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Here we presented the initial experience of clipping aneurysms using fully endoscopic techniques and aimed to evaluate the safety and feasibility of fully endoscopic techniques for aneurysms. This was a retrospective single-center study in which patients were scheduled to undergo aneurysm clipping using fully endoscopic techniques. We collected patients' records, radiological neuroimaging, aneurysm-related variables and surgical procedures in detail, as well as postoperative outcomes. All patients were followed up for neurological examinations and computed tomography (CT) as well as computed tomography angiography (CTA) regularly after surgery. We reviewed the radiological and clinical data of 7patients who underwent aneurysm clipping via fully endoscopic techniques at our department from Jan. 2022 to Jul. 2024, including 2 middle cerebral artery aneurysms, 3 cerebral anterior communicating artery aneurysms, 1 anterior cerebral aneurysm and 1 ophthalmic aneurysm. No uncontrolled rupture of aneurysm occurred during operation. Postclipping endoscopic inspection as well as postoperative CTA demonstrated complete occlusion of the aneurysm and preservation of parent, branching, and perforating vessels. None postclipping cerebral infarction caused by branch or perforator compromise were observed after clipping. No mortality was recorded. Follow-up ranged from 1 to 10 months. Six patients (71.4%) showed excellent or good recoveries. The remaining patient recorded improved KPS. With the accumulation of experience and technological progress, the fully endoscopic technique could enable safe and effective clipping of an aneurysm, which provided valuable information for decision-making during surgery and shed a new light on aneurysms clipping. [ABSTRACT FROM AUTHOR]

The transorbital approach (TOA) has a unique advantage to the more common lateral approaches as it provides direct access to the anterior middle fossa and medial sylvian fissure (SF) without significant dissection or retraction. However, when to use the TOA for surgical treatment of middle cerebral artery (MCA) aneurysms remains unclear. This study details the feasibility of clipping unruptured MCA aneurysms via the TOA by highlighting the anatomic features that either facilitate or hinder the approach. Virtual reality (VR) models of 25 MCA aneurysms from computed tomography angiograms of actual patients were rendered with the relevant anatomic structures, including the neighboring temporal lobe and SF. TOA was performed on the models in VR and the globe was translated medially and inferiorly, replicating retraction used intraoperatively. Anatomic data, including the area of surgical freedom (AOF) at the aneurysm, were recorded. Trials of aneurysm clipping were conducted in VR and each aneurysm was classified as "possible" or "impossible" candidates for clipping via TOA. Separately, the relationship between surgical view and SF visualized was analyzed. Sixteen aneurysms were eliminated as candidates for TOA treatment either through VR clip trial and/or because the SF was inaccessible. The remaining 9 (36%) were candidates for TOA. Comparing the details of these 2 aneurysm categories with Mann Whitney U tests, there was a statistically significant difference in the AOF of the TOA approach and the width of the aneurysm dome. A clinical case report is also provided highlighting the VR rehearsal similarity with surgery. Given the minimally invasive, technically challenging approach, the feasibility and safety of TOA for MCA aneurysms must be evaluated before wide clinical adoption. This study identified AOF, aneurysm width, and SF accessibility as three features that may significantly impact the possibility of clipping MCA aneurysms via TOA. [ABSTRACT FROM AUTHOR]

Introduction Postcraniotomy headaches are often underestimated and undertreaded. This study aimed to identify if postoperative administration of sumatriptan after minimally invasive craniotomy for clipping an unruptured aneurysm could reduce postcraniotomy headache and improve the quality of postoperative recovery. Settings and Design Tertiary care center, single-center randomized double-blind placebo-controlled trial. Materials and Methods Patients who complained of postoperative headaches after minimally invasive craniotomy for clipping of unruptured aneurysms were randomized to receive subcutaneous sumatriptan (6 mg) or placebo. The primary outcome was the quality of recovery measured 24 hours after surgery. Secondary outcomes were total opioid use and headache score at 24 hours after surgery. Data were analyzed using a Student's t -test or the chi-square test. Results Forty patients were randomized to receive sumatriptan (n = 19) or placebo (n = 21). Both groups had similar demographics, comorbidities, and anesthesia management. The Quality of Recovery 40 score was higher for patients receiving sumatriptan compared to placebo, however, not statistically significant (173 [156–196] vs. 148 [139–181], p = 0.055). Postoperative opioid use between sumatriptan and placebo was lower, but not significant (5.4 vs. 5.6 mg morphine equivalent, p = 0.71). The severity of headache was also not statistically different between the two groups (5 [4–5] vs. 4 [2–5], p = 0.155). Conclusion In patients undergoing minimally invasive craniotomies for aneurysm clipping, sumatriptan given postoperatively has a nonsignificant trend for a higher quality of recovery. Similarly, there was a nonsignificant trend toward lower postcraniotomy headache scores and opioid scores for the patient given sumatriptan. [ABSTRACT FROM AUTHOR]

Introduction Managing intracranial aneurysms in the posterior circulation is particularly challenging due to anatomical complexities and the high risk of rupture. The presence of a large, partially thrombosed aneurysm adds another layer of difficulty. This report details the case of a 66-year-old female patient presenting with a symptomatic intracranial arterial loop and a large, partially thrombosed aneurysm in the posterior circulation, successfully treated through microsurgical clipping. Material and Methods A 66-year-old female with a history of intermittent headaches, vertigo, and diplopia underwent neuroimaging, including computed tomography angiography (CTA) and magnetic resonance imaging (MRI). Imaging revealed a large aneurysm in the posterior circulation, with partial thrombosis and an associated intracranial arterial loop. The patient was scheduled for a craniotomy to perform microsurgical clipping of the aneurysm. Two titanium aneurysm clips were applied to achieve complete occlusion. Results Intraoperative findings confirmed the large, partially thrombosed aneurysm arising from the basilar artery, with a complex arterial loop intricately intertwined with the aneurysm and adjacent neurovascular structures. The first clip was placed to secure the primary inflow, and the second clip provided additional reinforcement. Postoperative imaging demonstrated successful clipping with no residual aneurysm filling. The patient had an uneventful recovery with no immediate postoperative complications. Clinically, the patient reported significant improvement in symptoms, with a complete resolution of headaches and vertigo. Conclusions This case highlights the challenges and considerations in managing large, partially thrombosed aneurysms in the posterior circulation, particularly in the presence of an intracranial arterial loop. Successful management requires precise microsurgical technique and careful intraoperative decision-making. Further research is needed to optimize treatment strategies, potentially incorporating adjunctive endovascular techniques to enhance surgical outcomes.

This study aimed to introduce a three-dimensional (3D) images fusion method for preoperative simulation of aneurysm clipping. Consecutive unruptured aneurysm cases treated with surgical clipping from March 2021 to October 2023 were included. In all cases, preoperative images of plain computed tomography (CT), CT angiography, magnetic resonance imaging (MRI) 3D fluid-attenuated inversion recovery, 3D heavily T2-weighted images, and 3D rotational angiography were acquired and transported into a commercial software (Ziostation2 Plus, Ziosoft, Inc. Tokyo, Japan). The software provided 3D images of skull, arteries including aneurysms, veins, and brain tissue that were freely rotated, magnified, trimmed, and superimposed. Using the 3D images fusion method, two operators predicted clips to be used in the following surgery. The predicted clips and actually used ones were compared to give agreement scores for the following factors: (1) type of clips (simple or fenestrated), (2) shape of clips (straight, curved, angled, or bayonet), and (3) clipping strategy (single or multiple). The agreement score ranged from 0 to 3 because a score of 1 or 0 was given for agreement or disagreement on each factor. Interoperator reproducibility was also evaluated. During the study period, 44 aneurysms from 37 patients were clipped. All procedures were successfully completed, thanks to the precisely reproduced surgical corridors with the 3D images fusion method. Agreement in clip prediction was good with mean agreement score of 2.4. Interobserver reproducibility was also high with the kappa value of 0.79. The 3D images fusion method was useful for preoperative simulation of aneurysm clipping.

Aneurysms located on the distal portion of the posterior inferior cerebellar artery (PICA) are a rare disease that requires special treatment. Keeping the artery patent while excluding the aneurysm from the blood flow is essential during surgery. The patency ensures adequate blood circulation in the surrounding tissues and reduces the risk of ischemic complications. Therefore, carefully manipulating nearby anatomical structures is crucial to ensure successful surgery, minimize complications, and achieve optimal treatment results. This article describes a case of successful surgical intervention in a patient with a complex distal PICA aneurysm. The surgery was performed in the area of the anterior medullary segment using an extended retrosigmoid retrocondylar approach combined with C1 hemilaminectomy and monitoring the V3 segment of the vertebral artery. This approach has proven safe and effective, representing a promising alternative for the microsurgical treatment of PICA aneurysms, both in the acute and subacute stages of hemorrhage. The chosen surgical tactics helped prevent recurrent subarachnoid and intraventricular bleeding, as well as minimize the risk of ischemia, edema, and compression of the brain stem. These complications could lead to severe disability or even death.

Objective Early exposure to niche specialities, like neurosurgery, is essential to inform decisions about future training in these specialities. This study assesses the impact of a hands-on simulated aneurysm clipping workshop on medical students’ and junior doctors’ perceptions of neurosurgery at a student-organized neurosurgical conference. Methods Ninety-six delegates were sampled from a hands-on workshop involving hydrogel three-dimensional printed aneurysms clipping using surgical microscopes. Consultant neurosurgeons facilitated the workshop. Changes in delegates’ perceptions of neurosurgery were collected using Likert scale and free-text responses postconference. Results Postworkshop, 82% of participants reported a positive impact on their perception of neurosurgery. Thematic analysis revealed that delegates valued the hands-on experience, exposure to microsurgery, and interactions with consultant neurosurgeons. Thirty-six of the 96 delegates (37.5%) expressed that the workshop dispelled preconceived fears surrounding neurosurgery and improved understanding of a neurosurgeon’s day-to-day tasks. Several delegates initially apprehensive about neurosurgery were now considering it as a career. Conclusion Hands-on simulated workshops can effectively influence medical students’ and junior doctors’ perceptions of neurosurgery, providing valuable exposure to the specialty. By providing a valuable and immersive introduction to the specialty, these workshops can help to dispel misconceptions, fears, and apprehensions associated with neurosurgery, allowing them to consider the specialty to a greater degree than before. This study of a one-time workshop cannot effectively establish its longterm impact on said perceptions, however. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to compare microvascular Doppler sonography (MDS) and laser speckle contrast imaging (LSCI) for assessing vessel patency and aneurysm occlusion during microsurgical clipping of intracranial aneurysms. Methods: MDS and LSCI were used after clip placement during six neurovascular procedures including six patients, and agreement between the two techniques was assessed. LSCI was performed in parallel or right after MDS evaluation. The Doppler response was assessed through listening while flow in the LSCI videos was evaluated by three blinded neurovascular surgeons after the surgery. Statistical analysis determined the agreement between the techniques in assessing flow in 18 regions of interest (ROIs). Results: Agreement between MDS and LSCI in assessing vessel patency was observed in 87 % of the ROIs. LSCI accurately identified flow in 93.3 % of assessable ROIs, with no false positive or negative measurements. Three ROIs were not assessable with LSCI due to motion artifacts or poor image quality. No complications were observed. Conclusions: LSCI demonstrated high agreement with MDS in assessing vessel patency during microsurgical clipping of intracranial aneurysms. It provided continuous, real-time, full-field imaging with high spatial resolution and temporal resolution. While MDS allowed evaluation of deep vascular regions, LSCI complemented it by offering unlimited assessment of surrounding vessels.

The use of the indocyanine green video angiography (ICG-VA) both endoscope and microscope has become popular in recent decades thanks to the safety, efficacy, and added value that they have provided for cerebrovascular surgery. The dual use of these technologies is considered complementary and has helped cerebrovascular surgeons in decision-making, especially for aneurysm clipping surgery; however, its use has been described for both aneurysm surgery, resection of arteriovenous malformations, or even for bypass surgeries. We conducted a review of the literature with the MeSH terms "microscope indocyanine green video angiography (mICG-VA)," "endoscopic review," AND/OR "intracranial aneurysm." A total of 97 articles that included these terms were selected after a primary review to select a total of 26 articles for the final review. We also present a case to exemplify its use, in which we use both technological tools for the description of the aneurysm, as well as for decision-making at the time of clipping and for reclipping. Both tools, both the use of the endoscope and the mICG-VA, have helped decision-making in neurovascular surgery. A considerable clip replacement rate has been described with the use of these technologies, which has helped to reduce the complications associated with poor clipping. One of the main advantages of their usefulness is that they are tools for intraoperative use, which is why they have shown superiority compared to digital subtraction angiography, which takes longer to use and has a higher risk of complications associated with the contrast medium. On the other hand, a very low rate of complications has been described with the use of the endoscope and mICG-VA, which is why they are considered safe tools to use. In some cases, mention has been made of the use of one or the other technology; however, we consider that its dual use provides more information about the status of the clip, its anatomy, its relationship with other vascular structures, and the complete occlusion of the aneurysm. We consider that the use of both technologies is complementary, so in case of having them both should be used, since both the endoscope and the mICG-VA provide additional and useful information. [ABSTRACT FROM AUTHOR]

Background: Vertebral artery aneurysms account for less than 5% of all cerebral aneurysms. They have a high risk of rupture and are associated with threatening clinical outcomes compared with anterior circulation aneurysms. Method: The endoscopic endonasal transclival approach (EETA) was used. During the temporary clipping, the neck of the aneurysm was dissected, and a permanent clip was applied. The repair of the skull base defect was carried out with the nasoseptal mucoperiosteal flap on the vascular pedicle. Conclusion: The EETA is a feasible alternative for the clipping of the medially located ruptured vertebral artery aneurysm. EETA can be recommended for centers with a large volume of cerebrovascular and endoscopic neurosurgical procedures. [ABSTRACT FROM AUTHOR]

Objective:Intracranial artery aneurysms can result in high morbidity and mortality when ruptured. Preventive treatments might be necessary to avoid adverse results. This paper aims to discuss and share the first-term findings of unruptured intracranial artery aneurysms (UIAs) of the anterior circulation surgery at a newly established clinic in light of our clinical principles and surgical approaches.Method:Patients diagnosed with UIAs of the anterior circulation in our establishment in September 2020 and November 2022 and treated with microsurgery clipping operations were retrospectively evaluated. Assistive devices such as a sodium fluorescein integrated microscope, videoangiography, and micro-Doppler ultrasonography were intraoperatively used. We actively used a second surgeon with a third hand in the microscopic field. With case studies, we provided various techniques, and our experiences were used to avoid complications. We compared our surgical findings with radiological and clinical data.Results:In our institution, 44 aneurysms and 40 patients diagnosed with UIAs of the anterior circulation were treated with 42 operations. The mean age was 50 years (31/69 years), and the follow-up time was 379 days (30/828 days). The modified Rankin scale (mRS) of the patients was evaluated; the mRS of patients was evaluated as three due to previous subarachnoid haemorrhage history, and postoperative change was not detected. Three patients had postoperative epileptic seizures; therefore, their mRS was evaluated as 1, and the mRS of 36 patients was 0 after follow-up. In the postoperative digital subtraction angiography of two patients, a rest was detected in the aneurysm neck; therefore, one patient underwent another surgery, and the endovascular team treated the other patient. Infarction due to loss of the parent artery and the perforating artery was not observed in any patient. Minor complications were seen in 20% of the patients.Conclusion:An increase in the variety and use of intraoperative assistive techniques and the active participation of the second surgeon using a third hand can decrease the complication rate. Additionally, the complication rate will decrease as the surgical experience increases in vascular institutions dealing with such cases.

Aim Clips in neurosurgery are made of titanium alloys, which reduce artifacts on computed tomography (CT). The radiological advantage of plastic clips on the CT image was demonstrated when they were placed in an inter-hemispherical position at an angle of 90º. The aim of this study was to investigate the behaviour of the clip placed at different angles. Methods Sixty heads of domestic pigs were divided into two groups, in group 1 a titanium clip was placed to the interhemispheric position at an angle of 90º, 45º, 0º, ten heads for each angle. In group 2 a plastic clip was placed in the same way. CT scan of the brain was performed for each angle. The size of the density and possible artifact were measured on CT. Results The size of the titanium clip ranged from 17.05 mm at an angle of 0º in the axial plane to 91.47 mm at an angle of 0º in the sagittal plane. The average size of the plastic clip ranged from 6.4 mm at an angle of 0º in the axial plane to 23.22 mm in an angle of 90º in the sagittal plane. Artifacts were observed only in the titanium clip. Conclusion Plastic clips have shown radiological advantages over titanium clips in the CT image. The average density size of the plastic clip in all planes and all angles was smaller than the titanium clip.

About 40% of patients with multiple intracranial aneurysms (MIAs) are admitted with poor-grade subarachnoid haemorrhage (Hunt & Hess Grades IVV). Therefore, an approach to identify the most appropriate strategy for an individual patient should be applied to obtain the best functional outcomes. However, there is still no consensus on selecting proper MIAs treatment in patients with acute subarachnoid haemorrhage with localization of all aneurysms in the surgical intervention area. The article presents a case of a 43-year-old patient with MIAs: a ruptured aneurysm of the anterior communicating artery (ACA) and intact right pericallosal and right middle cerebral arteries (MCA). The first stage included clipping the ruptured ACA aneurysm and decompressive craniectomy. After stabilization of the patient's condition, the second stage of treatment was performed: clipping the aneurysms of the right pericallosal and right MCA and autologous cranioplasty. The patient was discharged from the hospital in satisfactory condition. The presented case demonstrates the need for a flexible individual approach to treating patients with MIAs and acute subarachnoid bleeding. Staged surgical treatment and performing as the second stage clipping of intact aneurysms with simultaneous early cranioplasty after compensating the patient's condition allowed for good treatment outcomes.

Meningitis is a potential complication of elective intracranial surgery (EIS). The prevalence of meningitis after EIS varies greatly in the literature. The objective of this study was to estimate the overall pooled prevalence of meningitis following EIS. Four databases (PubMed, Scopus, Web of Science, and Embase) were searched to identify relevant studies. Meta-analyses of proportions were used to combine data. Cochran's Q and I2 statistics were used to assess and quantify heterogeneity. Additionally, several subgroup analyses were conducted to investigate the source of heterogeneity and examine differences in the prevalence based on variables such as geographical regions, income level, and meningitis type. The meta-analysis included 83 studies (30 959 patients) from 26 countries. The overall pooled prevalence of meningitis after EIS was 1.6% (95% CI 1.1–2.1), with high heterogeneity present (I2 = 88%). The pooled prevalence in low- to middle-income countries and high-income countries was 2.7% (95% CI 1.6–4.1) and 1.2% (95% CI 0.8–1.7), respectively. Studies that reported only aseptic meningitis had a pooled prevalence of 3.2% (95% CI 1.3–5.8). The pooled prevalence was 2.8% (95% CI 1.5–4.5) in studies that reported only bacterial meningitis. Similar prevalence rates of meningitis were observed in the subgroups of tumor resection, microvascular decompression, and aneurysm clipping. Meningitis is a rare but not exceptional complication following EIS, with an estimated prevalence of 1.6%. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Managing intracranial aneurysms in the posterior circulation is particularly challenging due to anatomical complexities and the high risk of rupture. The presence of a large, partially thrombosed aneurysm adds another layer of difficulty. This report details the case of a 66-year-old female patient presenting with a symptomatic intracranial arterial loop and a large, partially thrombosed aneurysm in the posterior circulation, successfully treated through microsurgical clipping. MATERIAL AND METHODS: A 66-year-old female with a history of intermittent headaches, vertigo, and diplopia underwent neuroimaging, including computed tomography angiography (CTA) and magnetic resonance imaging (MRI). Imaging revealed a large aneurysm in the posterior circulation, with partial thrombosis and an associated intracranial arterial loop. The patient was scheduled for a craniotomy to perform microsurgical clipping of the aneurysm. Two titanium aneurysm clips were applied to achieve complete occlusion. RESULTS: Intraoperative findings confirmed the large, partially thrombosed aneurysm arising from the basilar artery, with a complex arterial loop intricately intertwined with the aneurysm and adjacent neurovascular structures. The first clip was placed to secure the primary inflow, and the second clip provided additional reinforcement. Postoperative imaging demonstrated successful clipping with no residual aneurysm filling. The patient had an uneventful recovery with no immediate postoperative complications. Clinically, the patient reported significant improvement in symptoms, with a complete resolution of headaches and vertigo. CONCLUSIONS: This case highlights the challenges and considerations in managing large, partially thrombosed aneurysms in the posterior circulation, particularly in the presence of an intracranial arterial loop. Successful management requires precise microsurgical technique and careful intraoperative decision-making. Further research is needed to optimize treatment strategies, potentially incorporating adjunctive endovascular techniques to enhance surgical outcomes. [ABSTRACT FROM AUTHOR]

Background: Cerebral arteries experience aneurysms more commonly than systemic arteries. This case report discusses a blister aneurysm that affected the anterior cerebral artery's A1 segment. The histological and genetic background is related to the aneurysm's unique presentation. Case description: The blister aneurysm ruptured, leading to interventricular and basal subarachnoid hemorrhage. A right sided fronto-temporo-parietal decompressive craniotomy was performed to explore it, along which clipping operation was performed. A communicative hydrocephalus develops after the craniectomy for which a right parietal VP shunt was conducted that underwent malfunction. The patient succumbed due to septic shock after 4 months of VP shunt revision surgery. Discussion: Different forms of cerebral aneurysms were analyzed, with regards to their histo-pathological characteristics and underlying anatomical basis of their formation. Finally, the genetic propensity of all the aneurysm was explained. There was an interventricular and basal subarachnoid hemorrhage because of the blister aneurysm's rupture. To explore it, a fronto-temporo-parietal decompressive craniotomy on the right side was done, along with a clipping operation. After the craniectomy, a right parietal VP shunt was performed, however it malfunctioned, leading to a communicative hydrocephalus. After undergoing VP shunt revision surgery for 4 months, the patient passed away from septic shock. Conclusions: The common types of cerebral aneurysms (saccular, fusiform, mycotic and blister) and the anatomical basis of their occurrence are reviewed in-depth in the histopathological and genetic literature.

Abstract Background Methods Results Conclusions Paraophthalmic aneurysms present a challenge to surgeons and their ideal management remains up for debate. We studied recent outcomes of these lesions in a single center.A retrospective chart review of all patients undergoing treatment for paraophthalmic aneurysms from 2017–2019 was performed. Factors including patient demographics, aneurysm characteristics, treatment modality, radiographic treatment outcome, clinical outcome, and length of stay were collected, and bivariate analysis was performed.In total 84.5% (82/97) of aneurysms were treated endovascularly and 15.5% (15/97) surgically. In the surgery cohort, there were three transient perioperative complications (20%) and one minor postoperative complication (6.7%). Complete aneurysm occlusion or near complete (<2mm residual) was achieved in 100% (15/15). All but one patient had mRS ≤1 at the last follow-up. In the endovascular group, 78.1% (64/82) underwent flow diversion alone. Endovascular treatment was associated with a 4.9% (4/82) rate of periprocedural complications: 3 transient events, and 1 death, and a 3.7% (3/82) rate of delayed complications: 2 transient vision changes, and one death. Rate of total occlusion was 87.8% (72/82). 76 patients (92.7%) had mRS ≤1 at the last follow-up. Length of stay was significantly shorter in the endovascular group (3.4 days vs. 7.0 days) [p < 0.001].This series demonstrates similar safety to previously reported series as well as the efficacy of both surgical clipping and endovascular embolization of paraophthalmic aneurysms. Rate of complications and treatment efficacy were similar in both groups although this represents a single institution series not generalizable to all centers. [ABSTRACT FROM AUTHOR]

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目的 比较左侧优势血供的不同空间构型前交通动脉瘤开颅夹闭手术过程、效果及术中暴露情况，并探讨与之相关的手术适应证。 方法 回顾性分析山西医科大学第二医院2013年1月-2021年12月连续收治的确诊为左侧优势血供前交通动脉瘤，且进行了动脉瘤开颅夹闭手术的患者资料。根据大脑前动脉A2段的走行方向与冠状面的位置关系，将动脉瘤分为4型：大脑前动脉与冠状面夹角＜22.5°为水平型；大脑前动脉与矢状面夹角＜22.5°为纵向型；右侧大脑前动脉在前且与冠状面夹角112.5°～157.5°为右前左后型；左侧大脑前动脉在前且与冠状面夹角22.5°～67.5°为右后左前型。分别比较水平型组和纵向型组，右前左后型组和右后左前型组间的基线资料、进行左侧翼点入路夹闭手术的时间、夹闭方式（简单夹闭或复杂夹闭）、夹闭效果（是否完全夹闭）、术后3个月和1年动脉瘤是否复发、术后1年GCS评分等指标。 结果 研究共纳入50例患者，其中水平型8例，纵向型12例，右前左后型16例，右后左前型14例。水平型组与纵向型组各项指标差异均无统计学意义。右前左后型组与右后左前型组术前基线资料差异无统计学意义，右前左后型组的手术时间短于右后左前型组（85.1±19.2 min vs. 102.1±57.5 min，P=0.032），2组术后动脉瘤复发率、预后差异无统计学意义。 结论 右前左后型前交通动脉瘤的手术时间短于右后左前型，但预后方面与右后左前型无显著差异；水平型与纵向型前交通动脉瘤的手术和预后指标无显著差异。 Abstract: Objective To compare the surgical effect, operation procedure and intraoperative exposure of craniotomy clipping for anterior communicating aneurysms with of different spatial configurations superior blood supply on the left side, and to explore the related surgical indications. Methods The data of patients with left superior anterior communicating aneurysms receiving neurosurgical clipping in the Second Hospital of Shanxi Medical University from January 2013 to December 2021 were retrospectively analyzed. According to the positional relationship between the running direction of A2 segment of anterior cerebral artery (ACA) and the coronary plane, aneurysms were divided into four types: horizontal type, the angle between ACA and the coronary plane was less than 22.5°; longitudinal type, the angle between ACA and the sagittal plane was less than 22.5°; right anterior left posterior type, the right ACA in front and the angle between ACA and the coronary plane was between 112.5°-157.5°; right posterior left anterior type, the left anterior cerebral artery in front and the angle between ACA and the coronary plane was between 22.5°-67.5°. The operation time, clipping pattern (simple clipping or complex clipping), clipping results(complete clipping or not) , aneurysm recurrence from 3 months to 1 year and GCS score at 1 year after operation were compared between horizontal type and longitudinal type, between right anterior left posterior type and right posterior left anterior type. Results A total of 50 patients were included in the study, including 8 cases of horizontal type, 12 cases of longitudinal type, 16 cases of right anterior left posterior type, and 14 cases of right posterior left anterior type. There were no statistical differences in all the clinical indexes between horizontal type and longitudinal type. There were no statistical differences in the baseline data between right anterior left posterior type and right posterior left anterior type, while the operation time in right anterior left posterior type was shorter than that in right posterior left anterior type (85.1±19.2 min vs.102.1±57.5 min, P=0.032), and there were no statistical differences in the aneurysm recurrence rate and prognosis between the two groups. Conclusions For patients with left superior anterior communicating aneurysms, the operation time in right anterior left posterior type (based ACA) was shorter than that in right posterior left anterior type, and there was no statistical difference in prognosis indexes between the two groups; there were no statistical differences in operation and prognosis indexes between horizontal type and longitudinal type.

Patients undergoing cerebral aneurysm clipping are at risk for cerebral ischemia. Ischemic tolerance varies among individuals. Hence, multimodal intraoperative neuromonitoring (IONM) is essential. IONM is not available in many centers. This case report highlights the utilization of processed electroencephalography (EEG) as a cerebral ischemia monitor during temporary clip application. Our patient underwent clipping of a ruptured anterior-communicating artery aneurysm. After the temporary clip applications on the right and left, A1 arterial segments led to a transient drop of somatosensory evoked potentials (SSEPs). At the same time, the frontal four-channel processed EEG showed a burst suppression (BS) pattern. Blood pressure augmentation and the removal of temporary clips helped restore the SSEP back to baseline and the disappearance of the BS pattern in processed EEG. During the steady state of anesthesia, the sudden appearance of the BS pattern in processed EEG can be attributed to clip-induced cerebral ischemia after ruling out other potential causes for BS.

Background and objectivesIn recent decades, the rise of endovascular management of aneurysms has led to a significant decline in operative training for surgical aneurysm clipping. Simulation has the potential to bridge this gap and benchtop synthetic simulators aim to combine the best of both anatomical realism and haptic feedback. The aim of this study was to validate a synthetic benchtop simulator for aneurysm clipping (AneurysmBox, UpSurgeOn).MethodsExpert and novice surgeons from multiple neurosurgical centres were asked to clip a terminal internal carotid artery aneurysm using the AneurysmBox. Face and content validity were evaluated using Likert scales by asking experts to complete a post-task questionnaire. Construct validity was evaluated by comparing expert and novice performance using the modified Objective Structured Assessment of Technical Skills (mOSATS), developing a curriculum-derived assessment of Specific Technical Skills (STS), and measuring the forces exerted using a force-sensitive glove.ResultsTen experts and eighteen novices completed the task. Most experts agreed that the brain looked realistic (8/10), but far fewer agreed that the brain felt realistic (2/10). Half the expert participants (5/10) agreed that the aneurysm clip application task was realistic. When compared to novices, experts had a significantly higher median mOSATS (27 vs. 14.5; p

Background: Middle cerebral artery (MCA) M1-related dissecting aneurysms involving the M1 segment are difficult because of the involvement of M1 perforators and the short duration of ischemia tolerance during bypass. Method: We report a case of MCA M1-2 dissecting aneurysm resection and reanastomosis under bypass blood flow protection. Histological staining was used to show aneurysm pathological characteristics. Conclusion: This case demonstrates the value of distal bypass for blood flow protection in MCA M1-2 dissecting aneurysm dissection and reanastomosis. Pathological staining showed intramural thrombus, cell dysfunction, microtube formation, and obvious inflammation. [ABSTRACT FROM AUTHOR]

Up to 40% of intracranial aneurysms arise from the anterior cerebral artery and anterior communicating artery (ACA-ACoA) complex. The vast variability of vessel anomalies and the surrounding critical structures correlate with severe morbidity and mortality rates in case of rupture. In the era of cutting-edge advantages of endovascular procedures, surgical expertise is reducing. This article describes our institutional surgical technique in managing ACoA aneurysms, focusing on anatomical variants, approach selection, and technical intraoperative nuances., Competing Interests: Declarations. Ethical Approval: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Purpose: This study aimed to research the optimal energy range of dual-energy computed tomography angiography (DECTA)-based virtual monoenergetic imaging (VMI) for evaluations after cerebral aneurysm clipping., Methods: Sixty patients who underwent DECTA after cerebral aneurysm clipping were analyzed retrospectively. Conventional computed tomography angiography (CTA) was compared with VMIs at 60, 70, 80, 90, and 100 keV. The mean attenuation and standard deviation values within the regions of interest placed in the brain parenchyma and arteries with the worst artifact were measured, respectively. The ΔCT and artifact index (AI) values were calculated to assess the artifact severity. The contrast-to-noise ratio (CNR) was calculated to assess vascular contrast. Two radiologists assessed brain parenchyma and cerebrovascular scores qualitatively using a five-point Likert scale., Results: Quantitative analysis showed that the artifacts of VMIs were significantly reduced compared with conventional CTA ( P ≤ 0.014), except for the ΔCT and AI of 60 keV and the ΔCT of 70 keV. However, there was no significant difference in the vascular contrast on VMIs compared with conventional CTA, except for the CNR of 60 keV ( P = 0.008). In qualitative analysis, the proportions of brain parenchyma scores and cerebrovascular scores ≥4 on the VMIs of 70 and 80 keV were higher than those of conventional CTA and other VMIs., Conclusion: For the patients who underwent DECTA after cerebral aneurysm clipping, the 70-80 keV VMIs are expected to be the optimal energy range for balancing clip artifacts and visibility of adjacent vessels., Clinical Significance: Studying the optimal energy range of DECTA-based VMI for post-operative assessment of aneurysm clipping can reduce metal artifacts in images and increase vascular contrast. This facilitates the follow-up of patients after aneurysm clipping, offers timely and accurate detection of postoperative complications, provides assistance to clinicians in diagnosis and treatment, and improves patient prognosis.

The management of multiple intracranial aneurysms poses a significant clinical challenge. 1 Various factors, including the patient's neurologic status, age, risk factors, aneurysm morphology, location, ruptured or unruptured status, availability of equipment, the surgeon's surgical abilities, and patient preferences, influence the choice of treatment modality. 2 It has been observed that there is a higher risk of rupture during the perioperative period when surgical intervention is performed to treat a ruptured aneurysm. 3 Additionally, it is suggested that patients with multiple aneurysms located in both the anterior and posterior circulation are less likely to be treated with a single procedure. 4 This surgical strategy should be applied in the setting of multiple aneurysms in the anterior and posterior circulation that would, on the other hand, demand multiple interventions. 5 In an experienced scenario, microsurgery could be a viable option. We present the case of a 58-year-old patient who presented with chronic headaches, a medical history of hypertension, and tobacco use. The patient had no neurologic deficits. During imaging, 5 incidental aneurysms were found. Bilateral ophthalmic aneurysms, one ipsilateral ventral paraclinoid aneurysm, at the bifurcation of the internal carotid artery, and another at the top of the basilar. The aneurysms were clipped with an orbito-zygomatic approach, and the patient had no postoperative neurologic deficit (Video 1). The patient consented to the procedure and publication of her image. No institutional research ethics board approval was required because only intraoperative footage was shown. No identifiable data are displayed except for 2 photographs of the patient's head without the face, which was appropriately consented to., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

ObjectiveThis study aimed to evaluate the diagnostic effect of intraoperative neurophysiological monitoring in identifying intraoperative ischemic events and predicting postoperative neurological dysfunction during PCoA aneurysm clipping, as well as to explore the safe duration of intraoperative temporary clipping of the parent artery.MethodsAll 71 patients with PCoA aneurysm underwent craniotomy and aneurysm clipping. MEP and SSEP were used for monitoring during operation to evaluate the influence of MEP/SSEP changes on postoperative neurological function. Receiver operating characteristic (ROC) curve analysis was used to calculate optimal duration of intraoperative temporary clipping.ResultsPatients with intraoperative MEP/SSEP changes were more likely to develop short-term and long-term neurological deficits than those without MEP/SSEP changes (P 4.5 min was significantly higher than that in patients with temporary clipping ≤4.5 min (P = 0.015, P = 0.018).ConclusionIntraoperative MEP/SSEP changes are significantly associated with postoperative neurological dysfunction in patients with PCoA aneurysms. The optimal duration of temporary clipping of the parent artery during posterior communicating aneurysm clipping was 4.5 min under neurophysiological monitoring.

Introduction: Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality. Post-hemorrhagic vasospasm with neurological deterioration is a major concern in this context. NicaPlant®, a modified release formulation of the calcium channel blocker nicardipine, has shown vasodilator efficacy preclinically and a similar formulation known as NPRI has shown anti-vasospasm activity in aSAH patients under compassionate use. Research question: The study aimed to assess pharmacokinetics and pharmacodynamics of NicaPlant® pellets to prevent vasospasm after clip ligation in aSAH. Material and methods: In this multicenter, controlled, randomized, dose escalation trial we assessed the safety and tolerability of NicaPlant®. aSAH patients treated by clipping were randomized to receive up to 13 NicaPlant® implants, similarly to the dose of NPRIs previous used, or standard of care treatment. Results: Ten patients across four dose groups were treated with NicaPlant® (3–13 implants) while four patients received standard of care. 45 non-serious and 13 serious adverse events were reported, 4 non-serious adverse events and 5 serious adverse events assessed a probable or possible causal relationship to the investigational medical product. Across the NicaPlant® groups there was 1 case of moderate vasospasm, while in the standard of care group there were 2 cases of severe vasospasm. Discussion and conclusion: The placement of NicaPlant® during clip ligation of a ruptured cerebral aneurysm raised no safety concern. The dose of 10 NicaPlant® implants was selected for further clinical studies. Editor highlights: • Post-hemmorrhagic vasospasm with neurological deterioration is one major concern in this disease. • Oral or intravenous nimodipine is standard of care after aSAH, but systemic side-effects often hinders adequate application. • Local delivery of spasmolytics during angiography is short lasting and has not proven a benefit in terms of outcome. • Local delivery over the critical period via prolonged released formulation may overcome the systemic side effects and have a beneficial effect in terms of outcome.

Objective: Traumatic intracranial aneurysms (TICA) across all age groups make up less than 1% of all aneurysms. Traumatic aneurysms in children occur from 10 to 39%, and their treatment requires special considerations. Even though readily diagnosed, the management of traumatic intracranial aneurysms in children is still a subject for discussion. Two cases of traumatic aneurysms following penetrating and blunt trauma are presented. Case description: Two cases of traumatic aneurysms are presented. The first patient presented with an aneurysm of the distal M4 segment of the left middle cerebral artery (MCA) 1 week following blunt traumatic brain injury with skull fractures. The aneurysm was excised without complications. The second patient presented with a saccular aneurysm of the A2 segment of the left anterior cerebral artery (ACA) following penetrating traumatic brain injury with a metal rod. The aneurysm was discovered incidentally on computed tomography angiography (CTA) performed to exclude a brain abscess when the patient developed a persistent fever. After numerous unsuccessful attempts at endovascular embolization, microsurgical aneurysm clipping was performed without complications. Conclusion: Traumatic intracerebral aneurysms are relatively more common in childhood. They commonly occur in the first 21 days post-trauma but can also occur in the late period. We, therefore, recommend that CTA or direct cerebral angiography should be performed within the first 3 weeks to exclude TICA and in all patients with sudden deterioration in the early postoperative period. Considering the high mortality rate associated with conservative management, surgical and/or endovascular management should be performed once the diagnosis is made. [ABSTRACT FROM AUTHOR]

Background and Study Aims Aneurysm clips must have adequate closing forces because residual blood flow in clipped aneurysms may result in aneurysm recurrence. Such flow can be intraoperatively detected by visual inspection, microvascular Doppler sonography, indocyanine green videoangiography (ICG-V), angiography, and puncture. Patients We present two patients with ruptured very small middle cerebral artery aneurysms (3 and 2.9 mm). The necks of both aneurysms were microsurgically clipped with Yasargil aneurysm clips without any complications. Results In both aneurysms, visual inspection suggested complete occlusion, but ICG-V showed persistent residual blood flow between the middle parts of the clip blades. The first patient was treated with a 5.4-mm FT744T clip (closing force of 1.47 N). After the ICG-V finding, a second 3.9-mm FT714T clip (closing force of 1.08 N) was placed on the tips of the already implanted clip to increase the closing forces. Subsequent ICG-V did not show any further residual blood flow. In the second patient, the aneurysm was clipped with an 8.0-mm FE764K clip (closing force of 1.77 N). Intraoperative ICG-V showed persistent residual blood flow within the aneurysmal dome despite complete closure of the clip. The clip was repositioned closer to the parent vessel. Consecutive ICG-V did not show any residual blood flow. Conclusion Visually undetected incomplete aneurysm occlusion can be revealed with ICG-V. In very small aneurysms, standard closing forces of clips may not be sufficient and complete closure of the clip branches should be intraoperatively validated with ICG-V. [ABSTRACT FROM AUTHOR]

Aneurysms of the internal carotid artery are the second most common among cerebral aneurysms. When an aneurysm is located in the ophthalmic segment of the internal carotid artery (ICA), the intravascular treatment method is a priority. At the same time, the treatment of recurrent and non-radially switched-off aneurysms of this localization remains a subject of discussion.Case report. We present a 42-year-old patient with a ruptured ICA aneurysm who was admitted in a serious condition. Initially, the patient underwent partial occlusion of the aneurysm cavity with endovascular coiling. In the control cerebral angiography 3 months after the haemorrhage, the recanalization of the aneurysm was verified, which served as an indication for repeated surgical intervention. We preferred the microsurgical method of treatment. A control angiographic study 1 year after the second operation confirmed the radical shutdown of the aneurysm.Discussion. The presented case illustrates the need for a flexible approach in the treatment of complex paraclinoid aneurysms. The choice of endovascular treatment of such aneurysms in the acute period of haemorrhage is justified as the most sparing, although less radical. Depending on the nature of the embolization performed, the timing of the control angiographic examination should be selected individually and can be reduced to 2 months. If there are indications for repeated surgical intervention, it should be performed by the safest method, providing total shutdown of the aneurysm and reducing the volumetric impact of the aneurysm dome on the optic nerve.

Abstract Background Anterior communicating artery (AComA) aneurysm rupture is the most common cause of subarachnoid hemorrhage worldwide. In this study, we aimed to determine the factors associated with a poor clinical outcome in patients with ruptured AComA aneurysms undergoing microsurgical clipping. Methods We retrospectively reviewed the clinical and radiologic features as well as clinical outcomes of 150 consecutive patients with ruptured AComA aneurysm who underwent surgical clipping during the 11-year study period. Logistic regression analysis was performed to identify independent factors associated with unfavorable clinical outcomes (defined as a modified Rankin scale score of 3–6). Results The study included 83 male and 67 female patients, with a mean age of 51.3 ± 11.5 years. At admission, most of the patients had good neurological status, including 97 (64.7%) patients with a Hunt and Hess grade of 1 or 2 and 109 (72.6%) patients with a World Federation of Neurosurgical Societies grade of 1 or 2. Unfavorable outcomes at 6 months were observed in 23 (22.0%) patients, and the 6-month mortality rate was 8.0%. Multivariate analysis showed that preoperative intraventricular hemorrhage (odds ratio [OR], 19.66; 95% confidence interval [CI], 5.10–75.80; P

In certain cases, the closing force of a single vascular clip is not sufficient for complete aneurysmal occlusion, and the use of multiple clips, or clip stacking, is required. Many stacking techniques have been described in the literature, such as in tandem stacking and overstacking. However, these may not be feasible during procedures with limited exposure or narrow corridors. Clip reinforcement with a second high-pressure booster clip, also known as the piggyback technique, is an alternative for these cases along with anatomically complex aneurysms or aneurysms demonstrating atypical morphological features. Although this technique has been cited as a potential resource for certain aneurysms, descriptions of its characteristics and advantages are scarce. The purpose of this technical note was to discuss our experience with the piggyback clipping technique and use of a booster clip for a partially embolized and recanalized saccular posterior communicating artery aneurysm in a 50 year-old patient. [ABSTRACT FROM AUTHOR]

Aneurysms arising from the anterior communicating artery (ACOA) are the most common intracranial aneurysms encountered. Most aneurysms can be treated with surgical clipping or endovascular coiling; however, there are times when parent vessel sacrifice (PVS) is necessary such as aneurysms with fragile necks or large/giant aneurysms. Application of intraoperative neurophysiological monitoring (IONM) can assist in guiding permissive temporary vessel occlusion during complex aneurysm clippings. However, to-date there is no literature that describes how IONM can be used as a predictor of post-operative neurological status when PVS is employed or as a guide to determine whether PVS is safe. We present a case where IONM guided the sacrifice of the A1 and anterior communicating arteries after 2 hours and 25 min of temporary vessel occlusion. No attenuation was noted in the IONM at any point during the procedure, and the IONM predicted the patient would awake neurologically intact. [ABSTRACT FROM AUTHOR]

Patients undergoing cerebral aneurysm clipping are at risk for cerebral ischemia. Ischemic tolerance varies among individuals. Hence, multimodal intraoperative neuromonitoring (IONM) is essential. IONM is not available in many centers. This case report highlights the utilization of processed electroencephalography (EEG) as a cerebral ischemia monitor during temporary clip application. Our patient underwent clipping of a ruptured anterior-communicating artery aneurysm. After the temporary clip applications on the right and left, A 1 arterial segments led to a transient drop of somatosensory evoked potentials (SSEPs). At the same time, the frontal four-channel processed EEG showed a burst suppression (BS) pattern. Blood pressure augmentation and the removal of temporary clips helped restore the SSEP back to baseline and the disappearance of the BS pattern in processed EEG. During the steady state of anesthesia, the sudden appearance of the BS pattern in processed EEG can be attributed to clip-induced cerebral ischemia after ruling out other potential causes for BS. [ABSTRACT FROM AUTHOR]

IntroductionMicrosurgery for the clipping of intracranial aneurysms remains a technically challenging and high-risk area of neurosurgery. We aimed to describe the technical challenges of aneurysm surgery, and the scope for technological innovations to overcome these barriers from the perspective of practising neurovascular surgeons.Materials and MethodsConsultant neurovascular surgeons and members of the British Neurovascular Group (BNVG) were electronically invited to participate in an online survey regarding surgery for both ruptured and unruptured aneurysms. The free text survey asked three questions: what do they consider to be the principal technical barriers to aneurysm clipping? What technological advances have previously contributed to improving the safety and efficacy of aneurysm clipping? What technological advances do they anticipate improving the safety and efficacy of aneurysm clipping in the future? A qualitative synthesis of responses was performed using multi-rater emergent thematic analysis.ResultsThe most significant reported historical advances in aneurysm surgery fell into five themes: (1) optimising clip placement, (2) minimising brain retraction, (3) tissue handling, (4) visualisation and orientation, and (5) management of intraoperative rupture. The most frequently reported innovation by far was indocyanine green angiography (84% of respondents). The three most commonly cited future advances were hybrid surgical and endovascular techniques, advances in intraoperative imaging, and patient-specific simulation and planning.ConclusionsWhile some surgeons perceive that the rate of innovation in aneurysm clipping has been dwarfed in recent years by endovascular techniques, surgeons surveyed highlighted a broad range of future technologies that have the potential to continue to improve the safety of aneurysm surgery in the future.

Purpose: The best treatment for distal basilar artery aneurysms is controversial. We aimed to review our single-centre experience with coil embolisation of aneurysms at this location and compare it with the surgical and endovascular literature. Methods: Forty-two aneurysms in a distal basilar location in 42 consecutive patients (15 ruptured and 27 unruptured) were treated endovascularly from 2010 to 2015. Unassisted single and multiple microcatheter coil embolisation alone was used in all cases. We studied our immediate and long-term anatomical results, operative complications, and outcome. Results: The immediate angiographic results showed complete occlusion in 34 (81%), a neck remnant in seven (16.6%) and a residual aneurysm in one patient (2.4%). There were two thromboembolic events (4.7%) without clinical sequelae; therefore, the operative morbidity and mortality were zero. Three patients with ruptured aneurysms (7.1%) died due to complicated vasospasm. Thirty-nine patients (93%) had clinical and MR imaging follow-up (mean 32.3 months ± 18.6, range from 12 to 66 months). There was recanalization in 30.8% with a retreatment rate of 15.3% and no new bleedings. The aneurysm size was the most important predictor of early anatomical outcome and recurrence. Conclusion: Unassisted and multiple microcatheter coiling is a safe treatment for distal basilar aneurysms. Early anatomical results and recurrence depend on the aneurysm size. Morbidity and mortality are lower and recurrence rates are higher in comparison with clipping or other adjunctive endovascular techniques. [ABSTRACT FROM AUTHOR]

Posterior Cerebral Artery aneurysms are scarce, yet its territory is frequently associated to large and giant aneurysms. Treatment is mostly a binary option between microsurgical clipping and endovascular coiling. Hybrid approaches are an option too, whereas innovation with less frequent techniques such as endoscope-controlled and endoscope-assisted procedure may provide a safer surgical approach with same successful results. Hereby we report a case of a 53 years old male examined at the ER after presenting generalized seizures and altered state of consciousness. Upon arrival, neurological evaluation revealed homonymous right hemianopia. Computed tomography (CT) scan revealed a subarachnoid hemorrhage and left parieto-occipital intraparenchymal hemorrhage with intraventricular extension; computed tomography angiogram (CTA) revealed an aneurysm at the left posterior cerebral artery (PCA) in its P4 segment. We performed a vascular exploration with drainage of the occipital and intraventricular hematoma through a single endoscopic port through transulcal approach guided by neuronavigation, in addition to clipping and aneurysmectomy. The combination of microsurgical clipping with previous Endoport-guided endoscopic procedure may be a surgical-operative option that not only may facilitate the approach to the desired lesion, but also provides a safer surgical scenario. [ABSTRACT FROM AUTHOR]