Unruptured Saccular Intracranial Aneurysms Research Articles

The rupture risk of intracranial saccular aneurysm: a case-control study based on a three-dimensional computed tomography angiography model.

Assessing the risk of rupture in intracranial aneurysms is crucial. Advancements in medical imaging now allow for three-dimensional (3D) assessments of aneurysms, providing a more detailed understanding of their morphology and associated risks. This study aimed to compare the 3D morphological parameters of ruptured and unruptured intracranial saccular aneurysms (ISAs) using computed tomography angiography (CTA) and to analyze risk factors linked to ISA rupture. This retrospective case-control study included patients diagnosed with ISAs via CTA, for which data were sourced from both the Emergency Department and Inpatient Unit in The First Affiliated Hospital of Jinan University. The patients were categorized into rupture and unrupture groups. We used 3D-Slicer (version 5.2.2, Slicer Community) to construct morphological models of the ISAs and their parent arteries. These models facilitated assessments of intracranial aneurysmal volume (IAV), aneurysmal surface area (ASA), and maximum sectional area (MSA). Differences in 3D morphological parameters between ruptured and unruptured ISAs were then analyzed. For statistical analysis, we first performed single factor analysis on the data, constructed a receiver operating characteristic (ROC) curve one by one with statistically significant parameters, and screened out ROC curves that met the sample requirements. Second, we performed multiparameter logistic regression analysis to construct a ROC curve model and analyzed its predictive performance. The analysis encompassed 97 patients comprising 97 ISAs diagnosed from March 2016 to March 2022. Significant differences in morphological parameters were observed between the rupture and unrupture groups (P<0.05), including IAV, ASA, MSA, IAV/diameter (IAV/D), IAV/neck width (IAV/N), MSA/diameter (MSA/D), MSA/neck width (MSA/N), ASA/neck width (ASA/N), and ASA/MSA. It was found that the IAV, ASA, and MSA values of the rupture group were larger than those of the unrupture group. Meanwhile, the IAV/D, IAV/N, MSA/D, MSA/N, and ASA/N values were larger in the rupture group, while ASA/MSA and ASA/IAV were smaller. This study underscores the significance of specific morphological indicators, such as ASA/N and ASA/MSA, in predicting the rupture risk of ISAs. The IAV, MSA, and ASA parameters, especially in relation to diameter and neck width, provide crucial insights into the rupture potential of ISAs.

Optimizing Patient Care: A Multicentric Study on the Clinical Impact of Sim&Size™ Simulation Software in Intracranial Aneurysm Treatment With Pipeline Embolization Devices

Background and PurposeTo determine the clinical effects (stent size, and number of stents used) of the Sim&SizeTM simulation software on the endovascular treatment of unruptured saccular intracranial aneurysms with Pipeline Embolization Devices (PED). Materials and MethodsThis study is a retrospective analytical multicenter study of patients treated with PED (Flex and Flex with SHIELD) for intracranial aneurysm in XXXX and XXXX. ResultsThe study included 253 patients, of which 75 were treated in Colombia and 178 were treated in France. The majority of patients were women (83.8%), with a median age of 57.48 years, and had large vessel location (88.1%), with most aneurysms located in the ICA paraclinoid segment (56.8%). Patients in the group with Sim&SizeTM simulation had shorter stents than those without simulation (15.62 mm vs. 17.36 mm, p-value= 0.001). Also, a lower proportion of these patients required more than one stent (1.4% vs. 7.3%, p-value=0.022). There were 7 complications reported in the group that used the Sim&SizeTM simulation software, compared to 9 complications in the group that did not use the software. ConclusionsUsing Sim&SizeTM simulation software for endovascular treatment of patients with intracranial aneurysms using PED reduces the stent length and decreasing the number of devices needed per treatment.

Systematic Review and Meta‐Analysis of Endovascular Therapy Effectiveness for Unruptured Saccular Intracranial Aneurysms

Background Currently, endovascular treatment of intracranial aneurysms is limited by low complete occlusion rates. The advent of novel endovascular technology has expanded the applicability of endovascular therapies; however, the superiority of novel embolic devices over the traditional Guglielmi detachable coils is still debated. We performed a systematic review of literature that reported the Raymond–Roy occlusion classification (RROC) rates of modern endovascular devices to determine their immediate and follow‐up occlusion effectivenesses for the treatment of unruptured saccular intracranial aneurysms. Methods A search was conducted using electronic databases (PUBMED, Cochrane, ClinicalTrials.gov, and Web of Science). We retrieved studies published between 2000 and 2022, reporting immediate and follow‐up RROC rates of subjects treated with different endovascular intracranial aneurysm therapies. We extracted demographic information of the treated patients and their reported angiographic RROC rates. Results A total of 80 studies from 15 countries were included for data extraction. The RROC rates determined from angiogram were obtained for 21 331 patients (72.5% women, pooled mean age: 58.2 [95% CI]: 56.8–59.6), harboring 22 791 aneurysms. The most frequent aneurysm locations were the internal carotid artery (46.4%, 95% CI: 41.9%–50.9%), the anterior communicating artery (26.4%, 95% CI: 22.5%–30.8%), the middle cerebral artery (24.5%, 95% CI: 19.2%–30.8%), and the basilar tip (14.4%, 95% CI: 11.3%–18.3%). The complete occlusion probability (RROC‐I) was analyzed for Guglielmi detachable coils, the Woven EndoBridge, and flow diverters. The RROC‐I rate was the highest in balloon‐assisted coiling (73.9%, 95% CI: 65.0%–81.2%) and the lowest in the Woven EndoBridge (27.8%, 95% CI: 13.2%–49.2%). The follow‐up RROC‐I probability was homogenous in all analyzed devices. Conclusion We observed that the coil‐based endovascular therapy provides acceptable rates of complete occlusion, and these rates are improved in balloon‐assisted coils. Out of the analyzed devices, the Woven EndoBridge exhibited the shortest time to achieve &gt;90% probability of follow‐up complete occlusion (∼18 months). Overall, the Guglielmi detachable coils remain the gold standard for endovascular treatment of unruptured saccular aneurysms.

Abstract 174: Treatment of Unruptured Saccular Aneurysms with PED: A Systematic Review and Meta‐Analysis of Long‐Term Outcomes

Introduction The Pipeline Embolization Device (PED) is commonly used for intracranial aneurysm treatment. While its effectiveness for certain types of aneurysms is well‐established, its efficacy for saccular aneurysms remains debatable. This review and meta‐analysis aimed to assess the long‐term outcomes of PED treatment for unruptured intracranial aneurysms (UIA). Methods A systematic review and meta‐analysis were conducted following PRISMA guidelines. Studies with at least one year of follow‐up after PED treatment for saccular aneurysms were included. The primary endpoint was angiographic complete aneurysm occlusion at long‐term (≥ 12 mo.) follow‐up. Secondary outcomes included long‐term complications. We conducted a meta‐regression analysis to explore the potential sources of heterogeneity across studies. Results Eleven studies on 594 patients with 726 aneurysms were included, of which 5% were previously treated. The mean age was 55.7 years, and 78.3% were women. The mean aneurysm size was 7.72 mm, 8.95% were treated with more than one device, and 2.9% had adjunct coiling. The long‐term complete occlusion rate was 81% (CI 95%: 72% to 88%, p&lt;0.01). Regarding long‐term complications, the rate of symptomatic ischemic stroke was 1% (CI 95%: 0% to 4%, p=0.07), the rate of delayed rupture was 1% (95%, CI 0% to 3%, p=0.02), and the rate of intracranial hemorrhage was 3% (CI 95%: 1% to 6%, p=0.81). The meta‐regression analysis revealed a decreasing trend per year for aneurysmal occlusion, ischemic stroke rate, and aneurysmal rupture rate over time and an increasing trend for ICH over time. Conclusion PED demonstrates high long‐term occlusion and low complication rates, suggesting it is a safe and effective treatment option for unruptured intracranial saccular aneurysms. However, studies with greater than 5‐10 years of follow‐up are needed to evaluate the clinical and radiographical outcomes of incompletely occluded aneurysms Additionally, as newer devices exhibit reduced thrombogenic profiles and ICH rates increase over time, reevaluation of antiplatelet therapy's role, including dosage and DAPT, is warranted.

Early clinical experience with the new generation Pipeline Vantage flow diverter in the treatment of unruptured saccular aneurysms using short-term dual antiplatelet therapy.

The Pipeline Vantage flow diverter with Shield technology (PV) used in this study is a 4th-generation flow diverter (FD) designed to reduce thrombogenicity, promote endothelialization of the implant and increase efficiency in achieving aneurysm closure. In this study, we report the aneurysm occlusion rate, complication rate and clinical outcome with short-term dual antiplatelet therapy (DAPT) in the treatment of unruptured intracranial saccular aneurysms using the PV. We retrospectively identified patients treated between September 2021 and January 2023 with the PV and subsequently underwent short-term DAPT for 3 months. Patient and aneurysm characteristics, peri- and post-procedural complications, clinical outcomes and the grade of aneurysm occlusion were documented. Thirty patients with 32 aneurysms were treated. Successful FD implantation was achieved in all cases (100%). No periprocedural complications were documented. The overall symptomatic complication rate was 10% and the neurologic, treatment-related symptomatic complication rate was 6.6%. Only one symptomatic complication (3.3%) was device-related. Permanent clinical deterioration occurred in 2/30 patients (6.6%), leading to deterioration of the mRS within the first 3 months after treatment. No mortality was documented. The rate of complete aneurysm occlusion after 3 months and after a mean imaging follow-up of 9.9 months was 65.6% and 75%, respectively. Implantation of the PV for the treatment of saccular intracranial aneurysms achieves a good aneurysm occlusion rate with a low rate of complications. In addition, the use of short-term DAPT after PV implantation appears to be safe.

Association between underlying autoimmune disease and small aneurysm size at rupture.

Although the role of inflammation in the development of aneurysms is established, less is known about the development of intracranial aneurysms in the setting of underlying autoimmune disease. The underlying systemic inflammatory characteristics of disorders such as systemic lupus erythematosus, rheumatoid arthritis, and Sjögren's syndrome may influence the development of intracranial aneurysms through common inflammatory pathways. The authors hypothesized that there is an association between underlying autoimmune disease and aneurysm growth and rupture. Medical records of patients who underwent cerebral angiography between August 2018 and August 2021 were manually reviewed. Autoimmune diseases as defined for this study are those known to have systemic inflammatory effects on the central nervous system or multiple other organ systems. Statistical analysis, including construction of multivariable linear and logistic regression models, was performed using R version 4.1.0. Chart review identified 190 patients with 469 ruptured and unruptured saccular intracranial aneurysms. There were 31 patients with 44 aneurysms identified as having an autoimmune disease. The mean size of a ruptured aneurysm was significantly smaller among patients with autoimmune disease compared with patients without autoimmune disease (4.14 mm vs 5.34 mm, p = 0.03). The multivariate logistic regression model did not identify any significant association between rupture and autoimmune disease when controlling for other variables (p = 0.49). In the multivariate linear regression model, autoimmune disease was still significantly associated with a smaller size at rupture (p = 0.04), and smoking was associated with a larger size at rupture (p = 0.03) when controlling for other variables. A second multivariate logistic regression model found autoimmune disease to be independently associated with rupture at a size smaller than 7 mm (p = 0.02), while smoking was independently associated with rupture at a size larger than 7 mm (p = 0.01). Autoimmune disease is associated with a smaller aneurysm size at rupture, although it is not associated with rupture itself. This association may be due to inflammatory pathways that are common to autoimmune diseases as well as aneurysm wall development. Although the authors were unable to identify any association between rupture status and the presence of autoimmune disease, the association between smaller size at rupture and autoimmune disease warrants further studies, as autoimmune disease may influence the trajectory of aneurysm development and the decision to treat.

Unruptured intracranial aneurysms: relation between morphology and wall strength.

To determine the morphological features distinguishing small unruptured saccular intracranial aneurysms (sIAs) with high and low wall strength (WS) in post mortem subjects. Subarachnoid haemorrhage caused by sIA rupture is associated with increased mortality and morbidity. Analysis of the morphology and biomechanical properties of sIAs might facilitate the identification of clinically relevant risk factors for sIA rupture. Eight single unruptured sIAs were found among eight subjects during 184 post mortem examinations. After assessment of the dimensions, aspect ratio (AR), size ratio (SR), height/width ratio (HW), bottleneck factor (BNF), and shape, sIAs with adjacent cerebral arteries were subjected to quasi-static increasing pressure until the wall of the cerebral artery or sIA ruptured. In three specimens, the sIA ruptured at a significantly lower average pressure than the other cases, in which the rupture occurred within the wall of the adjacent cerebral artery (769 vs. 1,259 mmHg; p = 0.035). The sIAs with low WS, i.e. sIAs that ruptured during experiments, were characterised by significantly increased dome dimensions compared to sIAs with high WS (p < 0.05). At the same time, no significant differences were observed between high and low WS categories regarding AR, SR, HW, and BNF, or the presence of an irregular dome shape. Dome dimension was the only feature that distinguished unruptured sIAs as having low or high WS, and this supports observations that sIAs with increased dome dimensions are characterised by an increased risk of rupture. Thus, dome dimension may be more useful than other morphometric parameters, such as AR, SR, HW and BNF, in assessing the rupture risk assessment of small unruptured sIAs.

Prevalence and risk factors of unruptured intracranial saccular aneurysms in hospital population by 3D-TOF-MRA with VR reconstruction

PurposeThis study aimed to analyze the prevalence and risk factors of unruptured intracranial aneurysms (UIAs) in a hospital population using 3D-TOF-MRA with VR reconstruction. MethodsThis cross-sectional study included 2149 patients who underwent brain 3D-TOF-MRA at our hospital between January and December 2019. In them, complete clinical data were collected from 1541 patients. Results3D-TOF-MRA examination revealed UIAs in 194 patients (229 aneurysms), for a prevalence of 9%. The average size of the UIAs was 3.7 ± 1.5 mm (range, 2.0–15.5 mm). The incidence rates of UIAs in the internal carotid artery (ICA) was 72.9% (167/229), in anterior cerebral artery (ACA) was 11.4% (26/229), in middle cerebral artery (MCA) was 9.2% (21/229), and in posterior circulation was 6.5% (15/229). Clinical data were collected from 1541 patients completely. There were 158 patients with UIAs and 1383 patients without UIAs. Multivariable regression analysis suggested that age ≥60 years (OR = 1.81, 95%CI: 1.24–2.70, P = 0.003), female sex (OR = 1.50, 95%CI: 1.08–2.10, P = 0.016), and hypertension (OR = 1.55, 95%CI: 1.08–2.28, P = 0.021) were independently associated with UIAs. ConclusionsThis study suggested a high prevalence (9.0%) of UIAs in a hospital population. Age, female sex, and hypertension may be independently associated with UIAs.

Clinical impact of Sim & Size® simulation software in the treatment of patients with cerebral aneurysms with flow-diverter Pipeline stents.

This study evaluated the clinical impact of the Sim&Size® simulation software on the endovascular treatment with flow-diverter stents of patients with unruptured saccular intracranial aneurysms. This monocentric retrospective study evaluated a cohort of patients treated with flow-divert stents between June 1, 2014, and December 31, 2019, for cerebral aneurysms. Patients belonged to two groups, patients treated with and without the Sim&Size® simulation software. Univariate, bivariate, and multivariate analyses were used to evaluate the clinical impact of simulation software. Out of the 73 interventions involving 68 patients analyzed by the study, 76.7% were simulated using the Sim&Size® simulation software, and 23.3% were not. Patients treated with the simulation software had shorter stent lengths (16.00 mm vs. 20.00 mm p-value = 0.001) and surgical time (100.00 min vs. 118.00 min p-value = 0.496). Also, fewer of them required more than one stent (3.6% vs. 17.6% p-value = 0.079). Three patients belonging to the non-stimulated group presented hemorrhagic complications. Using the Sim&Size® simulation software for the endovascular treatment of intracranial aneurysms with pipeline flow-diverter stents reduces the stent length.

Increased aneurysm wall permeability colocalized with low wall shear stress in unruptured saccular intracranial aneurysm.

Aneurysm wall permeability has recently emerged as an in vivo marker of aneurysm wall remodeling. We sought to study the spatial relationship between hemodynamic forces derived from 4D-flow MRI and aneurysm wall permeability by DCE-MRI in a region-based analysis of unruptured saccular intracranial aneurysms (IAs). We performed 4D-flow MRI and DCE-MRI on patients with unruptured IAs of ≥ 5mm to measure hemodynamic parameters, including wall shear stress (WSS), oscillatory shear index (OSI), WSS temporal (WSSGt) and spatial (WSSGs) gradient, and aneurysm wall permeability (Ktrans) in different sectors of aneurysm wall defined by evenly distributed radial lines emitted from the aneurysm center. The spatial association between Ktrans and hemodynamic parameters measured at the sector level was evaluated. Thirty-one patients were scanned. Ktrans not only varied between aneurysms but also demonstrated spatial heterogeneity within an aneurysm. Among all 159 sectors, higher Ktrans was associated with lower WSS, which was seen in both Spearman's correlation analysis (rho = -0.18, p = 0.025) and linear regression analysis using generalized estimating equation to account for correlations between multiple sectors of the same aneurysm (regression coefficient = -0.33, p = 0.006). Aneurysm wall permeability by DCE-MRI was shown to be spatially heterogenous in unruptured saccular IAs and associated with local WSS by 4D-flow MRI.

Peptidomic profiling of cerebrospinal fluid from patients with intracranial saccular aneurysms

Intracranial saccular aneurysms (ISA) represent 90%–95% of all intracranial aneurysm cases, characterizing abnormal pockets at arterial branch points. Ruptures lead to subarachnoid hemorrhages (SAH) and poor prognoses. We applied mass spectrometry-based peptidomics to investigate the peptidome of twelve cerebrospinal fluid (CSF) samples collected from eleven patients diagnosed with ISA. For peptide profile analyses, participants were classified into: 1) ruptured intracranial saccular aneurysms (RIA), 2) unruptured intracranial saccular aneurysms (UIA), and late-ruptured intracranial saccular aneurysms (LRIA). Altogether, a total of 2199 peptides were detected by both Mascot and Peaks software, from which 484 (22.0%) were unique peptides. All unique peptides presented conserved chains, domains, regions of protein modulation and/or post-translational modification sites related to human diseases. Gene Ontology (GO) analyses of peptide precursor proteins showed that 42% are involved in binding, 56% in cellular anatomical entities, and 39% in intercellular signaling molecules. Unique peptides identified in patients diagnosed with RIA have a larger molecular weight and a distinctive developmental process compared to UIA and LRIA (P ≤ 0.05). Continued investigations will allow the characterization of the biological and clinical significance of the peptides identified in the present study, as well as identify prototypes for peptide-based pharmacological therapies to treat ISA. Significance•Intracranial aneurysms (IAs) are arterial dilations that occur due to weakness in the media layer of the arterial wall. Due to lack of symptoms, IAs are usually found incidentally when the rupture occurs. The mechanism that causes vasospasms are not completely understood.•Here, twelve cerebrospinal fluid (CSF) samples collected from eleven patients diagnosed with IAs were investigated by mass spectrometry-based peptidomics.•2199 peptides were identified by both Mascot and Peaks software, from which 484 (22.0%) were unique peptides.•Even considering the relatively low number of patients enrolled in this seminal study, all unique peptides presented conserved chains, domains, regions of protein modulation and/or post-translational modification sites related to human diseases.•Gene Ontology (GO) analyses of peptide precursor proteins showed that 42% are involved in binding, 56% in cellular anatomical entities, and 39% in intercellular signaling molecules.•Unique peptides identified in patients diagnosed with RIA have a larger molecular weight and a distinctive developmental process compared to UIA and LRIA (P ≤ 0.05).•These results suggest peptides as novel ISA markers.•Continued investigations will allow the undoubted characterization of specific peptides that can be used as prototypes for peptide-based diagnostics and pharmacological therapies, to predict, prevent and/or treat ISA.

Management decisions on unruptured intracranial aneurysms before and after implementation of the PHASES score

BackgroundIn management decisions on saccular unruptured intracranial aneurysms (UIAs) the risk of rupture is an important factor. The PHASES score, introduced in 2014, provides absolute 5-year risks of rupture based on six easily retrievable patient and aneurysm characteristics. We assessed whether management decisions on UIAs changed after implementation of the PHASES score. Patient and methodsWe included all patients with UIAs who were referred to two Dutch tertiary referral centers for aneurysm care in the Netherlands (University Medical Center Utrecht (UMCU) and Leiden University Medical Center (LUMC)) between 2011 and 2017. Analyses were done on an aneurysm level. We calculated the overall proportion of UIAs with a decision to treat before and after PHASES implementation and studied the influence of age and center on post-implementation management changes. ResultsWe included 623 patients with 803 UIAs. The proportion of UIAs with a decision to treat was 123/360 (34.2%) before and 117/443 (26.4%) after PHASES implementation (absolute risk difference: −7.8%; 95% CI: −14.1 to −1.4). The decision to treat was made at a higher median PHASES score after implementation (7 points (IQR 5;10) pre- versus 8 points (IQR 5;10) post-implementation; p = 0.14). The reduced proportion with a treatment decision after implementation was most pronounced in patients <50 years (−22.3%; 95% CI: −39.2 to −3.4) and was restricted to treatment decisions made at the UMCU (−10.6%; 95% CI: −18.5 to −2.5). Discussion and conclusionsManagement of UIAs changed following implementation of the PHASES score, but the impact of PHASES implementation on treatment decisions differed across age subgroups and centers.

An overview of intracranial aneurysms

Intracranial aneurysms are relatively common, with a prevalence of approximately 4%. Unruptured aneurysms may cause symptoms mainly due to a mass effect, but the real danger is when an aneurysm ruptures, leading to a subarachnoid hemorrhage. Most aneurysms are asymptomatic and will not rupture, but they grow unpredictably and even small aneurysms carry a risk of rupture. Intracranial aneurysms are diagnosed and monitored with imaging including intra-arterial digital subtraction angiography, computed tomography angiography, magnetic resonance angiography, and recently transcranial Doppler ultrasonograpy has been proposed as a potential modality. Treatment options include observation, endovascular coiling, and surgical clipping. This paper will review the epidemiology, pathogenesis, clinical presentation, diagnosis, natural history, and management of unruptured saccular intracranial aneurysms.

Intracranial aneurysm management in patients with late-onset Pompe disease (LOPD)

Pompe disease is a rare hereditary metabolic disorder caused by α-glucosidase (GAA) deficiency. The late-onset form of the disease (LOPD) is considered a multisystemic disorder which could involve vascular system with cerebrovascular abnormalities such as intracranial aneurysms or dolichoectasia. Intracranial aneurysm rupture may represent a life-threatening emergency. A possible treatment of unruptured intracranial aneurysms (UIAs) should consider both aneurysm-related (aneurysmal size, shape, localization, numbers and hemodynamic factors) and patient-related risk factors (patient's age and sex, hypertension, smoke exposure). Moreover, UIAs management of LOPD patients needs also to take into account the altered blood vessels integrity and elasticity, whose consistency is likely weakened by the deficient GAA activity as a further potential risk factor. We herein present our approach for of UIAs management in three patients with LOPD. Among them, only one patient with a left saccular UIA of the anterior communicating artery, after careful consideration of risk factors, underwent the endovascular treatment. The other two patients were scheduled for a 1-year follow-up, according to radiological, clinical, and risk evaluation features. Finally, we would like to suggest some general recommendations for UIAs management. In particular, if no risk factors are identified, a cautious yearly follow-up is suggested; otherwise, if risk factors are present, endovascular treatment should be considered.

Management of unruptured incidentally found intracranial saccular aneurysms.

Unruptured intracranial saccular aneurysms occur in 3-5% of the general population. As the use of diagnostic medical imaging has steadily increased over the past few decades with the increased availability of computed tomography (CT) and magnetic resonance imaging (MRI), so has the detection of incidental aneurysms. The management of an unruptured intracranial saccular aneurysm is challenging for both patients and physicians, as the decision to intervene must weigh the risk of rupture and resultant subarachnoid hemorrhage against the risk inherent to the surgical or endovascular procedure. The purpose of this paper is to provide an overview of factors to be considered in the decision to offer treatment for unruptured intracranial aneurysms in adults. In addition, we review aneurysm and patient characteristics that favor surgical clipping over endovascular intervention and vice versa. Finally, the authors propose a novel, simple, and clinically relevant algorithm for observation versus intervention in unruptured intracranial aneurysms based on the PHASES scoring system.

Unruptured aneurysmal clipping complicated by delayed and refractory vasospasm: case report

BackgroundDelayed symptomatic vasospasm is a rare complication following clipping of an unruptured intracranial saccular aneurysm. There have been ten reported cases of delayed symptomatic vasospasm and only two of these occurred after 2 weeks from initial intervention. Our case is the first to document the refractory nature of such vasospasm despite aggressive first line therapy.Case presentationHere, we present a 67-year-old female who had surgical clipping of a 10x7mm right middle cerebral artery (MCA) bifurcation aneurysm. Her surgery and initial postoperative course were uncomplicated, but she presented with acute left hemiparesis, dysarthria, headache and vomiting on post-op day 29 secondary to vasospasm of M2. She was initially stabilized with intra-arterial verapamil then managed with volume expansion, permissive hypertension, and nimodipine. She developed recurrent vasospasm of M2 the following day and was again treated with intra-arterial verapamil. Magnetic resonance imaging (MRI) brain showed an infarction involving the right basal ganglia, frontal lobe, and parietal lobe and her hospital course was complicated by super-refractory status epilepticus. At her follow up appointment she displayed continued left lower extremity weakness, left visual field defect, and left-sided neglect.ConclusionsOverall, cerebral vasospasms associated with unruptured aneurysms remain rare complications and are not often monitored for after initial recovery. Reviewing the documented cases highlights the unpredictability of when these events occur with our current knowledge. Current hypotheses for the mechanisms responsible for delayed and refractory vasospasms include: blood-derived breakdown products, mechanically induced vasospastic responses, and delayed reactions from the trigemino-cerebrovascular system (TCVS). The uncertainly of these events warrants further research and supports a strong argument for monitoring patients with initial surgical clipping up to a month out from their initial procedure.

Analysis of the Surgical Outcome of Unruptured Intracranial Saccular Aneurysms in Octogenarians (80-89 Years).

Background:The prevalence of unruptured intracranial aneurysms is increasing in elderly population in Japan. Octogenarians (80–89 years) are more prone to complications due to increased age, comorbidities, increased risk of vasospasm, and treatment risks.Aim:The aim is to study the surgical outcome of unruptured intracranial saccular aneurysms in elderly patients aged between 80 and 89 years.Patients and Methods:A retrospective study was conducted involving all the cases of unruptured intracranial saccular aneurysms operated surgically in elderly patients aged between 80 and 89 years. All the cases operated between January 2017 and October 2019 were included in the study. The preoperative neurological status was assessed using the Glasgow Coma Scale (GCS). The comorbidities and risk factors involved were assessed. Postoperative neurological status was assessed by (1) postoperative GCS score and by the (2) presence or absence of the motor weakness of limbs.Results:Thirty-three aneurysms were operated in 27 patients. Two patients were operated two times at separate occasions for different aneurysms during the study period and hence making a total of 29 surgeries. The age range was 80–88 years, with a mean of 82.4 years ± 2.64 standard deviation (SD). There were 7 (24.1%) males and 22 (75.86%) females. All the patients had a preoperative GCS score of 15/15 without focal neurological deficit. The mean size (mm) of the aneurysms was 6.57 ± 4.04 SD. There were 31 (93.94%) aneurysms in the anterior circulation and 2 (6.06%) aneurysms in the posterior circulation. The comorbidities and risk factors were analyzed and found to be not influencing the outcome of the patients. Clipping was done in 32 aneurysms. One case of posterior inferior cerebellar artery (PICA) aneurysm underwent occipital artery to PICA bypass surgery. The postoperative complications include chronic subdural hematoma (CSDH) in 7 (24.13%) patients, extradural hematoma in 1 (3.4%), meningitis in 1 (3.4%), and lower cranial nerve palsy in 1 (3.4%) patient. All the patients were discharged with GCS score 15/15 without motor weakness of the limbs. The mean duration of stay was 16.62 days ± 9.98 SD.Conclusion:Surgery for unruptured saccular aneurysms in octogenarians has got a good result in the tertiary care facility. Advanced age alone should not be considered for preferring coiling over clipping. Octogenarians are more prone to developing postoperative CSDH.

Pointwise encoding time reduction with radial acquisition in subtraction-based magnetic resonance angiography to assess saccular unruptured intracranial aneurysms at 3Tesla.

To investigate the clinical utility of pointwise encoding time reduction with radial acquisition in subtraction-based magnetic resonance angiography (PETRA-MRA) and time-of-flight magnetic resonance angiography (TOF-MRA) to evaluate saccular unruptured intracranial aneurysms (UIAs). A total of 49 patients with 54 TOF-MRA-identified saccular UIAs were enrolled. The morphologic parameters, contrast-to-noise-ratios (CNRs), and sharpness of aneurysms were measured using PETRA-MRA and TOF-MRA. Two radiologists independently evaluated subjective image scores, focusing on aneurysm signal homogeneities and sharpness depictions using a 4-point scale: 4, excellent; 3, good; 2, poor; 1, not assessable. PETRA-MRA and TOF-MRA acoustic noises were measured. All aneurysms were detected with PETRA-MRA. The morphologic parameters of 15 patients evaluated with PETRA-MRA were more closely correlated with those receiving computed tomography angiography over those receiving TOF-MRA. No significant differences between PETRA-MRA and TOF-MRA parameters were seen in the 54 UIAs (p > 0.10), excluding those with inflow angles (p < 0.05). In four patients with inflow angles on PETRA-MRA, the angles were more closely related to those of digital subtraction angiography than those of TOF-MRA. CNRs between TOF-MRA and PETRA-MRA were comparable (p = 0.068), and PETRA-MRA sharpness values and subjective image scores were significantly higher than those of TOF-MRA (p < 0.001). Inter-observer agreements were excellent for both PETRA-MRA and TOF-MRA (intraclass correlation coefficients were 0.90 and 0.97, respectively). The acoustic noise levels of PETRA-MRA were much lower than those of TOF-MRA (59 vs.73dB, p < 0.01). PETRA-MRA, with better visualization of aneurysms and lower acoustic noise levels than TOF-MRA, showed a superior diagnostic performance for depicting saccular UIAs.

Wall enhancement on black-blood MRI is independently associated with symptomatic status of unruptured intracranial saccular aneurysm.

This study aims to investigate whether aneurysm wall enhancement (AWE) is independently associated with symptomatic status of unruptured intracranial aneurysms (UIAs). One hundred thirty-nine consecutive patients (67 male, mean age 58 ± 11years) with 79 symptomatic and 87 asymptomatic UIAs were imaged using black-blood MRI pre- and post-gadolinium contrast administration and 3D DSA. Symptoms related to aneurysms were identified including cranial nerve deficits and headache. AWE grade and area were characterized, and aneurysm size was measured on DSA. Multivariate binary logistic regression analysis was used to identify factors associated with symptoms. Further subgroup analysis was performed for aneurysms size < 10mm. Symptomatic UIAs had significantly larger aneurysm size (11.2 ± 6.2mm vs. 6.4 ± 3.3mm), enhancement grade (1.3 ± 0.6 vs. 0.4 ± 0.6), enhancement area (2.0 ± 0.9 vs. 0.4 ± 0.7), and higher prevalence of thick enhancement (39% vs. 3%) compared with asymptomatic UIAs, all p < 0.001. In multivariate analysis, only AWE area (odds ratio [OR] 6.9, 95% confidence interval [4.0, 11.7]) was independently associated with symptoms. AWE area had an area under curve (AUC) value of 0.888, with 72.2% sensitivity and 92.0% specificity for symptoms, which was superior to aneurysm size (AUC of 0.771, with 75.9% sensitivity and 65.5% specificity). In the subgroup analysis of aneurysms smaller than 10mm (n = 118), AWE area (OR, 7.0, p < 0.001) remained the only independent risk factor associated with symptoms. Larger AWE area is independently associated with symptomatic UIAs, which may provide additional value to guide UIA management and improve patient outcomes. • Symptomatic intracranial aneurysms are larger and more often demonstrate significant wall enhancement than asymptomatic aneurysms. • Larger wall enhancement area is independently associated with symptomatic intracranial aneurysm.

Radiation dose and fluoroscopy time of modern endovascular treatment techniques in patients with saccular unruptured intracranial aneurysms

ObjectivesModern endovascular treatment of unruptured intracranial aneurysms (UIAs) demands for observance of diagnostic reference levels (DRLs). The national DRL (250 Gy cm2) is only defined for coiling. We provide dosimetric data for the following procedures: coiling, flow diverter (FD), Woven EndoBridge (WEB), combined techniques.MethodsA retrospective single-centre study of saccular UIAs treated between 2015 and 2019. Regarding dosimetric analysis, the parameters dose area product (DAP) and fluoroscopy time were investigated for the following variables: endovascular technique, aneurysm location, DSA protocol, aneurysm size, and patient age.ResultsEighty-seven patients (59 females, mean age 54 years) were included. Total mean and median DAP (Gy cm2) were 119 ± 73 (89–149) and 94 (73; 130) for coiling, 128 ± 53 (106–151) and 134 (80; 176) for FD, 128 ± 56 (102–153) and 118 (90; 176) for WEB, and 165 ± 102 (110–219) and 131 (98; 209) for combined techniques (p > .05). Regarding the aneurysm location, neither DAP nor fluoroscopy time was significantly different (p > .05). The lowest and highest fluoroscopy times were recorded for WEB and combined techniques, respectively (median 26 and 94 min; p < .001). A low-dose protocol yielded a 43% reduction of DAP (p < .001). Significantly positive correlations were found between DAP and both aneurysm size (r = .320, p = .003) and patient age (r = .214, p = .046).ConclusionsThis UIA study establishes novel local DRLs for modern endovascular techniques such as FD and WEB. A low-dose protocol yielded a significant reduction of radiation dose.Key Points• This paper establishes local diagnostic reference levels for modern endovascular treatment techniques of unruptured intracranial aneurysms, including flow diverter stenting and Woven EndoBridge device.• Dose area product was not significantly different between endovascular techniques and aneurysm locations, but associated with aneurysm size and patient age.• A low-dose protocol yielded a significant reduction of dose area product and is particularly useful when applying materials with a high radiopacity (e.g. platinum coils).