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The need to pursue long-term follow-up in patients treated for a ruptured aneurysm remains debated. New aneurysms development is a crucial element to consider but remains scarcely analyzed especially after a mean follow-up longer than 10 years. Our study was designed to provide rates of newly developed aneurysms in patients who have undergone prior clipping who were not followed with serial imaging. Patients were included if they were (1) treated more than 10 years ago by clipping of a ruptured aneurysm, (2) independent at time of discharge, (3) presently younger than 65 years, and if (4) they agreed to undergo a late digital subtraction angiography (DSA) control or to transmit results of a recent one performed elsewhere. Twenty patients were included with a mean delay between aneurysm treatment and late DSA of 18.0 years (10-26.5 years). Out of these patients, six (30%) harbored new aneurysms. Of these six individuals, four (66.6%) presented multiple aneurysms with a total of 15 newly discovered aneurysms. Aneurysm sizes ranged from 1 to 10 mm. One patient suffered from a de novo aneurysm rupture. Multiple aneurysms at the time of the first hemorrhage were a risk factor in developing de novo aneurysm (p=0.0175). In conclusion, based on a 30% rate of new aneurysm formation in patients clipped more than a decade ago, close screening on a very long-term perspective is encouraged. This study suggests aneurysm formation to be a continuous process.

Introduction: We report our experience with endovascular treatment (EVT) of circumferential and fusiform intracranial aneurysms by a reconstructive approach with self-expandable stents., Methods: A retrospective review of our prospectively maintained database identified all circumferential and fusiform aneurysms treated by a reconstructive endovascular approach over a 3-year period. Clinical charts, procedural data, and angiographic results were reviewed., Results: From April 2004 to May 2007, 13 patients were identified, of whom 12 were asymptomatic and 1 presented with a subarachnoid hemorrhage. Two patients with an aneurysm

Objective: Stent-assisted coiling is an accepted endovascular treatment (EVT) for complex intracranial aneurysms. The Enterprise self-expandable stent (Cordis, Miami Lakes, FL) is a new retractable stent that is delivered via a conventional coiling catheter to potentially circumvent the limitations of other stents. The aim of this study was to evaluate the use of this stent for EVT of complex aneurysms., Methods: Between January and May 2007, 14 patients with 15 unruptured wide-necked or fusiform aneurysms were treated. EVT consisted of stent placement and subsequent endosaccular coiling. Clinical outcome was assessed with the modified Glasgow Outcome Scale., Results: EVT was successfully performed and led to an excellent outcome in all patients. The stent was easily navigated and precisely positioned in all cases. However, the stent's visibility was poor once it was delivered. Moreover, procedural complications occurred in three patients, including stent migration (n = 1) and coil protrusion between the stent and the vessel wall (n = 2). In these latter two cases, a remodeling balloon was required to assist in delivery of the coils. No clinical incidence of complications was observed when the parent artery had a diameter of more than 4 mm. Angiographic results consisted of eight complete occlusions, four neck remnants, and three incomplete occlusions., Conclusion: The Enterprise stent is very useful for EVT of complex intracranial aneurysms because it is easy to navigate and place precisely. However, the currently available stent has two relatively limiting characteristics: 1) it has poor visibility, and 2) it should only be used for aneurysms located on a parent artery with a maximal diameter of 4 mm.

Background and Purpose: To prospectively evaluate the results of endovascular treatment (EVT) of intracranial aneurysms when it is considered as first-intention treatment., Methods: From April 2004-October 2006, 167 consecutive patients with 202 aneurysms were treated in our institution. Five patients with a ruptured aneurysm with an associated haematoma were excluded. In 162 patients with 197 aneurysms, EVT was considered as first-intention treatment., Results: Surgical clipping was performed in 25 aneurysms (25/197=12.7%) including 22 aneurysms excluded from EVT and three EVT failures. EVT was thus attempted in 144 patients with 175 aneurysms and successfully performed in 141 patients with 172 aneurysms (172/197=87.3%). EVT failure rate was 1.7%. Clinical outcome according to the modified Glasgow Outcome Scale was: Excellent, 81.5%; Good, 7%; Poor or Fair, 3.5%; Death, 8%. Procedural complications occurred in 17 cases (10%). Balloon- or stent-assisted techniques were used in 60 cases (34.9%) and were not associated with higher complication rate. Overall procedural morbidity and mortality rates were 4.2 and 2.1%. Initially, complete occlusion was obtained in 68%, neck remnant in 23%, and incomplete occlusion in 9% of aneurysms. Follow-up (mean 11 months) was obtained in 119 aneurysms and showed major recanalisation--that required re-treatment--in 13 cases (11%) and minor recanalisation in 17 cases (14.3%)., Conclusion: Our findings suggest that new endovascular techniques allow proposing EVT as first-intention treatment in 87.3% of patients with intracranial aneurysms. This therapeutic strategy is associated with good clinical results. However, anatomical results are not improved and remain the EVT limiting factor.

Objective: Intracranial stenting combined with endosaccular coiling is a therapeutic alternative for the endovascular treatment (EVT) of wide-necked intracranial aneurysms. The current limitation of available stents is the impossibility to reposition them once they are partially deployed. Recently, the first retractable self-expandable stent has been developed and we sought to evaluate the use of this stent for EVT of wide-necked intracranial aneurysms., Methods: Between March 2004 and March 2005, 11 patients with an unruptured aneurysm have been selected for this study. In all cases, previous attempts with EVT with the remodeling technique failed or was technically judged difficult. In all patients, EVT combined stent placement (Leo, Balt, Montmorency, France) across the aneurysm neck and subsequent coiling of the sac. Aneurysms were located on the carotid siphon (n = 9), the internal carotid artery bifurcation (n = 1), and the vertebral artery (n = 1). Aneurysms diameter size varied from 3 to 45 mm. Clinical outcome was assessed with the Modified Glasgow Outcome Scale., Results: EVT was successfully performed and led to an excellent outcome in all patients. The stent could be navigated within cerebral arteries without any exchange procedure. Thanks to its retractability, the stent could precisely be positioned in all cases. Angiographic results consisted of 9 complete occlusions and 2 incomplete occlusions in 2 giant aneurysms. No procedure-related complication occurred., Conclusion: The Leo stent appears very useful for EVT of wide-necked intracranial aneurysms. The advantage of this stent is the possibility to reposition it which allows a very precise positioning across the aneurysm neck.

Background and Purpose: The endovascular treatment (EVT) of intracranial aneurysms is no more limited by the presence of a branch at the neck or by the neck width. Saccular aneurysms with a branch arising from the sac, however, are mostly candidates for surgery rather than embolization. We prospectively evaluated the feasibility and safety of the EVT in such cases., Methods: Between May and November 2004, 9 consecutive patients with a saccular aneurysm that presents a branch arising from the sac were treated by embolization. There were 7 women and 2 men (mean age, 58 years). Six patients presented with a subarachnoid hemorrhage (SAH), and 3 were asymptomatic. All patients were treated by selective coiling with (n = 6) or without (n = 3) the remodeling technique. Clinical outcome was assessed with a modified Glasgow Outcome Scale at 3 months., Results: EVT was successfully performed in all patients and resulted in 7 excellent outcomes and 2 deaths related to SAH complications. The arterial branch could be preserved in 7 cases and intentionally occluded in 2. Neither embolic nor ischemic complication occurred in the vascular territory of the involved branch. Angiographic results showed 5 neck remnants, 2 incomplete occlusions, and 2 complete occlusions. No rebleeding occurred., Conclusion: Our study, though limited by its small patient population, suggests that saccular intracranial aneurysms with a branch arising from the sac may be treated by endovascular approach with excellent clinical results; however, larger series with long-term follow-up are mandatory to confirm these preliminary results mostly in terms of anatomic stability.

Introduction: Until recently, middle cerebral artery (MCA) aneurysms were mostly treated by surgery, and endovascular treatment (EVT) was only performed in selected cases. We prospectively evaluated the feasibility and the results of EVT when it is considered as the first therapeutic option for the treatment of MCA aneurysms., Methods: From April 2004 to April 2005, 32 patients with 32 MCA aneurysms were treated in our institution. Of these, 12 patients presented with subarachnoid hemorrhage and 20 were asymptomatic. Seven patients were surgically treated because of a compressive haematoma (n = 4), a failure of EVT (n = 1), or because EVT was judged unfeasible (n = 2). In 25 patients, EVT was performed and required the use of the remodelling technique in 16 cases and a stent alone in two. Clinical and anatomical outcome were assessed with the modified Rankin Scale (mRS) at 1 month and a conventional angiography at 6 months., Results: EVT was successfully performed and resulted in an excellent outcome (mRS = 0) in all patients but one, who experienced a thromboembolic complication and maintained a slight lack of vocabulary (mRS = 1). Immediate anatomical results included 15 complete occlusions, 8 neck remnants, and 2 incomplete occlusions in two patients treated by stenting alone. Control angiographies were obtained in 23 patients and showed 17 unchanged occlusions, five slight recanalisations, and one recanalisation that required a retreatment., Conclusion: This study showed that EVT of MCA aneurysms is feasible with good results in most patients thanks to new endovascular techniques. However, long-term imaging follow-up is mandatory to confirm these preliminary findings, mostly in terms of anatomical stability.

To describe the integration of magnetic resonance angiography (MRA) in neuronavigation procedures for microsurgery of intracranial aneurysms. MRA was combined with standard magnetic resonance image (MRI) acquisition in the image-guided planning for the microsurgical clipping of a saccular aneurysm in two patients (one 3-mm large middle cerebral artery and one 8-mm large pericallosal artery aneurysm, diagnosed by catheter angiography in both patients) using two different neurosurgical navigation systems. Conventional 3-D T1-weighted MRI with gadolinium and MRA pulse sequences were acquired in frameless stereotactic conditions the day before surgery and thereafter registered, allowing the definition a minimally invasive straight trajectory to the aneurysm neck. MRA-guided neurosurgery allowed a direct approach to the aneurysms at their proper location, reducing the invasiveness of the approach by tailoring the bone opening and reducing the duration and extension of brain retraction. The technique also avoided unnecessary dissection and exposure of the main trunks and collateral vessels. The aneurysms were successfully eradicated without complication. Integration of MRA in the planning and neuronavigation procedure for intracranial aneurysms may minimize the morbidity related to the surgical approach. This technique may be applicable more routinely using standard neuronavigation equipment., (Copyright 2004 W.S. Maney and Son Ltd)

For this study, we reviewed a series of 564 consecutive SAH among which 72 cases (12.7%) were older than 65 years. Etiology of SAH was: arterial aneurysms (65), arteriovenous malformations (1), unknown origin (6). Among the 65 aneurysms, 28 operated cases were between 65-69 years old. One year after surgery, the results are: GOS 1 and 2: 22 cases (57%); GOS 3: 4 cases; GOS 5: 13 cases. In the non operated group, 19 cases died (73%) and among the alive patients, one was GOS 2 (4%), 5 GOS 3 and 1 GOS 4. In the operated group, mortality is similar to other published series. In the non operated group, mortality is unsurprisingly higher (73%) than in the operated group, but also than in the literature. An explanation could be found with analyses of the income of our patient whose many are not referred cases from other hospital. Our analysis confirmed that the severity of SAH after 65 years is increasing. The raise of anterior communicating aneurysms location is demonstrated. Operative indication and timing are dependent of neurological grading, general condition and secondarily of the location and anatomy of the aneurysm.

Traumatic aneurysms constitute a very small percentage of all intracranial aneurysms. A high mortality results of a catastrophic rupture and they run an unpredictable course. Traumatic aneurysms usually involve the large basal arteries or the middle meningeal arteries. We report a case of an association of a traumatic aneurysm with a congenital aneurysm located on the same middle cerebral artery. At our knowledge, it is the first described case of the literature.

We report our preliminary results (seven cases) with a three-quarter prone approach to the pineal-tentorial region using an opening beneath the midline. The technique we have used eliminates the risk of air embolism because the head is just over the right atrium, the table remaining in an horizontal plane. Using the natural effect of gravity, it is no more necessary to use retraction on the occipital lobe. So, hemianopsia is eliminated. We confirm the results of other teams who have used this approach which seems to us to be the best way to treat any lesion in the pineal-tentorial area.

The authors present the results of the postoperative I.C.P. records in 35 patients. The results emphasize the relationship between the clinical grading and the degree of the intracranial pressure: 4/7 grades III (Hunt and Hess grading) and all the grades IV (4/4) had an abnormal intracranial pressure. The location of the aneurysm does not clearly appear as a significant factor of increased intracranial pressure in the postoperative period.

The authors present the results of surgical treatment of a consecutive series of 100 cases of intra cranial aneurysm. The results are analysed in relation to various factors such as the pre-operative delay, the clinical status, the location of the aneurysm and the age of the patient. Altogether, the percentage of excellent and good results is 83%. Bad results account for 10% of the total and deaths represent 7%. Shunted postoperative hydrocephalus was recorded in 10% of cases and half were due to aneurysm of the anterior communicating artery. Postoperative spasm (16%) was the severest complication, responsible for more than half the deaths.

The authors present, among 200 intracranial arterial aneurysms, 13 cases where the angiographic diagnosis of the aneurysm had been difficult. Among them, there were ten mistakes through default, and four mistakes through excess. Angiographic studies were done early, about the third day following subarachnoidal hemorrhage, so that conscious patients may have rapid surgery. The main diagnosis defaults were observed in aneurysms of the anterior communicating artery (cases 1, 2, 3, 4, 6), where the flexurae and arterial anomalies explain the diagnostic mistakes; double anterior cerebral artery, median anterior cerebral artery of Lazorthes, early origin of the frontopolar artery or of the callosomarginal artery. The aneurysms of the posterior wall of the carotid bifurcation, were hidden by this artery in the A.P. view and by the middle cerebral artery in the profile view (cases 5 and 7). Oblique views are necessary for the two localizations of these aneurysms. The middle cerebral aneurysms (case 8) may be hidden by a bony superposition. The Ziedses des Plantes subtraction method obviates this diagnostic default. Aneurysms of the peripheral branches of cerebral arteries (case 9) are filled later and slightly. Aneurysms of an artery less than 3 mm wide (posterior communicating artery, lenticular artery) are difficult to discriminate from their enlarged infundibulum (case 10). The small size of the aneurysm is not the only explanation of the difficult diagnosis. Indeed, few aneurysms are not evidenced by the first angiography, done at an early stage, even if any spasms exist. Only repeated angiographies could show the aneurysm particularly in young people. We repeat the angiography 15 to 20 days after the first one, and even some months later. In two young patients, angiographic studies were repeated a few times in three years and were normal; but after four years in one case and five years in the other, a new subarachnoidal hemorrhage occurred, and only then was the aneurysm shown by a new angiography (cases 4 and 5). In our series, the angiographic spasm could not afford an explanation for the diagnostic default. This, soon after the subarachnoidal hemorrhage, might be explained by the hemostatic clot which compresses or plugs the aneurysm. Further, the clot's lysis occurs, and the aneurysm can be evident. A double conlcusion must be drawn: --first, the angiography must be repeated if the image is dubious; the angiographic technique must be perfect and varied (oblique view, subtraction method, enlargement technique). Mistakes through excess, leading to useless operations, are as dangerous as mistakes through default; --secondly, great care should be exerted when reading and interpreting the X-ray films in the post-operative period in order to evaluate the surgical results, as well as in the preoperative period.

The association of two aneurysms on the distal posteroinferior cerebellar artery with an arteriovenous malformation fed by the same artery is reported. A one-stage operation was performed. The other cases in the literature are analyzed with particular regard to the origin of the subarachnoid hemorrhage and the location of the aneurysms.

Two series of cerebral aneurysms are compared. The first was composed of 86 cases. The second, 73 cases, benefited from modern techniques, such as microscope, arterial hypotension, Yasargil's clips, bipolar coagulation, as well as from greater experience on the part of the surgical and anesthetic team. To avoid the risk of recurrent subarachnoidal hemorrhage, the surgical procedure has been done during the first week when consciousness is good or when corotid angiography shows a large cerebral hematoma. The surgical procedure is postponed if the patient shows a low state of consciousness or a cerebral vasospasm. In these cases, controlled external ventricular drainage improves patients' conditions and often allows for surgical intervention after three to five days. The Botterrel classification is used to evaluate the surgical results: good results were obtained in 71% of the entire series, as well as in 94% of grades 1 and 2 patients. The overall mortality rate was 15%. That for grades 1 and 2 was 2.7% and that for grades 1, 2 and 3 was 7.5%. The preoperative, operative and postoperative factors affecting results are discussed with particular attention to cerebral vasospasm and hydrocephalus.

An unusual case of traumatic aneurysm of the A-1 part of the anterior cerebral artery associated with a contralateral carotid-cavernous fistula is presented. Trapping of the fistula was carried out, and an attempt to repair the vessel wall was made. Thrombosis of the vessel occurred, but remained asymptomatic. Causes, physiopathology, and treatment of traumatic aneurysms are discussed.

A case of a ruptured metastatic aneurysm of choriocarcinoma is reported. The fourteen other cases of the literature are summarized. The pathological significance of this rare presentation of metastatic disease is discussed. The treatment of choice is defined as excision followed by chemotherapy and whole brain irradiation. The prognosis remains poor.