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BACKGROUND: Pretreatment computed tomography perfusion parameter relative cerebral blood volume (rCBV) lesion volume has been shown to predict 90-day modified Rankin Scale score in small-core strokes with Alberta Stroke Program Early Computed Tomography Score ≥5, including those with medium-vessel occlusions (mid and distal M2 segment occlusions). Hence, in this study we aim to assess the performance of different rCBV lesion volume thresholds (rCBV

OBJECTIVE: Diagnostic cerebral angiograms (DCAs) are widely used in neurosurgery due to their high sensitivity and specificity to diagnose and characterize pathology using ionizing radiation. Eliminating unnecessary radiation is critical to reduce risk to patients, providers, and health care staff. We investigated if reducing pulse and frame rates during routine DCAs would decrease radiation burden without compromising image quality. METHODS: We performed a retrospective review of prospectively acquired data after implementing a quality improvement protocol in which pulse rate and frame rate were reduced from 15 p/s to 7.5 p/s and 7.5 f/s to 4.0 f/s respectively. Radiation doses and exposures were calculated. Two endovascular neurosurgeons reviewed randomly selected angiograms of both doses and blindly assessed their quality. RESULTS: A total of 40 consecutive angiograms were retrospectively analyzed, 20 prior to the protocol change and 20 after. After the intervention, radiation dose, radiation per run, total exposure, and exposure per run were all significantly decreased even after adjustment for BMI (all p

Background: Amphetamines possess sympathomimetic properties that can affect cerebral vasculature though conflicting reports exist about their effect on vasospasm risk and clinical outcomes in aneurysmal subarachnoid hemorrhage. This study aimed to characterize the impact of recent amphetamine use on vasospasm development in aneurysmal subarachnoid hemorrhage as well as neurological outcomes. Methods: We retrospectively screened 441 consecutive patients admitted with a diagnosis of subarachnoid hemorrhage who underwent at least one cerebral digital subtraction angiogram. Patients were excluded if no urinary toxicology screen was performed within 24 h of admission, if there was a diagnosis of non-aneurysmal subarachnoid hemorrhage, or if ictus was greater than 72 h from hospital admission. Vasospasm characteristics were collected from digital subtraction angiography and transcranial Doppler studies. Results: 129 patients were included and 24 tested positive for amphetamines on urine drug screen. No significant differences were found in respect to patient age, sex, or admission clinical severity scales (Hunt-Hess and modified Fisher) based on amphetamine use. There was no difference in the severity of vasospasm or time to peak severity based on recent amphetamine use. A trend toward more isolated posterior circulation vasospasm was observed in the amphetamine present group (16.7% vs. 4.8%, p = 0.06), while there was higher incidence of anterior circulation vasospasm in the amphetamine absent group (79.2% vs. 94.3%, p = 0.03). There was no difference in delayed cerebral ischemia incidence, length of hospital stay, need for ventriculoperitoneal shunt placement, functional outcome at discharge or hospital mortality based on amphetamine use. Interpretation: Recent amphetamine use was not associated with worse vasospasm severity or delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage patients. Further investigations about localized effects in the posterior circulation and impact on long-term functional outcomes are warranted. [ABSTRACT FROM AUTHOR]

António Egas Moniz, born in 1874, was a pioneer in neurology, neurosurgery and psychiatry who brought about important changes in the 1920s using groundbreaking brain imaging techniques, such as cerebral angiography. This innovative procedure allowed the visualization of brain structures, leading to many advances in neurology and neurosurgery. Moniz also made noteworthy contributions to psychosurgery, including the development of prefrontal lobotomy. Although initially praised for his inventive techniques, lobotomy sparked ethical debates and public controversies due to its adverse effects and questionable scientific foundation. Moniz's was awarded the Nobel Prize in Physiology or Medicine in 1949 and received various honors in Portugal for his scientific, literary, and artistic achievements. His work continues to influence the field of neuroscience, and angiography remains a crucial imaging method for diagnosing and treating brain disorders. Moniz's complex legacy highlights the intricate balance between medical advances, ethical considerations, and public perceptions in the history of medicine. [ABSTRACT FROM AUTHOR]

Purpose: To describe a case of large arterial ring formed by a duplicate origin of the right middle cerebral artery (MCA) associated with a frontal branch arising from the superior channel of the ring (main MCA) using magnetic resonance (MR) angiography. Methods: An 81-year-old man with spinocerebellar degeneration underwent cranial MR imaging and MR angiography using a 1.5-Tesla scanner. MR angiography was performed using a standard 3-dimensional time-of-flight technique. Results: MR imaging showed cerebellar atrophy and multiple cerebral white matter lesions. Regarding family history, he was diagnosed with Machado-Joseph disease. On MR angiography, an anomalous artery arose from the lateral wall of the supraclinoid segment of the right internal carotid artery (ICA) and fused with the main MCA, forming a large arterial ring. Thus, the anomalous artery was diagnosed as a duplicate origin of the MCA and not a duplicated MCA. The frontal branch of the MCA arose from the superior channel of the arterial ring (main MCA). Conclusion: This variation is called "segmental duplication of the MCA." However, this term may be confused with a duplicate origin or fenestration of the proximal M1 segment of the MCA. We report the first case of this combined variation diagnosed using MR angiography. [ABSTRACT FROM AUTHOR]

The superior hypophyseal arteries (SHAs) are well known in anatomical and surgical literature, with a wellestablished role in supply of the anterior hypophysis and superjacent optic apparatus. However, due to small size and overlap with other vessels, in vivo imaging by any modality has been essentially non-existent. Advances in high resolution cone beam CT angiography (CBCTA) now enables this deficiency to be addressed. This paper presents, to the best of our knowledge, the first comprehensive in vivo imaging evaluation of the SHAs. Methods Twenty-five CBCTA studies of common or internal carotid arteries were obtained for a variety of clinical reasons. Dedicated secondary reconstructions of the siphon were performed, recording the presence, number, and supply territory of SHAs. A spectrum approach, emphasizing balance with adjacent territories (inferior hypophyseal, ophthalmic, posterior and communicating region arteries) was investigated. Results The SHAs were present in all cases. Supply of the anterior pituitary was nearly universal (96%) and almost half (44%) originated from the 'cave' region, in excellent agreement with surgical literature. Optic apparatus supply was more difficult to adjudicate, but appeared present in most cases. The relationship with superior hypophyseal aneurysms was consistent. Patency following flow diverter placement was typical, despite a presumably rich collateral network. Embryologic implications with respect to the ophthalmic artery and infraoptic course of the anterior cerebral artery are intriguing. Conclusions SHAs are consistently seen with CBCTA, allowing for correlation with existing anatomical and surgical literature, laying the groundwork for future in vivo investigation. [ABSTRACT FROM AUTHOR]

Background A health advisory was issued in response to a fungal meningitis outbreak linked to epidural anesthesia exposure in two plastic surgery clinics in Mexico, from January 1 to May 13, 2023. This descriptive analysis describes the neuroendovascular and neurosurgical observations and management of patients treated at a single stroke center located along the US-Mexico Border. Methods We conducted a retrospective chart review of fungal meningitis patients presenting between April and July 2023. Results Among the patients diagnosed with fungal meningitis (n=12), the majority (n=11) were afflicted with angio-invasive Fusarium solani. 83% received dual antifungal therapy, with 40% initiated on alternateday intrathecal amphotericin B. Diagnostic cerebral angiography was performed on all patients, revealing aneurysms in 58% of cases, predominantly within the posterior circulation, notably the basilar artery, with a median size of 4.2 mm (IQR 3.3-4.8). Treatment strategies included flow diversion (70%) and primary coiling (14%) for aneurysms. Ventriculostomy placement was undertaken in 67% of patients, with 37.5% of these requiring conversion to ventriculoperitoneal shunts. Subarachnoid hemorrhage development was uniformly associated with 100% mortality. Conclusions In patients presenting with Fusarium solani meningitis, weekly angiographic surveillance proved instrumental for monitoring aneurysm and vasospasm development. Conventional angiography outperformed CT angiography due to its enhanced ability to detect small aneurysms. A proactive approach to aneurysm treatment is advocated, given their elevated rupture risk. While our findings suggest the potential reversibility of angiographic vasospasm with effective antifungal treatment, we acknowledge the challenge of drawing definitive conclusions based on a limited sample size. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the surgical outcomes of delayed microsurgical clipping for ruptured intracranial aneurysms (RICAs) of anterior circulation. Methods: This retrospective, cross-sectional study assessed the surgical outcomes of 50 patients who underwent surgical clipping for "ruptured aneurysms" with subarachnoid haemorrhage after the 21st post-bleed day, from May 01, 2022, till May 01, 2023, at the Department of Neurosurgery, Punjab Institute of Neurosciences, Lahore, Pakistan. Results: The mean age of patients was 49.66 ± 6.231 years with a female preponderance of 54%. Out of 50 cases, 21 were midline aneurysms (42%), followed by left-sided laterality in 16 cases (32%). Aneurysm of the anterior communicating artery was the most common accounting for 42% of the patients. Forty-nine patients returned home after first postoperative week without deficits, with a success rate of 98%. Seizures, surgical site infection and cerebrospinal fluid leak were noted in 6%, 4% and 2% patients, respectively. Conclusion: Delayed clipping in RICAs after the 21st post-bleed day is advocated, especially in resource-constrained settings. Meticulous surgical technique and asepsis are responsible for great postoperative outcomes. [ABSTRACT FROM AUTHOR]

The circle of Willis (COW) refers to the anastomotic arterial network found on the brain base, tasked with provision of collateral circulation aimed at prevention of ischemia. The COW is of immense clinical importance especially with regard to the assessment of neurovascular diseases. Individuals portray significant variations in the COW's anatomical configuration. The present study seeks to evaluate the existing anatomical variations of the COW and within the anterior and posterior segments of the COW. Thus, the study seeks to evaluate the different anatomical variations of the COW and its segments and components within the study population. To attain the set objectives, the present study has utilized the angiographic images for studying the COW variants in patients who underwent cerebral angiography during assessment of different types of cerebral anomalies and conditions. Therefore, this study used conventional angiography as an important tool in the evaluation of the different variations in the COW, and is most appropriate for evaluation of smaller anatomical variations owing to its perfect spatial resolution and portrayal of COW anatomy. The study findings indicated the existence between age and sex, and anatomical variations of the COW, particularly with regard to diameters of COW components like basilar artery (BA), P1, and internal carotid arterys (ICAs). Males had bigger BA, P1 and ICA diameters than females, while individuals aged below 40 years had bigger BA, A1, posterior communicating artery, and ICA diameters than those aged above 40 years. [ABSTRACT FROM AUTHOR]

To review morphometry, morphology, branching patterns and anomalies of middle cerebral artery (MCA). The databases of PubMed, Google Scholar and Scopus were searched with different keywords. The review comprised of 45 studies. Meta-analysis was done for dimensions of MCA, shapes, patterns and MCA anomalies. Newcastle-Ottawa Scale was used for assessment of literature. Statistical analysis was done using R software using meta package. Thirteen research were combined to determine the proportion of MCA length and pooled proportion was 16.53 cm (15.33 to 17.72 cm); I2=98%; P-value<0.01. Nine studies were combined to determine proportion of MCA diameter and pooled proportion was 2.85 cm (2.52 to 3.17 cm); I2=100%; P-value<0.05. M1 segment mean length is more on left side as compared to right side. Mean length in males (16.57±1.40 cm) is more than females (15.9±1.32 cm). Mean diameter of M1 segment is similar on both sides. Mean diameter in males (3.20±0.09 cm) is higher than females (3.14±0.18 cm). Different branching patterns observed were single trunk, early bifurcation, bifurcation, trifurcation, quadrifurcation and multiple trunks. The most typical MCA branching pattern is bifurcation. The shapes of MCA like straight shaped, U shaped, C shaped, inverted U shaped and S-shaped of M1 segment have been described. Straight MCA is the most common shape. The MCA measurements and branching pattern will assist surgeons in limiting errors in the treatment of cerebral aneurysms and infarcts and providing the best possible result for the patients. An understanding of MCA shape will aid surgeons and physicians in effective endovascular recanalization. [ABSTRACT FROM AUTHOR]

Background/Objectives: Arteriovenous malformations (AVMs) are complex vascular anomalies that can present with significant complications, including intracranial hemorrhage. This report presents the case of a 36-year-old female with Prothrombin G20210A mutation-associated thrombophilia, highlighting its potential impact on AVM pathophysiology and management. Methods: The patient presented with a right paramedian intraparenchymal frontal hematoma, left hemiparesis, and seizures. Cerebral angiography identified a ruptured right parasagittal frontal AVM classified as Spetzler–Martin Grade II. A right interhemispheric frontal craniotomy was performed, enabling microsurgical resection of the AVM. Intraoperative findings included evacuation of a subcortical hematoma and excision of a 20 mm AVM nidus with arterial feeders from the A4 segment of the anterior cerebral artery and a single venous drainage into the superior sagittal sinus. Results: Postoperative recovery was favorable, with significant neurological improvement. The patient demonstrated resolution of hemiparesis and a marked reduction in seizure activity. The hypercoagulable state associated with Prothrombin G20210A mutation was identified as a contributing factor in the thrombosis of the AVM's draining vein, potentially leading to increased venous pressure, rupture, and hemorrhage. Conclusions: This case underscores the importance of recognizing thrombophilia in patients with AVMs for optimal surgical planning and complication management. Despite the challenges posed by the hypercoagulable condition, microsurgical resection proved to be a viable and effective treatment option. Further research is warranted to elucidate the relationship between thrombophilic disorders and AVMs to enhance patient management strategies and outcomes. [ABSTRACT FROM AUTHOR]

The middle meningeal artery (MMA) is a major dural vessel that plays a significant role in developing chronic subdural hematomas (cSDHs). Understanding its variable anatomy is essential for the effective management of cSDH and the prevention of complications. MMA anatomy was retrospectively assessed in a population of 92 patients who underwent digital subtraction angiography of cerebral vessels before MMA embolization for cSDH. We assessed 121 MMAs in 92 patients who underwent digital subtraction angiography for cSDH treatment from October 2020 to July 2023. The most common type in the extended Adachi classification was IC (19.82%) and the rarest was IB (6.31%). The anterior branch of the MMA was the most frequently dominant, while the most common origin of the posterior branch was observed in the distal segment. We reported 4 cases (3.31%) of the MMA arising from the ophthalmic artery. The most common configuration of MMA was Adachi-type IC. The MMA most often originated from the maxillary artery. The posterior branch of the MMA was typically dominant and most frequently originated from the distal segment. There was no significant impact of Adachi type on treatment results or fluoroscopy time. [ABSTRACT FROM AUTHOR]

Moyamoya disease (MMD) is a rare progressive condition of unknown etiology that affects the blood vessels in the brain and is characterized by narrowing or stenosis of the distal parts of the internal carotid and major intracranial arteries, leading to the development of fragile collateral supplies. This makes it a significant causative factor for both ischemic strokes as well as intracerebral hemorrhages. As per the recommendations by the Research Committee on Moyamoya disease in 2021, the diagnostic criteria for MMD are essentially based on indicative radiological findings on cerebral angiography or MRI Brain and MRA, after excluding possible differentials. In this case report, we present the case of a 45-year-old Asian lady who presented with sudden-onset headaches and right-sided weakness. Her admission non-contrast CT brain scan was undiagnostic. MRI brain and MRA scans revealed bilateral anterior circulation watershed infarcts of variable age along with supra-clinoid stenosis. She was initially treated with steroids for vasculitis after discussions with a multidisciplinary team involving neurologists, stroke physicians and neuro-radiologists; however, further imaging revealed a diagnosis of MMD, and she was subsequently referred for revascularization surgery. Given the limited number of similarly documented cases, we hope this report will contribute to the knowledge base. [ABSTRACT FROM AUTHOR]

Objective To explore endovascular treatment for patients with blood blister-like aneurysms (BBA) of the internal carotid artery (ICA). Methods and Results A retrospective analysis of the clinical data of 25 patients with BBA of ICA admitted to The First Affiliated Hospital of Soochow University from January 2018 to January 2022 were conducted. All of them accepted endovascular treatment: 17 cases were treated with single-stent-assisted embolization, including 14 cases using Lvis stents and 3 cases using Enterprise stents; 4 cases were treated with double-stent-assisted embolization, all using Lvis stents; one case was treated with overlapping stent implantation, including 2 Lvis stents and one Enterprise stent; one case was treated with balloon -assisted embolization, and 2 cases were treated with Tubridge flow diverter. No aneurysm rupture occurred during the surgery. One patient had intra-stent thrombosis during the procedure, while other 24 patients showed smooth blood flow on postoperative immediate DSA. The Raymond classification showed that among the patients, there were 17 cases of grade I occlusion, 3 cases of grade II occlusion, and 5 cases of grade III occlusion. Postoperative complications included cerebral infarction (2 cases), cerebral vasospasm due to subarachnoid hemorrhage (one case), and hydrocephalus (2 cases). Six patients had aneurysm recurrence postoperatively (3 cases using a single Enterprise stent, one case using 2 Lvis stents, one case using Tubridge flow diverter, and one case using a balloon-assisted embolization), among whom 5 patients underwent repeat stent-assisted embolization treatment. And one patient still had recurrence after treatment but achieved cure by adjusting antiplatelet therapy regimen; one patient recovered by adjusting antiplatelet therapy regimen. At 12 months after surgery, the modified Rankin Scale (mRS) scores were as follows: 0 in 15 cases, 1 in 6 cases, 2 in 3 cases, and 6 in one case. The disability rate was 12% (3/25), and the mortality rate was 4% (1/25). Conclusions The degree of immediate postoperative occlusion is crucial for preventing aneurysm recurrence postoperatively. For recurrent BBA of ICA, adjustment of antiplatelet therapy should be considered first. [ABSTRACT FROM AUTHOR]

Background The Willis covered stent (WCS) and pipeline embolization device (PED) have partly overlapping therapeutic indications. However, the differences of effect between these two treatments remain unclear. Objective To compare clinical outcome, angiographic outcome, and complications following treatment with a WCS versus PED. Methods Patients with intracranial aneurysms treated by a WCS or PED between January 2015 and December 2020 were included. The primary outcomes were complications, clinical outcome (modified Rankin Scale score >2), and angiographic outcome (incomplete aneurysm occlusion). Propensity score matching was conducted to adjust for potential confounding factors. Results A total of 94 aneurysms treated by WCS and 698 aneurysms by PED were included. Compared with the PED group, patients in the WCS group are younger, a greater number have a poor condition at admission, a larger proportion of ruptured, non-saccular, and anterior circulation aneurysms, a smaller aneurysm neck width, and less coiling assistance is required. A total of 42 (44.7%) branches were covered by WCS. After adjustment for age, sex, aneurysm type, rupture status, neck size, aneurysm location, and coiling, 50 WCS and PED pairs were examined for internal carotid artery aneurysms. No significant differences were observed in clinical (10.4% vs 2.1%, P=0.206) and angiographic outcomes (12.8% vs 18.2%, P=0.713). However, 27 branches covered by WCS, including 22 ophthalmic arteries and five posterior communicating arteries. Patients in the WCS group had a higher intraoperative complication rate than those in the PED group (28% vs 6%, P=0.008), especially in the occlusion rate of covered branches (51.9% vs 11.1%, P<0.001). Conclusion The comparable clinical and angiographic outcomes of WCS or PED demonstrate the therapeutic potential of WCS as a viable alternative for aneurysms. However, the complication of occlusion of covered branches might not be negligible. [ABSTRACT FROM AUTHOR]

AbstractBackgroundMethodResultsConclusionAngiogenesis and nascent blood vessel formation is thought to be important in cerebral arteriovenous malformation (cAVM) development and maintenance, of which little is known. Digital subtraction angiogram (DSA) features of angiogenesis in cAVMs are poorly described and the aim of this study was to describe the frequency of angiogenesis in patients who had a DSA showing a cAVM. We also sought to evaluate the intra- and inter-observer agreement of a diagnosis of angiogenesis and explore which angioarchitectural features were associated with angiogenesis.Patients that underwent a DSA were identified from the database of referred cAVM patients at the Manchester Centre for Clinical Neurosciences. Data were collected from 100 patients (102 cAVMs). cAVM angioarchitecture, including the presence of angiogenesis, was described after reviewing cAVM patient angiograms. The association of angioarchitectural features with angiogenesis was determined using univariate analysis. Ten cases were distributed amongst two other observers for reporting (inter-observer agreement). Twenty cases (including the previous 10) were reported twice by the first author, after a six-month interval (intra-observer agreement).Angiogenesis was observed in 39 cAVMs (38.2%), with 12 having a complete border (11.8%). Most intra-observer agreement was strong (ranging from κ = 1 to 0.2), but inter-observer agreement was moderate (κ = 1 to −0.316). There was a significant association between angiogenesis and venous reflux (OR 2.52 [95% CI = 1.08–5.88]), venous congestion (OR 4.47 [95% CI = .671–2.52]), arterial ectasia (OR 16.6 [95% CI = 4.65–59.6]), and artery: vein ratio (4.28 [95% CI = .956–19.15]).We have demonstrated perinidal angiogenesis can be visualised on angiograms with moderate reliability, and that it may be related to angioarchitectural characteristics associated with venous hypertension. [ABSTRACT FROM AUTHOR]

Objective: We describe two cases of myelopathy onset due to intracranial dural arteriovenous fistulas (DAVFs) and present a literature review. Case Presentation: (Case 1) A 44-year-old man with subacute onset myelopathy underwent an MRI and DSA. MRI showed T2-hyperintensity from the medulla oblongata to the cervical spinal cord with vascular flow voids, suggestive of a spinal DAVF. Unexpectedly, cerebral angiography revealed a tentorial DAVF. (Case 2) A 47-year-old man with progressive myelopathy underwent a head and spinal MRI. Head MRI and MRA were considered to be normal. Spinal MRI revealed T2-hyperintensity in the cervical spinal cord without obvious vascular flow voids around the spinal cord. Contrast-enhanced MRI showed a patchy gadolinium enhancement in the same spinal cord region with the enhancement of perimedullary vessels. Although myelitis was initially suspected, subsequently spinal DAVF was suspected because cervical CTA revealed abnormal spinal venous drainage. Unexpectedly, cerebral angiography identified a foramen magnum DAVF. Conclusion: Regarding unexplained cervical myelopathy, even the absence of spinal cord surface vascular flow voids cannot necessarily exclude venous congestive myelopathy due to the DAVFs. In such cases, the contrast-enhanced MRI and cervical CTA are useful for visualizing abnormal vessels around the brain stem and the cervical spine. Especially, the co-presence of the abnormal vessels around the brain stem can suggest the intracranial DAVFs. Not only spinal DAVFs but also intracranial DAVFs should be considered as the differential diagnoses for venous congestive cervical myelopathy, in which cases cerebral angiography including carotid angiography is essential. [ABSTRACT FROM AUTHOR]

Stents are increasingly used for coiling difficult aneurysms, to reduce the risk of recurrences, or to modify blood flow. Currently, available bifurcation aneurysm models are ill-suited to assess stent performance before clinical use. We designed a new animal model of wide-neck canine Y-type bifurcation aneurysm (such as middle cerebral artery (MCA) bifurcation) and previously reported one of T-type (such as basilar bifurcation). Its potential value as a training tool as well as in the evaluation of new techniques or stent or embolic agents was assessed. Seven canine aneurysms were created (three: Y-type, four: T-type). Aneurysms were followed by transfemoral cerebral angiography (TFCA) and computed tomography angiography (CTA). We performed TFCA and self-expandable stent placement for the parent artery adjoined to the aneurysmal neck in one month's follow-up. We assessed the long-term patency of the parent artery with CTA and euthanasia and got a specimen for pathologic study at six months' follow-up. In six models except one (T-type), a wide-neck bifurcation aneurysm was created successfully and they showed good long-term patency at six months' follow-up. Stent placement was technically difficult in these cases, but did not lead to aneurysm thrombosis in CTA or neointimal closure of the aneurysm neck in pathologic finding at postoperative six months later. This model may be suitable for studying the effects of endovascular treatment on aneurysm and branch occlusion rates, for preclinical testing of stents and other intravascular devices, and for training students in endovascular technique. [ABSTRACT FROM AUTHOR]

Scalp arteriovenous fistulas (AVFs) are rare vascular anomalies characterized by abnormal connections between arterial and venous systems in the scalp. These lesions can lead to significant complications, including chronic headaches, tinnitus, cosmetic deformities, and in severe cases, high-output cardiac failure or intracranial hemorrhage. We present a case of a middle-aged female patient with a 20-year history of a pulsating mass on the left parietal scalp. Magnetic resonance imaging and cerebral angiography confirmed the presence of a scalp AVF with multiple arterial feeders from the external carotid artery and venous drainage into the left external jugular vein. Due to the tortuosity of the feeding arteries, a transarterial approach was unsuccessful, leading to the decision to perform transvenous embolization with balloon occlusion using Onyx-18. The procedure resulted in complete obliteration of the AVF without complications. This case highlights the efficacy of transvenous embolization with balloon occlusion as a treatment option for complex scalp AVFs, particularly when transarterial access is challenging. [ABSTRACT FROM AUTHOR]

A 24-year-old male was admitted with progressive cervical hypesthesia, tetraparesis, dyspnea, and a history of craniofacial fracture. Spinal magnetic resonance imaging (MRI) showed brainstem edema extending to the thoracic spine with multiple prominent perimedullary vascular structures. Cerebral digital-substraction angiography revealed Barrow type A carotid-cavernous fistula. Total occlusion with preservation of internal carotid artery flow was achieved using 1 detachable balloon and 6 coils. Postoperatively, immediate respiratory recovery, gradual extremities strength improvement, and right abducens nerve palsy were found. One month follow-up cervical MRI showed good recovery of spinal cord edema and perimedullary veins. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Arteriovenous malformations (AVMs) consist of fistulous connections of arteries and veins without intervening capillaries, organized as a mass with definable sides. AVMs are composed of enlarged feeding arteries, a nidus of dysmorphic vessels in relationship with the brain parenchyma, through which arteriovenous shunting occurs and draining veins. In a series of corticalised and deep avm's the senior author conceptualised the nidus as composed of two or more compartments that can be separated completely after partial disconnection from corresponding feeding arteries and unessential drainage veins. This surgical strategy allowed a wider surgical corridor to the deeper AVM compartments, a faster resection and reduced blood loss. MATERIAL AND METHODS: In this study we review 4 large and one giant AVM cases removed surgically using the technique of nidus compartmentalization. Clinical and imaging data included complete surgical videos, gender, age, clinical presentation, Spetzler-Martin and Lawton-Young grade, nidus size, modified Rankin Score (mRS) were collected. SURGICAL NUANCES: The surgical strategy was adapted to the location of the main feeders. when the main feeders were deep we preferred opening a narrow deep surgical corridor to interrupt them first and then enlarging it circumferentially from depth to surface. In this scenario, the main drainage vein has a trajectory that is not perpendicular to the nidus, folding many times in close contact with one or more faces of the nidus or even inside the nidus. In this case, the classical dissecting strategy by opening surgical corridors circumferentially around the AVM, can be hazardous as the main drainage vein can be injured, resulting in heavy haemorrhage from the remaining nidus which is attached to the vein. When the main feeders came from MCA branches a superficial to deep dissection of the nidus was followed. In order to facilitate the resection, after a partial dissection of the nidus was performed, this part of it, completely freed from feeders and drainage veins was separated from the rest of the AVM with a large clip. After coagulation and resection of the nidus compartment above the clip, the circumferential interruption of deep feeders continued beyond the clip, securing another compartment of the AVM. In only one case this manoeuvrer was repeated more than 3 times. In 3 cases the division of the nidus in two compartments was enough. In three of the cases, we encountered bleeding from the nidus, especially the part of the nidus disconnected from feeders. Applying a clip to compartmentalize the nidus in this situation controlled the bleeding and opened new corridors to advance the dissection. When bleeding was encountered from multiple sources, both in the compartment disconnected from feeders and in the not yet dissected compartment, clip disconnection of the compartments diminished the bleeding considerably and allowed us to focus on the bleeding from the perforators. In other two cases we applied this strategy of nidus separation by clips even if there was no bleeding as we gained more space to access the rest of the nidus once one compartment was completely disconnected. For the giant AVM, complete resection presumed resection in multiple steps as six nidus compartments were separated from the residual nidus and resected. RESULTS: Compartmentalization and staged disconnection of the nidus with large clips was performed in five cases. Three patients presented in the emergency care unit with ruptured AVMs and subsequent hematomas and two had only minor intraoperative bleeding. There were three and 2 females in the study. The mean (± SD) age of the patients was 40 years (± 14.6 years). On admission, three patients presented with altered mental status and hemiplegia and two patients with refractory epileptic seizures. Four patients underwent digital subtraction angiography (DSA) prior to surgery, while in one case only a computed tomography angiography (CTA) was performed, since the patient was in a critical state and needed urgent surgery. Three AVMs were located in the left dominant hemisphere, (two in the temporal lobe and one at the parietooccipital junction), one AVM was cited in the, fronto-parietal right hemisphere and one giant left hemispheric avm. The median (range) size of the nidus was 4 cm (3-6 cm). Two AVMs were classified as Spetzler-Martin and Lawton-Young Supplemented grade VIII, one grade X and two as grade V. Total resection of AVM was achieved in all cases as confirmed by postoperative CT cerebral angiography (Fig 3). Immediate postoperative CTA or DSA and magnetic resonance angiography (MRA) were performed in selected cases, also confirming total removal of the AVM. For ruptured AVMs, resection and hematoma evacuation was performed in less than 12 hours after the onset of symptoms. There were no signs of cerebral infarction attributable to the staged temporary clipping of AVM's compartments shown on postoperative CT scans and due to the lack of symptoms indicating ischemia, there was no need for diffusion-weighted imaging (DWI) or perfusion-weighted imaging (PWI) MRI sequences. There was no mortality in this case series. A modified Rankin's scale was used to assess the outcome at six months, with a score ranging from 0 to 2 points, all patients were free of seizures and neurological deficits, fully socially reintegrated and returned to their previous jobs one year after surgery. DISCUSSION: Once a high-flow AVM has ruptured and subsequent hematoma progresses, brain's protection mechanisms, such as local vasoconstriction and increased blood pressure are failing as the volume of the hematoma increases and cerebral oedema takes over. Therefore, is expressed the need for a faster removal of the AVM, regardless of the bleeding's mechanism: the rupture of the AVM with massive hematoma or intraoperative bleeding, especially from the perforating arteries which are more difficult to control. We propose in this paper a surgical reorganization of AVM's with separated compartments that are disconnected step by step from the lesion, in a decrescendo or crescendo way. Depending on the location of the main feeders, superficial or deep, this approach involves working circumferentially and spiralling deep from the surface or in the second scenario attacking deep feeders first, after creating a corridor in one of the AVM's walls, then coming toward the surface. For this staged disconnection and resection of each one of the "feeding compartments" is used a clip-by-clip technique, occluding the arterial input and even secondary drainage veins. After the flow arrest, vessels are more susceptible to be coagulated and cut (Fig 5). In many cases, a unique apparency of the nidus, with numerous loops all over its surface, possibly in close contact with the brain parenchyma can compromise the dissection, hence we recommend less coagulation on the surface of the nidus, to maintain the intranidal draining system. Once bleeding from the nidus occurs, it is important to avoid enlarging the surgical corridor and opening of new bleeding fronts, until active feeders are identified and controlled. Concrete identification and anatomical description of each AVM compartment, followed by stepwise disconnection as a whole entity, decreases the intranidal pressure with a better bleedingcontrol and easier mobilization of the remnant lesion and ensures a faster resection in case of emergency. Our study is limited by the small sample size, the emergency circumstances and the lack of intraoperative imaging techniques, such as intraoperative angiography in order to identify missing feeding arteries. Further understanding of the pathophysiology of brain AVM is a milestone for adapting microsurgical resection that suits better each one of these malformations, conceptualized as a box with multiple compartments. CONCLUSIONS: Developing strategies in refining microsurgical resection is a continuous target in AVMs approach. In emergency cases, with rupture and consequent hematoma, quick resection is mandatory. In order to achieve that, remodelling of the nidus and segmentation, with gradual clip application and separate disconnection is a safe solution with a good outcome. [ABSTRACT FROM AUTHOR]

Introduction: The establishment of diagnostic reference levels (DRLs) is challenge for interventional neuroradiology (INR) due to the complexity and variability of its procedures. Objective: The main objective of this systematic review is to analyse and compare DRLs in fluoroscopy-guided procedures in INR. Methods: An observational study reporting DRLs in INR procedures, specifically cerebral arteriography, cerebral aneurysm embolisation, cerebral thrombectomy, embolisation of arteriovenous malformations (AVM), arteriovenous fistulas (AVF), retinoblastoma embolisation, and spinal cord arteriography. Comprehensive literature searches for relevant studies published between 2017 and 2023 were conducted using the Scopus, PubMed, and Web of Science databases. Results: A total of 303 articles were identified through an extensive literature search, with 159 removed due to duplication. The title and abstract of 144 studies were assessed and excluded if they did not meet the inclusion criteria. Thirty-one out of the 144 articles were selected for a thorough full-text screening. Twenty-one articles were included in the review after the complete text screening. Conclusion: The different conditions of patients undergoing INR procedures pose a barrier to the standardization of DRLs; nevertheless, they are extremely important for monitoring and optimising radiological practices. [ABSTRACT FROM AUTHOR]

Purpose: Thrombolysis in Cerebral Infarction (TICI) 3 represents the optimal angiographic outcome following mechanical thrombectomy (MT) for acute ischemic stroke (AIS). Although it is known to yield better outcomes than TICI 2b, the influence of preprocedural cerebral hemodynamics on the clinical advantage of TICI 3 over TICI 2b remains unexplored. Methods: This single-center retrospective analysis involved patients with anterior circulation AIS who underwent successful recanalization during MT at the Comprehensive Stroke Center, University Hospital, Krakow between January 2019 and July 2023. We assessed the benefit of achieving TICI 2c/3 over TICI 2b on the basis of preprocedural computed perfusion imaging results, primarily focusing on early infarct volume (EIV) and tissue-level collaterals indicated by hypoperfusion intensity ratio (HIR). Good functional outcome (GFO) was defined as a modified Rankin Score < 3 on day 90. Results: The study comprised 612 patients, of whom 467 (76.3%) achieved TICI 2c/3. GFO was more frequent in the TICI 2c/3 group (54.5% vs 69.4%, p < 0.001). There was interaction between the recanalization status and both HIR (Pi = 0.042) and EIV (Pi = 0.012) in predicting GFO, with disproportionately higher impact of HIR and EIV in TICI 2b group. The benefit from TICI 2c/3 over TICI 2b was insignificant among patients with good collaterals, defined by HIR < 0.3 (odds ratio:1.36 [0.58–3.18], p = 0.483). Conclusion: TICI 2c/3 improves patient functional outcomes compared to TICI 2b regardless of EIV. However, such angiographic improvement may be clinically futile in patients with good tissue-level collateralization. Our findings suggest that preprocedural HIR should be considered when optimization of recanalization is considered during MT. [ABSTRACT FROM AUTHOR]

Background Historically, the transfemoral approach (TFA) has been the most common access site for cerebral intraoperative angiography (IOA). However, in line with trends in cardiac interventional vascular access preferences, the transradial approach (TRA) and transulnar approach (TUA) have been gaining popularity owing to favorable safety and patient satisfaction outcomes. Objective To compare the efficacy and safety of TRA/TUA and TFA for cerebral and spinal IOA at an institutional level over a 6-year period. Methods Between July 2016 and December 2022, 317 angiograms were included in our analysis, comprising 60 TRA, 10 TUA, 243 TFA, and 4 transpopliteal approach cases. Fluoroscopy time, contrast dose, reference air kerma, and dose-area products per target vessel catheterized were primary endpoints. Multivariate regression analyses were conducted to evaluate predictors of elevated contrast dose and radiation exposure and to assess time trends in access site selection. Results Contrast dose and radiation exposure metrics per vessel catheterized were not significantly different between access site groups when controlling for patient position, operative region, 3D rotational angiography use, and different operators. Access site was not a significant independent predictor of elevated radiation exposure or contrast dose. There was a significant relationship between case number and operative indication over the study period (P<0.001), with a decrease in the proportion of cases for aneurysm treatment offset by increases in total cases for the management of arteriovenous malformation, AVF, and moyamoya disease. Conclusions TRA and TUA are safe and effective access site options for neurointerventional procedures that are increasingly used for IOA. [ABSTRACT FROM AUTHOR]

Background Early detection of intracranial aneurysms (lAs) is crucial for patient outcomes. Typically identified on angiographic scans such as CT angiography (CTA) or MR angiography (MRA), the sensitivity of experts in studies on small I As (diameter <3 mm) was moderate (64-74.1% for CTAs and 70-92.8% for MRAs), and these figures could be lower in a routine clinical setting. Recent research shows that the expert level of sensitivity might be achieved using deep learning approaches. Methods A large multisite dataset including 1054 MRA and 2174 CTA scans with expert IA annotations was collected. A novel modality-agnostic two-step IA detection approach was proposed. The first step used nnU-Net for segmenting vascular structures, with model training performed separately for each modality. In the second step, segmentations were converted to vascular surface that was parcellated by sampling point clouds and, using a PointNet++ model, each point was labeled as an aneurysm or vessel class. Results Quantitative validation of the test data from different sites than the training data showed that the proposed approach achieved pooled sensitivity of 85% and 90% on 157 MRA scans and 1338 CTA scans, respectively, while the sensitivity for small IAs was 72% and 83%, respectively. The corresponding number of false findings per image was low at 1.54 and 1.57, and 0.4 and 0.83 on healthy subject data. Conclusions The proposed approach achieved a state-of-the-art balance between the sensitivity and the number of false findings, matched the expert-level sensitivity to small (and other) IAs on external data, and therefore seems fit for computer-assisted detection of IAs in a clinical setting. [ABSTRACT FROM AUTHOR]

Background Aneurysm location is a key element in predicting the rupture risk of an intracranial aneurysm. A common impression suggests that pure ophthalmic aneurysms are under-represented in ruptured intracranial aneurysms (RIAs). The purpose of this study was to specifically evaluate the risk of rupture of ophthalmic aneurysms compared with other aneurysm locations. Methods This multicenter study compared the frequency of ophthalmic aneurysms in a prospective cohort of RIAs admitted to 13 neuroradiology centers between January 2021 and March 2021, with a retrospective cohort of patients with unruptured intracranial aneurysms (UIAs) who underwent cerebral angiography at the same neuroradiology centers during the same time period. Results 604 intracranial aneurysms were included in this study (355 UIAs and 249 RIAs; mean age 57 years (IQR 49-65); women 309/486, 64%). Mean aneurysm size was 6.0 mm (5.3 mm for UIAs, 7.0 mm for RIAs; P<0.0001). Aneurysm shape was irregular for 37% UIAs and 73% RIAs (P<0.0001). Ophthalmic aneurysms frequency was 14.9% of UIAs (second most common aneurysm location) and 1.2% of RIAs (second least common aneurysm location; OR 0.07 (95% CI 0.02 to 0.23), P<0.0001). Conclusions Ophthalmic aneurysms seem to have a low risk of rupture compared with other intracranial aneurysm locations. This calls for a re-evaluation of the benefit-risk balance when considering preventive treatment for ophthalmic aneurysms. [ABSTRACT FROM AUTHOR]

The coexistence of a meningioma and an unruptured intracranial aneurysm was considered a rare phenomenon, accidentally detected by radiological assessment. The relationship between these 2 entities is complex and represents a neurosurgical challenge. We share our experience of a case involving a 36-year-old male patient with no prior medical history who consulted for chronic unilateral left periorbital headaches. The imaging diagnosis revealed 2 lesions, including a partially calcified jugo-olfactory meningioma and an anterior communicating artery aneurysm. He was successfully treated in a single surgical procedure using a left pterional craniotomy for excision of the meningioma followed by clipping of the aneurysm. The patient was discharged home on the fifth postoperative day in good clinical condition. This experience underlines the importance of preoperative imaging assessment, in order to make the right therapeutic decision and avoid unexpected intraoperative disasters.

This case report aims to describe the clinical presentation, imaging findings, diagnostic challenges, and management of a patient with a cerebellopontine angle lesion. A 63-year-old woman presented with progressive headaches, tinnitus, right ear pressure, and dizziness. Initial imaging studies (computed tomography and magnetic resonance imaging) suggested either a thrombosed aneurysm or a lipoma. However, advanced imaging with cone beam computed tomography provided a definitive diagnosis of temporal bone exostosis. This case highlights the importance of cone beam computed tomography in diagnosing complex intracranial lesions due to its superior spatial resolution and lower radiation dose.

Abstract Background Cerebral angiography through the transradial approach (TRA) is associated with a low risk of complications, but in rare cases, these complications can be life-threatening. Case presentation A 56-year-old female patient was admitted for transradial cerebral angiography due to the complaint of right limb weakness and the diagnosis of cerebral infarction and cerebral artery stenosis. During the procedure, the patient coughed with expectoration and complained of throat discomfort, palpitations, and pains in the right shoulder and back. Emergency CT scan indicated hematoma in the middle mediastinum and the right thoracic cavity, and perforation of a branch of the subclavian artery was highly suspected. Subclavian artery angiography was conducted immediately, which revealed a patchy contrast medium overflow in a branch of the right costocervical trunk. Selective endovascular occlusion therapy was performed successfully with gelfoam particles and placement of 2 microcoils. At 12 days after cerebral angiography, the patient recovered well and was discharged from the hospital. Conclusion Mediastinal and thoracic hematoma may occur due to vessel perforation during TRA cerebral angiography, in which guidewire advancement must be cautious. Early detection and appropriate countermeasures can reduce the severity of vascular perforation and subsequent hematoma.

摘要： Sneddon综合征是一种罕见的神经皮肤综合征，主要累及中小动脉，典型临床表现为广泛的皮肤网状青斑，伴随反复发作的缺血性卒中。本病例是一位青年女性，在近10年多次经历小卒中事件，并伴有脊髓蛛网膜下腔出血和多发颅内动脉瘤。基因检测提示腺苷脱氨酶2（adenosine deaminase 2，ADA2）基因杂合突变（c.1240G＞A）。患者曾接受氯吡格雷抗血小板聚集治疗，后停止该治疗。对于卒中反复发作的青年患者，医师应密切观察并详细询问皮肤病变情况，同时建议进行脑血管造影和基因检测，以便更全面地评估和管理这类病例。 Abstract: Sneddon syndrome is a rare neurocutaneous syndrome that mainly involves the small and medium arteries. It is clinically characterized by widespread livedo reticularis with recurrent ischemic strokes. This case described a young woman who has suffered multiple minor strokes over the past decade, accompanied by spinal subarachnoid hemorrhage and multiple intracranial aneurysms. Genetic testing revealed a heterozygous mutation in the adenosine deaminase 2 (ADA2) (c.1240G>A). The patient had been treated with clopidogrel for antiplatelet aggregation but later discontinued the therapy. For young patients with a history of recurrent strokes, physicians should closely observe and inquire about the skin lesions in detail and recommend cerebral angiography and genetic testing to more comprehensively assess and manage such cases.

Objective To compare and analyze the clinical outcomes of endovascular treatment of anterior circulation large vessel occlusion (ac-LVO) caused by large artery atherosclerosis (LAA) and simple arterial embolization. Methods From August 2020 to September 2022, 87 patients with ac - LVO hospitalized in The Second Affiliated Hospital of Bengbu Medical University were enrolled. All patients were treated with endovascular treatment, including intravenous thrombolysis, stent thrombectomy, aspiration thrombectomy or angioplasty (balloon dilatation or stent implantation). According to intraoperative findings (etiology), they were divided into LAA group (n = 32) and simple arterial embolization group (embolization group, n = 55). The primary outcome was the 90 d modified Rankin Scale (mRS) score, and the secondary outcomes were postoperative vascular recanalization rate [modified Thrombolysis Cerebral Infarction (mTICI)] and incidence of symptomatic cerebral hemorrhage 1 d after surgery. Results The proportions of patients with atrial fibrillation (χ2 = 17.672, P = 0.000) and thrombus retrieval ≥ 3 times (χ2 = 10.606, P = 0.001) in the embolization group were higher than those in the LAA group, the proportion of intravenous thrombolysis in the embolization group was less than that in the LAA group (χ2 = 5.403, P = 0.020). However, the time from onset to operation (Z = 1.111, P = 0.267), the time from admission to operation (Z = 0.149, P = 0.882), preferred surgical approach for endovascular treatment (Fisher's exact probability: P = 0.153), as well as the rate of good prognosis (mRS score ≤ 2; χ2 = 0.004, P = 0.950) and mortality (χ2 = 0.035, P = 0.851) at 90 d after surgery, the rate of postoperative vascular recanalization (mTICI grade ≥ Ⅱb; χ2 = 0.033, P = 0.856) and symptomatic cerebral hemorrhage rate 1 d after surgery (χ2 = 0.345, P = 0.557) for the secondary outcome were observed in both groups, the above differences were not statistically significant. Conclusions The efficacy and prognosis of endovascular treatment of ac-LVO caused by LAA and simple arterial embolization has the same effect and clinical prognosis.

Background: The questions of whether the spatial resolution of navigated 3D-ultrasound (3D-US) power-Doppler angiography imaging rendered by existing 3D-US systems is sufficient for the intraoperative visualization of cerebral aneurysms, and in what percentage of cases, are largely unanswered. A study on this topic is lacking in the literature. Methods: From 2015 to 2022, we performed 86 surgeries on 83 aneurysm patients. Navigated 3D-US was used at the discretion of the operating neurosurgeons when available (i.e., not being used during parallel tumor surgeries). Twenty-five aneurysms (15 ruptured) were operated on using 3D-US; 22 aneurysms were located at the middle cerebral artery (MCA). Patient 3D-US power-Doppler angiography images and surgical reports were retrospectively reviewed to assess the intraoperative ultrasound visibility of aneurysms. Results: In 20 patients (80%) the aneurysms were successfully visualized. In five patients (20%), the aneurysms visualization was insufficient or absent. Nineteen of 22 aneurysms (86.4%) were visualized in the MCA aneurysm subgroup. We observed no association between aneurysm visibility and aneurysm size or the presence of subarachnoid hemorrhage. In the subgroup of MCA aneurysms, no association between aneurysm visibility and the presence of subarachnoid hemorrhage was found; a trend toward poor sonographic visibility of smaller aneurysms was observed (p = 0.09). Conclusions: Our initial data show that intraoperative 3D-US power-Doppler angiography, rendered by current navigated 3D-US systems, clearly depicts the majority of aneurysms in the MCA aneurysm subgroup. However, future prospective studies performed on a higher number of aneurysms localized at various anatomic sites are needed to confirm our initial findings and determine their potential clinical relevance. [ABSTRACT FROM AUTHOR]

Purpose: This technical note introduces the novel faucet technique, which enables neurosurgeons to evaluate the patency of a bypass during superficial temporal artery–middle cerebral artery bypass surgery. The technique is particularly useful when there is a lack of equipment such as micro-Doppler or indocyanine green in the operating rooms. This is often the case in Central Asian countries. Methods: The faucet technique involves carefully examining the graft by gently opening a valve, comparable to a faucet, to observe the blood flow through the bypassed vessel. Overall, 36 procedures underwent the faucet technique for assessing the superficial temporal artery–middle cerebral artery bypass patency. Results: The results indicate that the bypass remained patent in all cases, as confirmed through the intraoperative faucet technique, postoperative magnetic resonance angiography, or cerebral angiography. Conclusion: By visually inspecting the blood flow through the faucet technique, surgeons can confirm the effectiveness of the graft and ensure that the bypass remains unobstructed during the surgery. [ABSTRACT FROM AUTHOR]

Background: Cerebral angiography through the transradial approach (TRA) is associated with a low risk of complications, but in rare cases, these complications can be life-threatening. Case presentation: A 56-year-old female patient was admitted for transradial cerebral angiography due to the complaint of right limb weakness and the diagnosis of cerebral infarction and cerebral artery stenosis. During the procedure, the patient coughed with expectoration and complained of throat discomfort, palpitations, and pains in the right shoulder and back. Emergency CT scan indicated hematoma in the middle mediastinum and the right thoracic cavity, and perforation of a branch of the subclavian artery was highly suspected. Subclavian artery angiography was conducted immediately, which revealed a patchy contrast medium overflow in a branch of the right costocervical trunk. Selective endovascular occlusion therapy was performed successfully with gelfoam particles and placement of 2 microcoils. At 12 days after cerebral angiography, the patient recovered well and was discharged from the hospital. Conclusion: Mediastinal and thoracic hematoma may occur due to vessel perforation during TRA cerebral angiography, in which guidewire advancement must be cautious. Early detection and appropriate countermeasures can reduce the severity of vascular perforation and subsequent hematoma. [ABSTRACT FROM AUTHOR]

Objective: To determine the frequency of cerebral aneurysm in patients with subarachnoid haemorrhage on CT cerebral angiography. Methods: This prospective cross-sectional study was conducted at Department of Radiology, JPMC, Karachi from 5th June 2022 to 30th January 2023. Total 176 patients with subarachnoid haemorrhage irrespective of gender were selected. CT angiography of cerebral vessels was performed. Cerebral aneurysm was noted as per operational definition and recorded. Results: Age range was from 18 to 60 years. Mean age was 39.516±6.77 years, Mean BMI 29.630±3.08 Kg/m2. and mean duration of symptoms was 7.721±2.40 days. Male patients were 80.1% and females were 19.9%. Cerebral aneurysm was observed in 91.4% female and 78.7% male patients. Aneurysmal percentage was slightly higher in younger (18-40 years) age group (84.2% vs 80.4%) as compared to older (40-60) age group but statistically not significant. Although total percentage of female was quite less 19.9% (n=35 vs n=141 male), in this lesser female percentage, aneurysmal detection was higher as compared to male gender (91.4% vs 78.7%). Distribution of aneurysms according to vessel involved was; 28.7% along anterior communicating artery, 28.3% related to middle cerebral artery and, 22.9% were along posterior communicating vessel. Rest was distributed among other vessels including tip of basilar artery. Conclusion: In Our study aneurysms was seen 81.3% in patients of subarachnoid hemorrhage having CT angiography at our center in Karachi Pakistan. [ABSTRACT FROM AUTHOR]

Surgical treatment of large or giant thrombosed anterior cerebral artery (ACA) aneurysms often involves revascularization. Herein, we describe a unique and effective bypass technique to treat partially thrombosed giant distal ACA aneurysms in extremely narrow surgical corridors. A 68-year-old man underwent aneurysm trapping and ACA revascularization for a partially thrombosed giant ACA aneurysm in a surgical corridor that was narrow due to anatomic factors. By combining a side-to-side anastomosis and an end-to-side anastomosis at a single anastomotic site, we successfully redirected blood flow from the left pericallosal artery to the right pericallosal and callosomarginal arteries. Postoperatively, cerebral angiography showed that the blood flow in the aneurysm had disappeared, and the bypass remained open. The patient's functional disability gradually improved, and he reported consistently positive outcomes at the 6-month postoperative follow-up examination. This revascularization technique may represent an effective novel treatment option, particularly when multiple revascularization procedures are required within a narrow surgical field. [ABSTRACT FROM AUTHOR]

Arterial spin labeling (ASL) is a noninvasive imaging technique that labels the proton spins in arterial blood and uses them as endogenous tracers. Brain perfusion imaging with ASL is becoming increasingly common in clinical practice, and clinical applications of ASL for intracranial magnetic resonance angiography (MRA) have also been demonstrated. Unlike computed tomography (CT) angiography and cerebral angiography, ASL‐based MRA does not require contrast agents. ASL‐based MRA overcomes most of the disadvantages of time‐of‐flight (TOF) MRA. Several schemes have been developed for ASL‐based MRA; the most common method has been pulsed ASL, but more recently pseudo‐continuous ASL, which provides a higher signal‐to‐noise ratio (SNR), has been used more frequently. New methods that have been developed include direct intracranial labeling methods such as velocity‐selective ASL and acceleration‐selective ASL. MRA using an extremely short echo time (eg, silent MRA) or ultrashort echo‐time (TE) MRA can suppress metal susceptibility artifacts and is ideal for patients with a metallic device implanted in a cerebral vessel. Vessel‐selective 4D ASL MRA can provide digital subtraction angiography (DSA)‐like images. This review highlights the principles, clinical applications, and characteristics of various ASL‐based MRA techniques. Level of Evidence: 5 Technical Efficacy: Stage 2 [ABSTRACT FROM AUTHOR]

Background We aimed to investigate the radiation dose to the eye lens (lens dose) during cerebral angiography and to evaluate the effectiveness of the lens dose reduction protocol for 3-dimensional rotational angiography (3D-RA) in reducing overall lens dose exposure. Methods We conducted a randomized, controlled clinical trial at a tertiary hospital with patients undergoing cerebral angiography. The lens dose reduction protocol in 3D-RA involved raising the table to position the patient's eye lens away from the rotation axis. The lens dose was estimated by measuring the entrance surface air kerma using a photoluminescent glass dosimeter. The lens doses of 3D-RA, overall examination, and image quality were analyzed and compared between the two groups. Results A total of 20 participants (mean age, 58±9.4 years; including 12 men [60%]) were enrolled and randomly assigned to either the conventional group or the dose reduction group. The median lens dose in 3D-RA was significantly lower in the dose reduction group compared with the conventional group (1.1 mGy vs 4.5 mGy, p<0.001). The total dose was significantly lower in the dose reduction group (median of 7.5 mGy vs 10.2 mGy, p=0.003). In the conventional group, 3D-RA accounted for 46% of the total lens dose, while in the dose reduction group, its proportion decreased to 16%. No significant differences were observed in the image quality between the groups. Conclusion The lens dose reduction protocol resulted in a significant reduction in the lens dose of the 3D-RA as well as entire cerebral angiography, while maintaining the image quality. [ABSTRACT FROM AUTHOR]

Background Diffusion-weighted imaging (DWI) lesions have been linked to poor outcomes after intracerebral hemorrhage (ICH). We aimed to assess the impact of cerebral digital subtraction angiography (DSA) on the presence of DWI lesions in patients who underwent minimally invasive surgery (MIS) for ICH. Methods Retrospective chart review was performed on ICH patients treated with MIS in a single health system from 2015 to 2021. One hundred and seventy consecutive patients who underwent postoperative MRIS were reviewed. Univariate analyses were conducted to determine associations. Variables with p<0.05 were included in multivariate analyses. Results DWI lesions were present in 88 (52%) patients who underwent MIS for ICH. Of the 83 patients who underwent preoperative DSA, 56 (67%) patients demonstrated DWI lesions. In this DSA cohort, older age, severe leukoaraiosis, larger preoperative hematoma volume, and increased presenting National Institutes of Health Stroke Score (NIHSS) were independently associated with DWI lesion identification (p<0.05). In contrast, of 87 patients who did not undergo DSA, 32 (37%) patients demonstrated DWI lesions on MRI. In the non-DSA cohort, presenting systolic blood pressure, intraventricular hemorrhage, and NIHSS were independently associated with DWI lesions (p<0.05). Higher DWI lesion burden was independently associated with poor modified Rankin Scale (mRS) at 6 months on a univariate (p=0.02) and multivariate level (p=0.02). Conclusions In this cohort of ICH patients who underwent minimally invasive evacuation, preprocedural angiography was associated with the presence of DWI lesions on post-ICH evacuation MRI. Furthermore, the burden of DWI lesions portends a worse prognosis after ICH. [ABSTRACT FROM AUTHOR]

Infective endocarditis (IE) is associated with high morbidity and a mortality rate of 9-30% due to its life-threatening complications including systemic embolization of various organs. The complications are more common in culture-positive cases. In culture-negative IE, systemic embolism especially with multiorgan involvement occurring in a single patient is very rare. Such condition may significantly increase the hospital mortality and poses unique challenges in diagnosis and management. We present a case of a 14-year-old female who presented with a oneweek history of vague left upper quadrant pain and fever. She had a history of recurrent mild chest pain in the last one month but did not seek any treatment. She had no risk factors of IE. On presentation, she was fully conscious but with signs of septic shock requiring vasoconstrictor support and administration of a broad-spectrum antibiotics. There was loud pansystolic murmur on auscultation and generalised abdominal tenderness. Abdominal ultrasound showed geographic hypoechogenicity of the spleen with small bowel wall thickening. Contrast-enhanced computed tomography (CECT) abdomen confirmed splenic and renal infarction with ischaemic small bowel. Transthoracic echocardiography showed vegetation at the mitral valve. She developed a severe headache during admission. CT head and conventional cerebral angiography demonstrated a ruptured mycotic aneurysm. Her CRP and ESR were elevated. Anti-DNase B Titre was elevated raising suspicion of previous group A streptococcus infection. All her blood culture results were persistently negative throughout admission possibly due to the initiation of antibiotics prior to sample collection. Despite a negative culture, she developed disseminated embolism to various organs as described. The planned mitral valve surgery was delayed due to the intracranial bleed, and she underwent craniectomy for clot removal. Mitral valve replacement was performed one month later. During follow-up, she had good recovery with no signs of heart failure or significant impairment of quality of life. [ABSTRACT FROM AUTHOR]

Lateral spinal artery (LSA) aneurysms are extremely rare lesions that can rupture and cause subarachnoid hemorrhage (SAH) even though the spinal arteries communicate directly with the subarachnoid space. To date, six cases of LSA aneurysms have been reported in the literature. Herein, three such cases are reported. All patients presented to the emergency department with headaches. The patients in the first two cases were confirmed to have SAH and LSA aneurysms on a brain computed tomography (CT) angiography performed at the hospital. Two patients had prior instances of cerebral infarction and coronary disease, respectively, and were undergoing antiplatelet therapy. The antiplatelet medication was stopped for 2 weeks and 1 week, respectively, while conservative care was provided. Subsequently, a suboccipital craniectomy was performed, followed by aneurysm clipping. Following the surgery, both patients were discharged without any significant neurological deficits. Regarding the third patient, no aneurysm was found on brain CT angiography, and cerebral angiography was performed during the patient’s hospital stay. She was hospitalized, where she received medication and conservative care, and was discharged with an improvement in bleeding without neurological symptoms. Subsequently, a LSA aneurysm was identified on a brain CT angiography performed at an outpatient clinic; however, the patient was transferred because she wanted to be treated at another hospital. LSA aneurysms are difficult to visualize using CT angiography; therefore, careful angiographic studies are required. Surgical clipping is the treatment of choice if the aneurysm is inaccessible by the endovascular treatment. [ABSTRACT FROM AUTHOR]

Introduction Predicting the shape of the occluded middle cerebral artery (MCA) from the contralateral MCA might help catheterization in endovascular mechanical thrombectomy (EMT). Materials and Methods We analyzed magnetic resonance (MR) angiography in 100 consecutive patients who had MR imaging for diseases other than acute ischemic stroke. To assess the symmetricity of MCA, the shape of M1, length of M1, number of M2, number of early branches (EBs), and distance from the top of the internal carotid artery to EB were investigated. Results The shape of M1 was upward in 42%, horizontal in 47%, and downward in 11%. The M1 shape was the same on both sides in 64%, which exceeded the probability assumed to be left–right independent. The number of M2 trunks and EBs matched left and right in 86 and 55% of patients, respectively; however, these agreement rates were not higher than those with independent left and right sides. No left–right correlation was found between the M1 length and the distance from the internal carotid artery to EB. Conclusion Based on our data, the symmetry of MCA was observed only in the shape of the M1 segment. This finding could be beneficial for EMT targeting MCA embolisms. [ABSTRACT FROM AUTHOR]

Bifurcations are a common site for saccular aneurysms, but rarely can be a site for dissecting aneurysms. Identification of these aneurysms is extremely important because the management plan depends on it. We describe a rare case of a ruptured dissecting aneurysm at the right ICA bifurcation in a pre-teen child which posed a diagnostic dilemma but ultimately was successfully managed with flow diversion. [ABSTRACT FROM AUTHOR]

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Background To assess the frequency, imaging appearances, and risk factors of brain microemboli following pediatric neuroangiography, as assessed by early diffusion-weighted MRI imaging (DWI). Methods This single-center, retrospective analysis investigated early DWI post-pediatric neuroangiography. Patients aged 0-18 years who had diagnostic neuroangiography and DWI within a week postprocedure were included. Data on clinical and procedural parameters and MRI findings were recorded. Univariate and multivariate analyses were performed on the following risk factors: age, weight, vasculopathy, antiplatelet drug use, access type, intraprocedural heparin, procedure duration, neck arteries catheterized, and angiographic runs. A p-value<0.05 indicated statistical significance. Results Eighty-two children were included (40.2% female), mean age 10.1±4.5 years (range: 7 months-17 years). There were no intraprocedural thromboembolic complications recognized. DWI positivity was seen following 3.6% (3/82) procedures: two with transient symptoms, and one instance of silent microemboli. There were no territorial infarcts or clinical stroke. Children with underlying vasculopathy had a higher risk of microemboli from angiography than children without vasculopathy (OR 31.6, p=0.02), and the OR of microemboli following transradial angiography was 79.1 (p=0.005) as compared with transfemoral angiography. Univariate and multivariate analysis showed a significant association between microemboli and number of angiographic runs (p=0.004). Follow-up MRI in all three patients showed no residual abnormal signal. Conclusions Cerebral microemboli are unusual following uncomplicated neuroangiography in children. However, in the presence of underlying vasculopathy and with transradial technique, the incidence approaches that reported in the adult literature. An increased association with the number of angiographic runs is an important and controllable factor. [ABSTRACT FROM AUTHOR]