Unruptured Saccular 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.

Abstract WP181: Treatment of Unruptured Small and Medium Wide-Necked Aneurysms of the Internal Carotid Artery Using the 64-Wire Surpass Evolve: Results of the SEASE International Registry

Introduction: The management of wide-necked internal carotid artery (ICA) aneurysms is technically challenging with established endovascular and microsurgical techniques that are limited by the associated morbidity and/or recurrence. The PREMIER study first demonstrated high rates of complete occlusion without parent vessel stenosis or permanent neurological complications after the treatment of wide-necked small and medium-sized intracranial ICA aneurysms with the 48-wire pipeline. We aimed to assess the effectiveness and safety of the new generation 64-wire Surpass Evolve (SE) flow diverter for the treatment of the same intracranial ICA aneurysm population. Methods: This is a sub-analysis from the Safety and Effectiveness Assessment of the Surpass Evolve (SEASE) registry, an observational cohort study including 15 academic institutions in North America and Europe spanning between 2020-2023. Analysis included patients with unruptured wide-necked saccular aneurysms (not previously treated), measuring &lt;12 mm along the ICA segments. Primary effectiveness was complete occlusion (Raymond Roy Class 1) without retreatment at 1-year follow-up (core lab adjudicated), and primary safety was major stroke (ischemic/hemorrhagic) in the territory supplied by the target artery or death. Results: 129 cases were included (median age 58 years, IQR: 50-67 years, 85% females). Median aneurysm and neck size were 5.8 mm (IQR: 4.0-7.5) and 4.1 (IQR, 3.0-5.5). Most aneurysms were in the ICA C6 segment (66.7%, 86/129), followed by the C7 segment (21.0%, 21/129). Successful implantation was encountered in 99% (128/129) of the cases. At a median 10.1 months (IQR: 6.3-12.6), the rate of complete occlusion was 75.2% (91/121), ≥50% in-stent stenosis 7% (9/129), and retreatment 0.8% (1/129). Major stroke and overall mortality were reported in 1.6% (2/129) of the cases. Conclusion: Our study evaluating outcomes from the SEASE international multicenter registry found that patients with wide-necked unruptured saccular small to medium-sized aneurysms can be effectively treated with the 64-wire chrome-cobalt SE. Furthermore, the SE showed a considerable safety profile for this patient population.

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.

Safety and Efficacy of Endovascular Coils and Non–Flow-Diverting Stents for Management of Unruptured Intracranial Aneurysms: A Location-Specific Outcomes Analysis

IntroductionThe relationship between the anatomical location of an unruptured saccular aneurysm, the efficacy and the potential complications associated with coil and non-flow-diverting stents remains poorly documented. Therefore, the aim of this study is to evaluate the efficacy and safety of endovascular treatment based on the anatomical position of the unruptured intracranial aneurysm (UIA). MethodsA retrospective cohort study was conducted using an anonymized database of patients who underwent endovascular therapy for UIA between 2014 and 2021. Results138 patients with 147 UIA were included. The immediate Raymond Roy I-II occlusion was achieved in 99.2% of patients in all anatomical locations, with a 96.2% occlusion rate at the 12-month follow-up. Complications occurred more frequently in the anterior cerebral artery (35%) and the internal carotid artery in its ophthalmic segment (25%), however the difference was not statistically significant. ConclusionOur study shows that endovascular treatment with stents and coils is effective and safe for managing unruptured intracranial aneurysms in various anatomical locations. Thromboembolic complications were significantly higher in the anterior cerebral artery located 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.

Abstract 008: Morphomechanical Analysis of Saccular Aneurysms

Introduction An irregular morphology is considered a high‐risk feature of unruptured intracranial aneurysms. Some of these aneurysms may have blebs where there is a high likelihood of rupture. The process of aneurysm rupture is dynamic and involves factors such as aneurysm geometry, flow dynamics, and aneurysmal wall enhancement. In our study, we aimed to conduct a comprehensive analysis of brain aneurysms, specifically focusing on irregular and regular aneurysms. This analysis included the examination of aneurysmal wall enhancement (AWE), computational fluid dynamics (CFD), and finite element analysis (FEA). Methods The study focused exclusively on unruptured aneurysms and employed high‐resolution vessel wall imaging using 3T MRI. Aneurysms were classified as irregular if they displayed a bleb or multiple lobes. A 3D segmentation of the aneurysm and vessel was generated using 3D Slicer software. Orthogonal spokes were extended from the segmentation into the vessel wall, enabling the creation of intensity (SI) heatmaps. Aneurysmal wall enhancement (AWE) was calculated based on the post‐contrast SI. Furthermore, wall tension (WT) was determined using FEA, and time‐averaged wall shear stress (TAWSS) was computed through CFD utilizing the 3D segmentation. To identify regions of notable activity within the aneurysm, an analysis was conducted by examining values exceeding the 50th percentile threshold. This approach facilitated the inclusion of areas demonstrating heightened activity within the aneurysm. The study comprised two primary analyses: first, a comparison between regular and irregular aneurysms, and second, a secondary analysis that focused specifically on aneurysms with blebs. During this analysis, the bleb, body, and neck regions were isolated for comparative evaluation among different compartments within the aneurysms. Results The study included a total of forty‐seven unruptured saccular aneurysms, with 38% (18/47) classified as having irregular morphology. Comparing aneurysms with irregular morphology to those with regular morphology, it was observed that irregular aneurysms exhibited higher WT (p=0.05) and lower TAWSS (p=0.04). Among the irregular aneurysms, 61% (11/18) were found to have blebs. Within aneurysms containing blebs, significant differences were observed in terms of WT and AWE between the bleb, neck, and aneurysm body (p&lt;0.001 and p=0.03, respectively). Specifically, the blebs exhibited the highest AWE within the aneurysm, followed by the aneurysm body and the neck. The neck exhibited the highest value of WT, followed by the aneurysm body and the bleb. Finally, the neck also demonstrated the highest value of TAWSS, followed by the aneurysm body and the bleb. Conclusion Irregular aneurysms had a higher WT and lower TAWSS. Furthermore, the morphomechanical characteristics of irregular aneurysms varied between the aneurysm neck and body, indicating distinct properties in these regions. Unstable regions of the aneurysm, such as blebs, exhibited elevated AWE along with low TAWSS and WT.

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.

Teaching NeuroImages: High-resolution MRI before and during a sentinel headache demonstrates aneurysm wall hemorrhage

A 3T brain MRI, performed in a 48-year-old woman presenting with progressive headaches, demonstrated a 20-mm unruptured saccular basilar artery aneurysm. High-resolution vessel-wall MRI showed a chronic mural thrombus and a circumferential aneurysm wall enhancement (figure), an imaging marker of aneurysm instability.1 Two days later, she had a transient thunderclap headache, considered the worst headache she had ever reported. Repeated 3T MRI demonstrated acute mural hemorrhage without subarachnoid hemorrhage. Sentinel headaches, reported in every fourth patient preceding aneurysm rupture,2 have been interpreted as reflecting a warning for subarachnoid leak or, alternatively, structural wall changes, such as stretching or acute mural hemorrhage.

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.

Abstract Number ‐ 214: Woven EndoBridge in Conjunction with Coiling: Novel Technique for Treatment of a Large Basilar‐tip Aneurysm

Introduction Basilar tip aneurysmscan bechallenging to treatgiven their location andoftencomplex geometryand size.Endovascular coilinghas historically been the standardoftreatmentfor less complex aneurysms, proving to bebothsuccessfulandsafe.However, recanalization ratesfor large and giant aneurysmshave beenunacceptably high.More recently, devicessuch asthe Woven EndoBridge (WEB) have been developed toreduce the rate of recanalization.Here we describea uniquecase of alarge basilar tip aneurysm that was treated withcombination oftheWEBdeviceandcoilembolizationsimultaneously. Methods Case report. Results A woman in her fifties presented with several days of headache, nausea and vomiting, vision changes, and unsteady gait. MRA of the brain visualized a large unruptured basilar tip saccular aneurysm which was confirmed via a diagnostic cerebral angiogram (size: 12.9×11.2×14.0 mm, neck: 4.5 mm) [Figure 2A]. Given the sizeand locationof the aneurysm,we attempted embolization with the largest available WEBSLdevice. This device was undersized for the aneurysm.We therefore utilized a novel combinationcoiling,to partially fill the dome and posterior aneurysm sac,and the largest WEB SL available (11×9 mm). Using a radial system, the WEB device was partly unsheathed at the base of the aneurysm. Then, using a femoral system three coils (18 Hydroframe 28cm 7mm, 18 Hydroframe 15cm 7mm 10, 10 Hydroframe 23cm 7mm) were introduced into the remaining space of the aneurysm, filling the void between the aneurysm dome and the partly deployed WEB SL device. Once all coils were appropriately placed and stable, the WEB device was fully deployed, which lead to successful embolization and occlusion of the aneurysm [Figure 2B]. Conclusions The challenge of treatinglargebasilar tip aneurysmshasencouragedthedevelopment of innovative devices and novel interventional techniques.Here we demonstratethepossibility ofcombiningaWEBdevicewith standard coilingto treatlarge, wide‐necked basilar tip saccularaneurysms that are not ideal candidates for standard therapy.

Abstract Number: LBA5 Predictors of Occlusion After Flow Diversion of Internal Carotid Artery Aneurysms: A Pooled Analysis

Introduction Flow diverters (FDs) have demonstrated a safe and effective profile for the treatment of intracranial aneurysms with complex morphologies and variable anatomic locations. However, aneurysmal persistence after flow diversion still presents in up to 25% of treated aneurysms. Herein, we aimed to perform a pooled analysis of two large studies (SCENT [Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Neck Wide Neck Aneurysms] and SESSIA [Safety and Efficacy of the Surpass Streamline for Intracranial Aneurysms]) to evaluate the predictors of occlusion at final follow‐up after treatment with a 72–96 wire device. Methods We pooled all data from the SCENT (prospective) and SESSIA (retrospective) studies that included patients treated with the Surpass Streamline. From the studies, a subset of patients with unruptured saccular aneurysms located in the internal carotid artery (ICA) up to its terminus were included. The authors collected baseline demographics, comorbidities, aneurysm dimensions, and procedural and follow‐up characteristics for each patient. For our analysis, the outcome was complete aneurysm occlusion, as reported by the studies. We performed a multivariable logistic regression to identify the predictors of complete occlusion. Next, we performed a mediation analysis framework to identify the causal relationship of the predictors with the outcome. Finally, we calculated the predicted probability of occlusion for the continuous predictors. Results A total of 348 patients with 348 aneurysms were included, 394 devices were implanted (1.13 per patient). Median age was 61 [22‐85] years, and 83.6% were females. Hypertension was the most common comorbidity (57%) followed by hyperlipidemia (36%). The ICA paraophthalmic segment was the most common location (45%), followed by the petrocavernous (29%) and supraclinoid (25%). Median aneurysm size was 7.5 [1‐29] mm, and neck size was 4.3 [1‐23] mm. At the final follow‐up, the complete occlusion rate was 73% (255/348). After adjusting for confounders and accounting for collinearity, the multivariable analysis identified aneurysm size (OR 0.89; 95% CI 0.85‐0.93;p&lt; .001), procedural technical events (OR 0.31; 95% CI 0.15‐0.65;p = .002), and first device length (OR 0.98; 95% CI 0.96‐1.00;p = .036) as predictors of complete occlusion. Age had a non‐significant direct effect on complete occlusion (p = .091) but a significant indirect effect mediated through aneurysm size (p&lt; .001) and technical events (p&lt; .02). Using our model, the predicted probability of occlusion is≥ 75% in aneurysms measuring &lt; 10 mm when no technical events are encountered. However, when technical events are encountered, the probability decreases to 50–75%. Conclusions Successful aneurysm occlusion after flow diversion is associated with aneurysm size, procedural technical events, and FD length. Age does not directly affect occlusion, but its influence is mediated through the aneurysm size and technical events. Therefore, a priori knowledge of the patient and aneurysm characteristics might guide FD selection to favor the best treatment outcomes.

Magnetic resonance imaging of saccular intracranial aneurysm wall

Hemorrhage from intracranial aneurysms is associated with high risk of adverse outcomes. In this regard, surgical treatment of unruptured asymptomatic aneurysms has been actively developed in recent decades. One of the objectives is searching for predictors of aneurysm rupture to clarify the indications for surgery. Non-invasive analysis of vascular wall is actively discussed in last years. To evaluate the possibilities of MRI of ruptured and unruptured intracranial aneurysm walls and determine clinical significance of certain morphological patterns. The study included 111 patients with 158 ruptured and unruptured saccular aneurysms who underwent MRI according to a special protocol between November 2020 and September 2023. We analyzed each aneurysm regarding features of contrast enhancement and changes in SWAN images. After that, we compared these data with ruptures. Wall of ruptured and unruptured aneurysms can accumulate contrast agent. We found 5 types of contrast enhancement. Thick-layer contrast enhancement was accompanied by 9.6-fold higher risk of aneurysm rupture compared to aneurysms without contrast enhancement. Dark MR signal from intracranial aneurysm wall in SWAN imaging is a significant sign of rupture. MRI of the vascular wall is valuable to verify ruptured aneurysms. Unruptured aneurysms can accumulate contrast agent inside the wall, and pattern of accumulation differs from ruptured aneurysms. Morphological analysis is needed to confirm contrast enhancement as a marker of aneurysm rupture.

Comparative proteomic analysis of ventricular and cisternal cerebrospinal fluid in haemorrhagic stroke patients

BackgroundAnalysis of cerebrospinal fluid (CSF) using mass spectrometry is a relatively novel analytical tool, and comparisons of ventricular and cisternal proteomes are yet to be performed. This may have implications for clinical medicine, particularly in demonstrating continuity of the ventricular system with preserved flow in the presence of ventricular blood. Other uses include the identification of novel biomarkers, including for diagnosis of subarachnoid haemorrhage and of aetiology. The primary objective was therefore to characterise and compare the proteomes of ventricular and CSF after haemorrhagic stroke. MethodsPaired CSF samples were prospectively collected from the optico-carotid cistern and the frontal horn of the lateral ventricle at the time of craniotomy and clipping in 8 patients with haemorrhagic stroke. Six patients had an aneurysmal subarachnoid haemorrhage (aSAH) from a ruptured saccular aneurysm, one patient had an aSAH after rupture of a mycotic aneurysm and one patient had a spontaneous intracerebral haemorrhage (IPH) with an adjacent unruptured saccular aneurysm. Samples were processed and proteins identified and quantified using data-dependent liquid chromatography tandem mass spectrometry (DDA LC-MSMS). ResultsThere was no systematic difference between the cisternal and ventricular proteomes. However, blinded principal component analysis (PCA) of the cisternal and ventricular samples separated patients according to pathophysiology. Additionally CSF D-Dimer levels were not detected in the IPH patient but were reliably measured in aSAH patients. ConclusionsVentricular CSF is representative of cisternal CSF after aSAH. CSF proteomic PCA analysis can distinguish between haemorrhage types. CSF D-dimer levels may represent a novel diagnostic marker for aSAH. Label free DDA LC-MSMS CSF analysis may inform possible biomarkers.

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.

Rupture pressure values of cerebral arteries in the presence of unruptured intracranial aneurysm

Cerebral arteries (CAs) are prone to the saccular aneurysm formation. Since aneurysms may be considered as balloon-like dilations of the locally weakened arterial wall, it should be determined whether the presence of intracranial aneurysm is related to the generalized weakening of CAs. Among 184 consecutive forensic autopsies, eight brains with a single unruptured saccular aneurysm were identified. Aneurysms with adjacent CAs and specific CA segments were excised, namely: the anterior communicating artery complex, and bifurcations of the basilar artery, internal carotid arteries, and middle cerebral arteries. Then, aneurysm and CA specimens were subjected to pressure-inflation tests until rupture occurred at the arterial bifurcation or at the wall of the CA or aneurysm. The same protocol was applied to the control group composed of CAs excised from eight brains without aneurysm. No significant differences were noted between the experimental and control groups, depending on the mean rupture pressure (1054 vs. 1048 mmHg) and rupture site (bifurcation vs. wall) of the analyzed specimens. These findings indicate that the presence of unruptured saccular aneurysm is not related to generalized weakening of CAs among autopsy subjects. Moreover, the CA bifurcations do not represent regions of decreased wall strength.

Intracranial Unruptured Right Internal Carotid Artery Aneurysm in A Cadaver: A Case Report

Background: Dilatations of localised segments of the artery are called ‘aneurysms. Approximately 80% of aneurysms form in anterior circulation of circle of Willis. While 20% form in the posterior circulation of the brain. All aneurysms can cause symptoms because of compression of surrounding structures, thrombosis, rupture of emboli. Material and Methods: During routine dissection for I MBBS students in Department of Anatomy, JSS Medical College during intracranial dissection we encountered unruptured saccular aneurysm of intracranial internal carotid artery on right side Case report: Aneurysm of intracranial internal carotid artery was seen on right side of middle cranial fossa in a male cadaver. The aneurysm was close to right optic nerve and measured about 2.2 cm in width and 1.8 cm antero-posteriorly. No other intracranial pathology or anatomical variations were noted. Conclusion: The anatomical knowledge of aneurysm is important to Neurosurgeons, Endovascular surgeons, ENT surgeons and interventional Radiologists. KEYWORDS: Internal carotid artery, aneurysm, intracranial, subarachnoid haemorrhage.

Treatment of Ruptured and Nonruptured Aneurysms Using a Semisolid Iodinated Embolic Agent.

Saccular aneurysms (SAs) are focal outpouchings from the lateral wall of an artery. Depending on their morphology and location, minimally invasive treatment options include coil embolization, flow diverter stents, stent-assisted coiling, and liquid embolics. Many drawbacks are associated with these treatment options including recanalization, delayed healing, rebleeding, malpositioning of the embolic or stent, stent stenosis, and even rupture of the SA. To overcome these drawbacks, a nanoclay-based shear-thinning hydrogel (STH) isdeveloped for the endovascular treatment of SAs. Extensive in vitro testing isperformed to optimize STH performance, visualization, injectability, and endothelialization in cell culture. Femoral artery saccular aneurysm models in rats and in pigs arecreated to test stability, efficacy, immune response, endothelialization, and biocompatibility of STH in both ruptured and unruptured SA. Fluoroscopy and computed tomography imaging consistently confirmed SA occlusion without recanalization, migration, or nontarget embolization; STH isalso shown to outperform coil embolization of porcine aneurysms. In pigs with catastrophic bleeding due to SA rupture, STH isable to achieve instant hemostasis rescuing the pigs in long-term survival experiments. STH is a promising semisolid iodinated embolic agent that can change the standard of medical practice and potentially save lives.

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.