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A 29-year-old woman is diagnosed with a large broad-base right ophthalmic artery aneurysm. Despite an intact visual field, she complained of mild right visual blurriness. Between endovascular and surgical treatments, surgery was favored due to her young age. It was decided to perform the surgery with simultaneous endovascular temporary carotid balloon occlusion. A right pterional craniotomy and intradural anterior clinoidectomy were performed, the balloon was positioned in the petrous carotid, and the distal durai ring was opened exposing the proximal neck. Under temporary proximal carotid balloon occlusion and distal carotid clip occlusion, the aneurysm was fully dissected and clipped. Intraoperative angiogram confirmed complete aneurysm occlusion and patency of the ophthalmic artery. The patient's neurological exam remained unchanged. The video can be found here: http://youtu.be/BIQKTl9bDqA .

Objective: To evaluate the feasibility of the direct visualization of the distal dural ring (DDR) and adjacent anatomic structures in patients with paraclinoid internal carotid artery aneurysms at 3-T magnetic resonance imaging (MRI)., Methods: Six consecutive patients (1 man, 5 women; mean age, 45.5 years; age range, 34-51 years) who underwent a 3-T MRI examination for the evaluation of 7 paraclinoid carotid artery aneurysms were reviewed retrospectively. MRI scans were acquired using a T2 turbo-spin echo sequence with 2-mm thickness without gap on the coronal plane perpendicular to the diaphragma sellae. Identifications of the DDR, adjacent regional anatomic landmarks, and paraclinoid aneurysms were analyzed. The locations of the paraclinoid aneurysms were categorized into intradural (aneurysm neck and sac located above the DDR), transdural (aneurysm neck or sac were straddling the DDR), and extradural (aneurysm neck and sac located below the DDR). Interstudy agreement between computed tomographic angiography and 3-T MRI for the anatomic location of the paraclinoid aneurysms was assessed in 6 patients who underwent both examinations., Results: In all cases, the DDR was clearly identified and the relationship between the DDR and the paraclinoid aneurysm was successfully determined on 3-T MRI. The aneurysm locations determined with 3-T MRI were 4 intradural and 3 extradural. A comparison between computed tomographic angiography and 3-T MRI revealed discordant anatomic locations in 3 aneurysms (3 of 6, 50%)., Conclusion: Direct visualization of the DDR as well as precise evaluation of paraclinoid aneurysm location with high-resolution 3-T MRI is possible. This study shows that high-resolution 3-T MRI is an important means to determine the appropriate management for patients with paraclinoid aneurysms.

Disappearing intracranial aneurysms are rare and have not been extensively reported in the literature. They are often small or partially thrombosed and carry a significant risk of recurrence. We discuss a unique case of a 65-year-old woman who presented in 2006 with a subarachnoid hemorrhage and was found to have a ruptured posterior communicating artery and an unruptured P1 aneurysm. Follow-up angiography and imaging showed no changes in the size of a left P1 aneurysm for 11 years (2006–2017). However, in 2021, 15 years after initial presentation, no aneurysm was seen on magnetic resonance angiography, and subsequent digital subtraction angiography in 2022 showed almost complete disappearance of the unruptured P1 aneurysm. Literature review reveals only six reported cases during which a small, unruptured anterior circulation aneurysm disappeared, or regressed on follow-up imaging and no reported cases in the posterior circulation. [ABSTRACT FROM AUTHOR]

Introduction: Quantitative magnetic resonance angiography and non-invasive optimal vessel analysis serve as powerful tools to collect and analyze hemodynamic data from pipeline embolization patients. At our institution, patients receive post-embolization quantitative magnetic resonance angiography within 24 h of treatment and within 6 months for follow-up to evaluate pipeline patency. Here, we aim to elucidate the long-term hemodynamic changes following pipeline embolization device placement and report two cases in which in-stent stenosis was detected. Methods: Medical records of patients who underwent pipeline embolization device placement for an internal carotid artery aneurysm between 2017 and 2019 were reviewed. Patients who received post-procedure NOVA and follow-up NOVA were included in the study (n = 32). Location and size of aneurysm, number of pipeline embolization device deployed, and complications were collected along with the non-invasive optimal vessel analysis report (flow volume rate (ml/min), mean, systolic, and diastolic flow velocities (cm/s), and vessel diameter (mm)). Internal carotid artery vessel flow rate was measured proximal to the pipeline embolization device. Derivations of hemodynamic parameters (pulsatility index, Lindegaard ratio, and wall shear stress) were calculated. Results: The middle cerebral artery mean and diastolic flow velocities were significantly lower on the follow-up NOVA compared to the post-procedure NOVA. Moreover, follow-up NOVA demonstrated lower middle cerebral artery wall shear stress on the side with flow diversion compared to the post-procedure NOVA. In-stent stenosis, requiring intervention, was detected in two patients on follow-up NOVA. One patient had a successful balloon angioplasty of the stented internal carotid artery that resolved her stenosis. However, the second patient developed progressive stenosis and expired despite intervention. Conclusion: Long-term hemodynamic adaptations post-pipeline embolization device demonstrate decreased wall shear stress and decreased mean and diastolic flow velocities in the distal middle cerebral artery, which suggest decreasing velocity of blood flow with endothelialization of the device. Furthermore, follow-up NOVA is a useful tool for detecting potential flow-related complications such as in-stent stenosis. [ABSTRACT FROM AUTHOR]

Introduction: Delayed intraparenchymal hemorrhage is a known complication of the Pipeline Embolization device (PED); however, its etiology is unclear and some have suggested it is a flow related phenomenon. Quantitative magnetic resonance angiography (QMRA) serves as a powerful tool to collect and analyze hemodynamic data. We report a detailed characterization of short-term hemodynamics after PED placement. Methods: Patients who underwent PED placement for a distal internal carotid artery (ICA) aneurysm between 2017 to 2019 with post embolization QMRA were reviewed. Aneurysm characteristics, flow volume rate (ml/min), mean, systolic, and diastolic flow velocities (cm/s), vessel diameter (mm), pulsatility index, Lindegaard ratio, and wall shear stress (WSS) were collected. Results: A total of 67 patients were included. Post-procedure patients were found to have a significantly lower ICA flow on the side with flow diversion when compared to the side without flow diversion (218 vs. 236.3; P < 0.05). Average ICA flow after flow diversion for aneurysms >2 cm was significantly lower when compared to the untreated side (187.7 vs. 240.4; P < 0.05). There was no difference in MCA or ACA flow or velocity. WSS was significantly lower in the treated ICA (8.2 vs. 9.0; P < 0.05). Lindegaard ratio was not different in the treated vs. contralateral untreated sides. Conclusion: PED placement for distal ICA aneurysms results in lower flow, mean velocity, and WSS when compared to the contralateral untreated ICA. This is not demonstrated distal to the Pipeline device in the ACA or MCA territories. Ultimately these findings suggest hemodynamic changes are not a cause of PED complications. [ABSTRACT FROM AUTHOR]

Introduction: The concurrent use of endoluminal flow diversion with coils is a viable option when treating complex or large aneurysms. Alternatives to coil embolization as an adjunctive treatment are currently limited. The Food and Drug Administration recently approved the Woven EndoBridge (WEB) device (Microvention, Aliso Viejo, California) as an intrasaccular flow diverter for wide-neck bifurcation aneurysms. We present the technical aspects of combined WEB device plus endoluminal flow diversion for the treatment of complex wide-necked intracranial aneurysms. Methods: A retrospective chart review of all patients treated via intrasaccular flow diversion at a single institution over the last 12 months was performed. Results: In total, seven patients underwent treatment of eight aneurysms via combined intrasaccular and endoluminal flow diversion. Of the seven patients, six were treated in a single setting. The most common aneurysm location was the posterior communicating artery. The majority of the aneurysms required steam shaping of the Via deployment catheter to place the WEB device orthogonally to the aneurysm dome. There were no complications. Conclusions: We believe this is one of the first series reporting the combined use of the WEB device and endoluminal flow diversion for the treatment of intracranial aneurysms. This series demonstrates that the concurrent use of the WEB device with endoluminal flow diversion is safe for achieving immediate aneurysm treatment and may enhance the long-term durability in complex aneurysms. [ABSTRACT FROM AUTHOR]

A 29-year-old male presented with subarachnoid haemorrhage and a diagnosis of a ruptured distal superior cerebellar artery (SCA) aneurysm. The distal SCA harboured perforators to the brainstem; electrophysiological changes during temporary clipping proved the need for surgical clipping over endovascular occlusion. Successful clipping without distal occlusion was performed. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Intraoperative neuromonitoring for intracranial vascular surgery is primarily aimed at detecting early ischemic changes to prevent subsequent infarction. Despite various neurophysiological approaches detection of early and focal ischemic changes remains difficult. This study explores the feasibility and sensitivity of intraoperative monitoring using surface EEG (scalp EEG) and multilobar Electrocorticography (mEcoG) recording during intracranial vascular procedures. Methods: About 21 recordings were acquired in 20 patients undergoing craniotomies for intracranial aneurysms (17), superficial temporal-middle cerebral artery bypass (twice in the same patient) and arteriovenous malformation (2). The recording of scalp EEG (needle electrodes) and EcoG was performed (cupules electrodes) during all of the surgery. Signal was visually analyzed online and using spectral analysis software offline. Results: Good recordings were obtained in all cases, without adding any procedural morbidity. The most common abnormalities on mEcoG were high frequency waves (23–37Hz; HF-β3), which appeared just after vascular occlusion and were occasionally followed by slow waves or burst suppression pattern. This focal pattern was seen in a majority of cases (20/21) on the mEcoG, but only in 4 out of 21 cases on the EEG. Conclusions: Multi-lobe (mEcoG) recording is feasible during craniotomies and detects earlier and more EEG pattern variation than surface EEG monitoring during intracranial vascular manipulations. The authors discuss the high sensitivity of this technique to ischemic changes. Significance: By detecting earlier and more focal changes than scalp EEG, mEcoG may favor during surgery an increase in interactive strategies and reduction of deleterious event. [Copyright &y& Elsevier]

Endovascular coiling of small, intracranial aneurysms remains controversial and difficult, despite advances in technology.We retrospectively reviewed data for 62 small aneurysms (<3.99 mm) in 59 patients. Occlusion rates, complications rates, and coil packing densities were compared between subgroups based upon coil type and rupture status.Ruptured aneurysms predominated (67.7%). Aneurysms measured 2.99 ± 0.63 mm by 2.51 ± 0.61 mm with an aspect ratio of 1.21 ± 0.34 mm. Brands included Optima (Balt) (29%), MicroVention Hydrogel (24.2%), and Penumbra SMART (19.4%) coil systems. Average packing density was 34.3 ± 13.5 mm3. Occlusion rate was 100% in unruptured aneurysms; 84% utilized adjuvant devices. For ruptured aneurysms, complete occlusion or stable neck remnant was achieved in 88.6% while recanalization occurred in 11.4%. No rebleeding occurred. Average packing density (p = 0.919) and coil type (p = 0.056) did not impact occlusion. Aspect ratio was smaller in aneurysms with technical complications (p = 0.281), and aneurysm volume was significantly smaller in those with coil protrusion (p = 0.018). Complication rates did not differ between ruptured and unruptured aneurysms (22.6 vs. 15.8%, p = 0.308) or coil types (p = 0.830).Despite advances in embolization devices, coiling of small intracranial aneurysms is still scrutinized. High occlusion rates are achievable, especially in unruptured aneurysms, with coil type and packing density suggesting association with complete occlusion. Technical complications may be influenced by aneurysm geometry. Advances in endovascular technologies have revolutionized small aneurysm treatment, with this series demonstrating excellent aneurysm occlusion especially in unruptured aneurysms. [ABSTRACT FROM AUTHOR]