinical outcomes, and lower complete occlusion rates among the first 40 patients. Microsurgical operative times progressively and significantly decreased during the learning curve. We observed a high prevalence of wide-necked aneurysms. Young neurosurgeons must be trained and prepared to deal with these aneurysms early in their careers. Although we observed a decrease in unfavorable results with cumulative surgical experience, the first 40 cases were associated with higher rates of major surgical complications, worse clinical outcomes, and lower complete occlusion rates, indicating that this period may be more critical to patient safety.

Fluoroscopy, CT, and MR imaging characteristics of a novel primarily bioresorbable flow-diverting stent for aneurysms.

Five to ten percent of the global population have unruptured intracranial aneurysms, and ruptured brain aneurysms cause approximately 500,000 deaths a year. Flow-diverting stent treatment is a less invasive intracranial aneurysm treatment that induces aneurysm thrombosis. The imaging characteristics of a novel primarily bioresorbable flow-diverting stent (BFDS) are assessed in comparison to the leading metal stent using fluoroscopy, CT, and MRI. X-ray/fluoroscopic images of stents were taken using a human cadaveric skull model. CT and MRI were acquired using silicone flow models of residual aneurysms. Images were analyzed with Likert scales in anonymous surveys by neurointerventionalists. Quantitative measurements of radiographic density (CT) and artifact boundary size (CT & MRI) were also obtained. Visibility of the BFDS on X-ray was less than the metal stent but deemed adequate for deployment and intraprocedural assessment. The metal stent was more radiopaque than the BFDS on CT, but qualitative assessment was not significantly different for the two stents. MRI imaging was significantly better using the BFDS in terms of overall artifact and intraluminal assessment. The BFDS has adequate visualization on X-ray/fluoroscopy and should be clinically acceptable for fluoroscopic deployment. On MRI, there is less quantitative artifact as well as overall improved qualitative assessment that will allow for more detailed non-invasive imaging follow-up of treated aneurysms, potentially reducing the need for digital subtraction catheter angiography.

IL-6 Quotient (The Ratio of Cerebrospinal Fluid IL-6 to Serum IL-6) as a Biomarker of an Unruptured Intracranial Aneurysm.

BackgroundStudies conducted so far have focused mainly on the assessment of IL-6 levels in patients with ruptured brain aneurysms. Carrying out detailed studies in patients with un-ruptured brain aneurysms (UIA) would be extremely important, as it would answer the question of whether IL-6 plays also a role in primary aneurysm formation and growth.MethodsIL-6, S100, NSE, and albumin concentrations in 67 UIA patients and 17 individuals without vascular lesions in the brain were tested using in vitro diagnostic immunoassays according to the manufacturers’ instructions. IL-6 Quotient was calculated by dividing cerebrospinal fluid (CSF) IL-6 by serum IL-6.ResultsWe showed that IL-6 Quotient was significantly higher in UIA patients (1.78) compared to the control group (0.87; p<0.001). Multivariate logistic regression analysis demonstrated that a growth in IL-6 Quotient increases the probability of UIA diagnosis. In UIA patients CSF IL-6 concentration was significantly higher (4.55 pg/ml) compared to the serum concentration (2.39 pg/ml; p<0.001). In both the study and control group, the blood-brain barrier was intact, thus the CSF-blood gradient of the IL-6 concentration in UIA patients was likely to be the expression of local synthesis of the cytokine within the central nervous system. Patients with multiple brain aneurysms had significantly higher CSF IL-6 levels (5.08 pg/ml) compared to individuals with a single aneurysm (4.14 pg/ml; p=0.0227).ConclusionThis totality of the may suggest IL-6 as a biomarker for UIA formation; however, further studies are needed to unequivocally confirm clinical application of IL-6 concentration evaluation.

Flow-diverter stents in the early management of acutely ruptured brain aneurysms: effective rebleeding protection with low thromboembolic complications.

Flow-diverter stents (FDSs) are not generally used for the management of acutely ruptured aneurysms with associated subarachnoid hemorrhage (SAH). Herein, the authors present their experience with FDSs in this scenario, focusing on the antiplatelet regimen, perioperative management, and outcome. The authors retrospectively reviewed their institutional database for the treatment and outcomes of all patients with acutely ruptured aneurysms and associated SAH from July 2010 to September 2018 who had received an FDS implant as stand-alone treatment within 4 days after diagnosis. The protocol with the use of flow diversion in these patients includes a low threshold for placement of external ventricular drains before stenting, followed by the administration of aspirin and clopidogrel with platelet testing before stent implantation. With this approach, the risk of hemorrhage and stent-related thrombus formation is limited. Demographic, clinical, technical, and imaging data were analyzed. Overall, 76 patients (61% females, mean age 42.8 ± 11.3 years) met the inclusion criteria. FDS implantation was performed a median of 2 days after diagnosis. On average, 1.05 devices were used per procedure. There was no procedural mortality directly attributed to the endovascular intervention. Procedural device-related clinical complications were recorded in a total of 6 cases (7.9%) and resulted in permanent neurological morbidity in 2 cases (2.6%). There was complete immediate aneurysm occlusion in 11 patients (14.5%), and persistent aneurysm filling was seen in 65 patients (85.5%). Despite this, no patient presented with rebleeding from the target aneurysm. There was an excellent clinical outcome in 62 patients (81.6%), who had a 90-day modified Rankin Scale score of 0-2. Among the 71 survivors, total or near-total occlusion was observed in 64/67 patients (95.5%) with a 3- to 6-month angiographic follow-up and in all cases evaluated at 12 months. Five patients (6.6%) died during follow-up for reasons unrelated to the procedure or new hemorrhage. Flow diversion is an effective therapeutic strategy for the management of select acutely ruptured aneurysms. Despite low rates of immediate aneurysm occlusion after FDS implantation, the device exerts an important protective effect. The authors' experience confirmed no aneurysm rerupture, high rates of delayed complete occlusion, and complication rates that compare favorably with the rates obtained using other techniques.

Blood pressure variability and prognosis in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis.

The subarachnoid hemorrhage due to a ruptured brain aneurysm is a neurological emergency with high mobility and mortality. Hypertensive states are related to a bad prognosis and a higher risk of a ruptured aneurysm. However, the relationship between the blood pressure variability with the aneurysmal subarachnoid hemorrhage and its prognosis is quite unknown. A systematic review was performed across the databases. The following descriptors and related were used for the search: blood pressure, arterial pressure, variability, subarachnoid hemorrhage, hemorrhage, aneurysmal, aneurysmal subarachnoid hemorrhage. The following data were extracted: Glasgow Outcome Scale or Modified Rankin Scale, and blood pressure variabilities to categorize the prognosis. Five studies were selected. The blood pressure variability and the related outcome were assessed by mean systolic blood pressure and minimum systolic blood. The meta-analysis of mean systolic blood pressure (cut-off >95.3 mmHg) showed an odds ratio of 11.23 (95% CI: 4.423 to 28.537) (P≤0.001), predicting the good outcome after the aneurysmal subarachnoid hemorrhage. The pooled analysis revealed AUC of the ROC predicting the good outcome was statistically significant (AUC: 0.85, P<0.001). The pooled data analysis of minimum systolic blood pressure revealed an odds ratio of 6.43 (95% CI: 2.834-14.589, P<0.001) and AUC of the pooled ROC 0.931 (95% CI: 0.851 to 1.000, P<0.001) to predict poor outcome. The funnel plot through Egger's test for the analysis showed different grades of asymmetry. The blood pressure variability (mean and minimum systolic blood pressure) is a good predictor and parameter in the aneurysmal subarachnoid hemorrhage prognosis and outcome prediction.

Clusters Across Multiple Domains of Health-Related Quality of Life Reveal Complex Patient Outcomes After Subarachnoid Hemorrhage.

Patients with subarachnoid hemorrhage were prospectively identified. Clinical data were prospectively recorded. Health-related quality of life was prospectively assessed at 3-month follow-up using the National Institutes of Health Patient Reported Outcomes Measurement Information System and neuro-quality of life in the domains of mobility, cognitive function, satisfaction with social roles, and depression. We used k-means clustering to analyze prospectively recorded health-related quality of life data, identifying clusters of complex patient outcomes. Decision tree analysis identified index hospital stay factors predictive of a patient having a particular complex patient outcome at follow-up. Academic medical center. One hundred three survivors of subarachnoid hemorrhage. None. We analyzed 103 patients, of whom 75 (72.8%) were female, and mean age was 53.6 ± 13.4 years. There were three complex patient outcomes: health-related quality of life greater than 1 sd better than the U.S. mean across all domains (n = 23, 22.3%), health-related quality of life greater than 1 sd worse than U.S. mean across all domains (n = 26, 25.2%), and satisfaction with social roles greater than 0.5 sd worse than U.S. mean with cognitive function, depression, and mobility scores near the U.S. mean (n = 54, 52.4%). In decision tree analysis, hospital disposition and Hunt and Hess Grade were associated with complex patient outcome. Complex patient outcomes across multiple domains of health-related quality of life at follow-up after subarachnoid hemorrhage are distinct and may be predictable.

Functional outcome 1 year after aneurysmal subarachnoid hemorrhage due to ruptured intracranial aneurysm in elderly patients

BackgroundPopulation aging raises questions about extending treatment indications in elderly patients with aneurysmal subarachnoid hemorrhage (aSAH). We therefore assessed functional status 1 year after treatment. MethodsThis study involved 310 patients, aged over 70 years, with ruptured brain aneurysm, enrolled between 2008 and 2014 in a prospective multicentre trial (FASHE study: NCT00692744) but considered unsuitable for randomisation and therefore analysed in the observational arms of the study: endovascular occlusion (EV), microsurgical exclusion (MS) and conservative treatment. The aims were to assess independence, cognition, autonomy and quality of life (QOL) at 1 year post-treatment, using questionnaires (MMSE, ADLI, IADL, EORTC-QLQ-C30) filled in by independent nurses after discharge. ResultsThe 310 patients received the following treatments: 208 underwent EV (67.1%), 54 MS (17.4%) and 48 were conservatively managed (15.5%). At 1 year, independence rates for patients admitted with good clinical status (WFNS I-III) were, according to the aneurysm exclusion procedure (EV, MS or conservative), 58.9%, 50% and 12.1% respectively. MMSE score was pathological in 26 of the 112 EV patients (23.2%), 10 of the 25 MS patients (40%) and 4 of the 9 patients treated conservatively (44%), without any statistically significant difference [Pearson's Chi2 test, F ratio=4.29; P=0.11]. Regarding QoL, overall score was similar between the EV and MS cohorts, but significantly lower with conservative treatment. ConclusionElderly patients in good clinical condition with aSAH should be treated regardless of associated comorbidities. Curative treatment (EV or MS) reduced mortality without increasing dependence, in comparison with conservative treatment.

Efficiency of Iterative Metal Artifact Reduction Algorithm (iMAR) Applied to Brain Volume Perfusion CT in the Follow-up of Patients after Coiling or Clipping of Ruptured Brain Aneurysms

Metal artifacts resulting from coiling or clipping of a brain aneurysm degrade image quality and reduce diagnostic usefulness of computed tomography perfusion CTP. Our aim was to assess the diagnostic value of the iterative metal artifact reduction algorithm (iMAR) in CTP studies after coiling or clipping of ruptured intracranial aneurysms. Fifty-eight CTP exams performed in 32 patients were analysed. iMAR was applied to the source images from the CT scanner. Perfusion maps were generated from datasets both with and without iMAR, and both datasets were compared qualitatively and quantitatively. Qualitative analysis included evaluation of intensity of artifacts, image quality, presence of new artifacts, and the reader’s confidence in their diagnosis as well as diagnostic impression. Quantitative analysis included evaluation of tissue attenuation curves, evaluation of region of interest (ROI)-based measurement of perfusion values at levels that do and do not contain metal, compared to previously published reference ranges of perfusion values. Our results showed that application of iMAR reduced artifacts and significantly improved image quality. New artifacts were observed adjacent to metallic implants, but did not limit the evaluation of other regions. After correction for artifact readers’ confidence in their diagnosis increased from 41.3% to 87.9%, and the diagnostic impression changed in 31% of the exams. No difference between tissue attenuation curves was found. For slices without metal, no difference was noted between values measured before and after iMAR, and the total number of ROIs in the reference range of perfusion values was unchanged. At the level of the metal implant, 89.85% of ROIs obtained before using iMAR showed calculation errors. After using iMAR, only 1.7% showed errors. Before iMAR 3.1% of values were in the reference range, whereas after iMAR this increased to 33.1%. In conclusion, our results show that iMAR is an excellent tool for reducing artifacts in CTP. It is therefore recommended for use in clinical practice, particularly when severe artifacts are present, or when hypoperfusion is suspected at the level of the coil or clip. After the application of iMAR, the perfusion values at the level of the metal can be better calculated, but may not lie within the reference range; therefore, quantitative analysis at the level of artifacts is not advisable.

Prevalence of Previously Undiagnosed Abdominal Aortic Aneurysms in Patients with Intracranial Aneurysms: From the Brain and Aortic Aneurysms Study (BAAS).

A relationship between intracranial and abdominal aortic aneurysms (AAA) has been appreciated through genome-wide association studies suggesting a shared pathophysiology. However, the actual prevalence of AAA in patients presenting with ruptured intracranial aneurysms is not known. Our aim was to estimate the prevalence of previously undiagnosed AAA in patients presenting with aneurysmal subarachnoid hemorrhage (aSAH) to see if it may be high enough to justify formally testing the utility of screening. A prospective, observational inception cohort study of 81 consecutive patients presenting to Mayo Clinic Florida with aSAH was performed from August 14, 2011 to February 10, 2014. These individuals were then screened using an abdominal ultrasound technique for an AAA. Our primary end point was detection of AAA. Our secondary end points were 30-day good-to-fair functional status (modified Rankin scale < 4) and all-cause mortality. We detected an AAA in 10 patients (rate: 12%; 95% CI 6-22%) with aSAH. The mean diameter of these AAA was 3.4 ± 1.0cm. Among these 10 patients, there was one death within the first month of aSAH hospitalization. There were no significant differences in demographic or clinical characteristics based on AAA detection status. Mean follow-up time was 4.7years. The rate of good-to-fair functional status at 30-days was 79%. All-cause mortality during follow-up at 1-year was higher for patients with AAA (36%; 95% CI 0-61%) compared to patients without AAA (7%; 95% CI 1-14%) (log-rank p = 0.045). The co-prevalence of AAA in patients presenting with ruptured brain aneurysms may be sufficiently high such that screening for AAA among likely survivors of aSAH might be appropriate. Larger studies would be needed to establish a net clinical benefit from screening AAA and then treating newly identified large AAAs in this morbid population.

Transcranial doppler in patients with ruptured brain aneurysms in cerebral hemodynamics evaluation and outcomes predicting

The purpose: to develop Doppler criteria in the evaluation of cerebral hemodynamics in predicting the outcome of the disease in patients with cerebral aneurysm rupture.Materials and methods. 172 patients (76 male, 96 female) with cerebral aneurism rupture were participated in the research. All patients were continuously monitored by Doppler studies (a total of 803 studies) in the period from 1 to 20 days after the rupture of the arterial aneurysm. TCD was performed on the apparatus DWL MULTI-DOP T (Germany) with sensors 2 and 4 MHz. All patients were divided into 5 groups depending on the Glasgow outcome Scale (GOS) assessment. Group 1 (n = 87; 50.6%): with an excellent outcome of the disease (GOS 1); group 2 (n = 27; 15.7%): with an good outcome of the disease (GOS 2); group 3 (n = 8; 4.65%): with an acceptable outcome of the disease (GOS 3); group 4 (n = 6; 3.48%): with an acceptable outcome of the disease (GOS 4); group 5 (n = 8; 4.65%): with a lethal outcome of the disease (GOS 5) Systolic blood flow velocity (BFV), Lindegaard index and pulsatility index were estimatedResults. Doppler prognostic criterion of disease outcome were developed: early and progressive increase in blood flow velocity (development of spasm on the 1 day delay after hemorrhage); the development of critical spasm (blood flow velocity over 300 cm/s) by 7–8 days after subarachnoid hemorrhage, the rise of the blood flow velocity per day more than 36 cm/s; the duration of the spasm more than 16 days; increase in pulsatility index (more than 1.0) and Lindegaard index (more than 4.8), the presence of diffuse spasm.Conclusion. The transcranial Doppler can be an additional screening non-invasive diagnostic method for cerebral hemodynamic evaluation and for determination complications in ruptured cerebral aneurysm.

Nonindex Readmission After Ruptured Brain Aneurysm Treatment Is Associated with Higher Morbidity and Repeat Readmission

Aneurysmal subarachnoid hemorrhage (aSAH) requires complex multidisciplinary care. After initial treatment (index hospital), readmission to a different hospital (nonindex) can compromise quality of care, resulting in increased morbidity. We aimed to evaluate factors associated with nonindex readmission and evaluate association of nonindex hospital readmission on outcomes in patients with ruptured aneurysm. Readmissions within 90 days after aSAH treatment were identified in the 2010-2014 Nationwide Readmissions Database. Multivariable logistic regression identified patient and hospital characteristics associated with nonindex readmission. Separate multivariable models determined increased morbidity or risk of second readmission for nonindex readmissions. A total of 9254 patients who underwent treatment of ruptured aneurysms from 2010 to 2014 were identified. Of these, 1985 (21.5%) were readmitted within 90 days. Three hundred and fifty-five of these readmissions (17.9%) occurred to nonindex hospitals. Patients that were discharged to a skilled nursing or other facility (odds ratio [OR], 1.70; 95% confidence interval [CI], 1.27-2.28]) had higher odds of nonindex readmission, whereas patients with private insurance were associated with lower odds of nonindex readmission (OR, 0.65; 95% CI, 0.46-0.92). Patients readmitted to a nonindex (vs. index) hospital were associated with increased likelihood of major complications (OR, 1.71; 95% CI, 1.18-2.48) and second readmissions (OR, 1.51; 95% CI, 1.17-1.96). After treatment of a ruptured cerebral aneurysm, 17.9% of readmissions occurred at a nonindex hospital. These patients were at increased risk for major complications or subsequent readmissions, which may be because of care fragmentation. Interventions aimed at improving continuity of care may reduce higher morbidity associated with nonindex readmission.

Necessity of follow-up cerebral digital subtraction angiography after endovascular coiling or microsurgical cliping of ruptured intracranial aneurysms to exclude de novo or aneurysmal regrow and avoid its rupture: report of 2 cases

Objective – to improve treatment results of patients with ruptured brain aneurysms using follow-up cerebral digital subtraction angiography to avoid de novo or aneurismal regrow.Materials and methods. Analysis of follow-up cerebral digital subtraction angiography and treatment results of two patient (60 and 64-year-old females) with brain anterior communicated artery de novo aneurysm and regrowed aneurysm of an anterior communicated artery after microsurgical clipping.Results. Two patient underwent endovascular treatment of ruptured brain aneurysms after non follow-up cerebral digital subtraction angiography. In first case de novo aneurysm of anterior communicating artery and in second – regrowed aneurys of anterior communicating artery after surgical clipping. Both patients were discharged from the clinic in I and IV modified Rankin scale. Conclusions. Digital subtraction angiography follow-up of intracranial aneurysms treated by endovascular or microsurgical approach is important for the detection and prediction for the risk of bleeding (aneurysm recurrence and de novo aneurysm). There exist no guidelines on the frequency of monitoring and imaging modality to adopt and the monitoring is adapted on a case-by-case basis. Digital subtraction angiography is the gold standard for the evaluation of aneurysmal occlusion after coiling and microsurgical clipping and remains also necessary for evaluating other devices.