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Intracranial arterial aneurysms in children are rare. They differ from adult aneurysms in their etiology, natural history, and management approach. Unruptured asymptomatic aneurysms in children can often be observed for growth over time. Endovascular treatment has become the primary interventional modality in children with intracranial aneurysms. The authors discuss the management approach to pediatric intracranial aneurysms., (Crown Copyright © 2024. Published by Elsevier Inc. All rights reserved.)

Aneurysms are bulges of an artery, which require clinical management solutions. Due to the inherent advantages, endovascular coil filling is emerging as the treatment of choice for intracranial aneurysms (IAs). However, after successful treatment of coil embolization, there is a serious risk of recurrence. It is well known that optimal packing density will enhance treatment outcomes. The main objective of endovascular coil embolization is to achieve flow stasis by enabling significant reduction in intra-aneurysmal flow and facilitate thrombus formation. The present study numerically investigates the effect of framing coil orientation on intra-aneurysmal hemodynamics. For the purpose of analysis, actual shape of the embolic coil is used, instead of simplified ideal coil shape. Typically used details of the framing coil are resolved for the analysis. However, region above the framing coil is assumed to be filled with a porous medium. Present simulations have shown that orientation of the framing coil loop (FCL) greatly influences the intra-aneurysmal hemodynamics. The FCLs which were placed parallel to the outlets of basilar tip aneurysm (Coil A) were found to reduce intra-aneurysmal flow velocity that facilitates thrombus formation. Involving the coil for the region is modeled using a porous medium model with a packing density of 20 % . The simulations indicate that the framing coil loop (FCL) has a significant influence on the overall outcome., (© 2024. International Federation for Medical and Biological Engineering.)

Introduction: The Woven EndoBridge (WEB) device is emerging as a novel therapy for intracranial aneurysms, but its use for off-label indications requires further study. Using machine learning, we aimed to develop predictive models for complete occlusion after off-label WEB treatment and to identify factors associated with occlusion outcomes., Methods: This multicenter, retrospective study included 162 patients who underwent off-label WEB treatment for intracranial aneurysms. Baseline, morphological, and procedural variables were utilized to develop machine-learning models predicting complete occlusion. Model interpretation was performed to determine significant predictors. Ordinal regression was also performed with occlusion status as an ordinal outcome from better (Raymond Roy Occlusion Classification [RROC] grade 1) to worse (RROC grade 3) status. Odds ratios (OR) with 95 % confidence intervals (CI) were reported., Results: The best performing model achieved an AUROC of 0.8 for predicting complete occlusion. Larger neck diameter and daughter sac were significant independent predictors of incomplete occlusion. On multivariable ordinal regression, higher RROC grades (OR 1.86, 95 % CI 1.25-2.82), larger neck diameter (OR 1.69, 95 % CI 1.09-2.65), and presence of daughter sacs (OR 2.26, 95 % CI 0.99-5.15) were associated with worse aneurysm occlusion after WEB treatment, independent of other factors., Conclusion: This study found that larger neck diameter and daughter sacs were associated with worse occlusion after WEB therapy for aneurysms. The machine learning approach identified anatomical factors related to occlusion outcomes that may help guide patient selection and monitoring with this technology. Further validation is needed., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Object: Treatment of ruptured basilar artery trunk (BAT) aneurysms is challenging, and is associated with high complication and mortality rates. Herein, we analyzed the complications, long-term outcomes, and outcome predictors of endovascular treatment for ruptured BAT aneurysms., Methods: Between January 2011 and July 2023, 36 patients with 36 ruptured BAT aneurysms underwent endovascular treatment at our institution. The postprocedural complications and clinical and angiographic outcomes were subsequently reviewed, and the risk factors for postprocedural complications were evaluated., Results: All 36 aneurysms in 36 patients were treated successfully. The median clinical follow-up time was 47.0 (IQR: 10.5, 84.5) months. Overall, complications occurred in 10 (27.8%) patients, including 3 (8.3%) deaths. Ischemic events occurred in seven (19.4%) patients, while three (8.3%) patients had shunt-dependent hydrocephalus, of whom one (2.8%) patient had both shunt-dependent hydrocephalus and ischemic events. The cumulative survival rates at 3 and 5 years were 94.1% and 87.8%, respectively. The cumulative 3- and 5-year complication-free survival rates were 75.0% and 70.0%, respectively. Multivariate Cox regression analysis revealed that diabetes mellitus (HR:8.76, 95%CI:2.35-32.69, p=0.001), and Glasgow coma scale score ≤ 12 before the procedure (HR:5.04, 95%CI:1.40-18.12, p=0.013) were associated with overall postprocedural complications. The complete aneurysm occlusion rate was 61.5% at a median angiography follow-up time of 6.0 (IQR: 5.0, 6.0) months., Conclusions: Endovascular treatment is a safe and feasible option for treating ruptured BAT aneurysms. The rate of favorable outcomes at the final follow-up was satisfactory. However, postprocedural complications, particularly ischemic events, should be carefully considered., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background and Importance: Fusiform vertebrobasilar aneurysms carry significant morbidity. Endovascular strategies are preferred; however, unsafe or unfeasible access can call for innovative strategies., Clinical Presentation: An octogenarian patient with an enlarging fusiform proximal basilar artery aneurysm causing a sixth nerve palsy was found to have multiple anatomic features that precluded a transradial or transfemoral endovascular approach. She was thus treated with direct microsurgical access of the V3 segment of the vertebral artery for subsequent coil embolization and flow diversion., Conclusion: This case introduces a novel combined microsurgical and endovascular strategy for treating a complex partially thrombosed fusiform basilar artery aneurysm. This approach should be reserved only for patients where conventional endovascular access is dangerous or unfeasible., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Objectives: Distal anterior cerebral artery (DACA) aneurysms account for 1%-9% of all intracranial aneurysms. Microsurgical treatment is generally preferred for DACA aneurysms; however, it presents challenges owing to the anatomical complexities. Advances in neuro-interventional techniques have yielded promising results. This study aims to compare the clinical outcomes of DACA aneurysms treated with microsurgery and endovascular treatment (EVT) to elucidate the efficacy of EVT., Materials and Methods: A multicenter observational registry comprising 16 stroke centers was utilized for this study. Data was retrospectively and prospectively analyzed from 166 patients with DACA aneurysms in our database, which included 4,552 consecutive patients with ruptured or unruptured intracranial aneurysms who underwent microsurgical or endovascular treatment between January 2013 and December 2021., Results: Surgical clipping was performed in 115 patients, and 51 underwent coil embolization. The median follow-up duration was 15.3 months. No significant differences were observed in patient characteristics between the two treatment modalities. There were no differences in complication-related morbidity between the microsurgical treatment and EVT groups in either unruptured (10.5% vs. 9.1%, p=1.00) or ruptured aneurysms (5.2% vs. 6.9%, p=0.66). Coil embolization resulted in higher recurrence and retreatment rates than surgical clipping did, especially for ruptured aneurysms (2.6% vs. 27.6%, p<0.01)., Conclusions: Endovascular treatment is an alternative to microsurgery for DACA aneurysms especially in unruptured cases or the patients who have difficulty undergoing craniotomy due to their general condition, albeit with considerations for higher recurrence and retreatment rates, particularly in ruptured cases. Close follow-up is crucial for the effective management of these challenges. Further studies are needed to refine the treatment strategies for DACA aneurysms., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: The Woven EndoBridge (WEB), functioning as an intrasaccular disruption device, offers a novel option for complex aneurysms, particularly bifurcation aneurysms. In this systematic review and meta-analysis, our goal is to compare the safety and efficacy of WEB devices with stent-assisted coiling (SAC) for intracranial bifurcation aneurysms., Methods: We conducted a systematic search of PubMed, Scopus, and Embase, and Web of Science databases in September 2024 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We aimed to compare aneurysmal occlusion, procedural time, the retreatment, and complication rates as secondary objectives. The comparison between the two techniques was performed using a weighted random-effects model, and the quality of the studies was assessed using the Newcastle-Ottawa Scale (NOS) for cohort studies., Results: The authors analyzed five studies encompassing 298 and 203 patients in SAC and WEB groups, respectively. Complete (OR, 0.97; 95%CI: 0.63-1.49, I 2  = 0%) and adequate (OR: 0.88; 95%CI: 0.51-1.5, I 2  = 0%) occlusion didn't differ between two groups. The overall procedural time mean difference was 38.2 min, significantly higher in the SAC group (95%CI, 26.9-49.6, I 2  = 53.4%). Retreatment rates did not significantly differ between the two groups (OR: 1.34; 95%CI: 0.37-4.85, I 2  = 61.7%). The SAC group experienced more complications during and after the operation (OR, 2.82; 95%CI: 1.07-7.44, I 2  = 0%). The pooled follow-up duration was 22.1 and 13.5 months for SAC and WEB groups respectively., Conclusion: The WEB demonstrates comparable efficacy in occluding bifurcation aneurysms compared to SAC, with the added benefits of reduced procedural time and lower complication rates., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Intrasaccular flow disruption with the Woven Endobridge (WEB) has become a well-established endovascular technique for the treatment of intracranial aneurysms. This study presents our 12-year experience with the WEB and evaluates its evolving indications, procedures, and outcomes. A consecutive series of 324 aneurysms treated with WEB between 2011 and 2023 at three neurovascular centers was retrospectively analyzed and the study group was divided into four treatment periods. Uni- and multivariate analyses were performed to evaluate factors associated with technical success, thromboembolic complications, and angiographic outcome. The mean aneurysm size was 7.0 ± 3.6 mm and decreased during the study period, while the proportion of atypical sites for WEB implantation increased. WEB implantation was technically successful in 96.0%, and the ratio of WEB width to dome width increased during the study period, indicating oversizing. The neurological complication rate was 4.9% (1.5% major, 3.4% minor) and the mid-term complete occlusion rate was 60.6% (81.9% adequate occlusion), with no statistical differences in either outcome measure between the study periods. In multivariate analyses, the use of WEB 17 was associated with increased technical success (HR: 7.4, 95%CI: 2.4-23.6, p<0.01), whereas ruptured aneurysm status (HR: 2.5, 95%CI: 1.0-6.0, p=0.04) and the use of additional stents (HR: 4.8, 95%CI: 1.6-14.4, p<0.01) predicted thromboembolic complications. Appropriate oversizing of the WEB favored mid-term complete occlusion (HR: 10.5, 95%CI: 1.3-83.3, p=0.03). The results suggest an expansion of the indications for WEB implantation and highlight the importance of oversizing for treatment efficacy., (© 2024. The Author(s).)

Background: Pediatric patients with intracranial aneurysms face high risks of spontaneous subarachnoid hemorrhages. Despite its approval for adults aged 22 and above, the Pipeline Embolization Device (PED, Covidien/Medtronic, Irvine, California, USA) is being considered for younger patients due to its efficacy. This study aims to assess the safety and effectiveness of using PEDs in pediatric aneurysm treatment., Methods: A retrospective study across 14 institutions identified 25 patients (age ≤ 18) treated with PED from November 2014 to October 2019. A literature review included all published pediatric aneurysm cases treated with PED from 2007 to 2023. Analyzed data included patient demographics, aneurysm characteristics, treatment, clinical outcomes, and complications., Results: We analyzed 81 pediatric patients, including 25 from the multi-center registry and 56 from 38 relevant literature. In the entire cohort of 81 patients, mean age of the patients was 11.9 ± 4.0 years (ranged from 9 months to 18 years), with 58.0% males. Ruptured aneurysms were observed in 7 patients (8.6%), whereas 43 patients (53.1%) harbored large/giant aneurysms. The aneurysm occlusion rate was 87.7% during the median 7 months follow-up. Complications occurred in 12.3% of patients, resulting in morbidity in 5 cases (6.1%) and mortality in 4 cases (4.9%). Patient age was not associated with the occurrence of aneurysm residual, complications, and mortality following PED treatment., Conclusions: PED can be effective for pediatric aneurysms, but morbidity and mortality can be substantial compared to the adults. Surgical timing should depend on clinical judgment and patient factors, without age-related delays., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Although coil embolization is commonly perceived as a minimally invasive procedure, the associated radiation exposure cannot be disregarded. To date, no specific study has investigated radiation exposure during coil embolization. This study aimed to investigate the potential of lowering the pulse rate to decrease radiation exposure during coil embolization while maintaining patient safety. Radiation data and clinical features of 70 patients who underwent coil embolization between 2015 and 2020 were retrospectively analyzed. Since July 2017, the pulse rate was regulated from 7.5 to 4 frames per second (f/s). Statistical analyses were performed to examine the correlation between pulse rate and radiation exposure. Out of the 70 procedures, 30 were performed at the standard pulse rate (7.5 f/s), and 40 were performed at the lower pulse rate (4 f/s). In the lower-pulse-rate group, the absorbed dose to the patient (AK) was 2580.7 (±217) mGy, whereas in the standard-pulse-rate group, it was 4760 (±411.1). Both the dose-area product (DAP) and AK were substantially reduced in the low pulse rate group (p = 0.000002). There was a significant correlation between DAP and AK and pulse rate (p = 0.004, p = 0.0017, respectively). Moreover, there was no significant correlation between pulse rate and perioperative complications. Our findings suggest that using a lower pulse rate (4 f/s) can effectively reduce radiation exposure during coil embolization for cerebral aneurysms while ensuring patient safety.

Background: The Neuroform Atlas Stent System is an established treatment modality for unruptured anterior and posterior circulation intracranial aneurysms. Location-specific results are needed to guide treatment decision-making. However, it is unclear whether there are differences in safety and efficacy outcomes between carotid and more distal anterior circulation aneurysms., Methods: The ATLAS IDE trial was a prospective, multicenter, single-arm, open-label interventional study that evaluated the safety and efficacy of the Neuroform Atlas Stent System. We compared differences in efficacy and safety outcomes of proximal internal carotid artery (ICA) versus distal and bifurcation anterior circulation aneurysms., Results: Of 182 cases, there were 70 aneurysms in the ICA and 112 in the distal anterior circulation (including ICA terminus/bifurcation). There were no significant differences in the primary efficacy endpoint (85.5% vs 83.9%, p=0.78) and complete aneurysm occlusion rates (88.7% vs 87.9%, p=0.78) between proximal ICA aneurysms and distal aneurysms, respectively. Complications were more often encountered in distal and bifurcation aneurysms, but the overall rate of major safety events was low and comparable between the two groups (1.4% vs 6.3%, p=0.14). Recanalization and retreatment rates were also similar between the groups., Conclusion: The results of this study suggest that the Neuroform Atlas Stent System is a safe and efficacious treatment modality for unruptured anterior circulation intracranial aneurysms, regardless of aneurysm location., Trial Registration Number: NCT02340585., Competing Interests: Competing interests: RAH is a consultant for Medtronic, Stryker, Cerenovous, Microvention, Balt, Phenox, Rapid Medical and Q’Apel, Imperative Care, Phenox, and Rapid Medical. He is on the advisory board for MiVI, eLum, Three Rivers, Shape Medical, and Corindus. He is in receipt of unrestricted research grants from the National Institutes of Health (NIH), Interline Endowment, Microvention, Stryker, CNX, and Balt. He is an investor/stockholder for InNeuroCo, Cerebrotech, eLum, Endostream, Three Rivers Medical Inc, Scientia, RisT, BlinkTBI, and Corindus. BTJ is a consultant for Stryker and a consultant/proctor for Medtronic. ES reports a speaker’s agreement with Stryker. BG is a consultant for Medtronic, Microvention, and Stryker. RGG is a consultant and receives personal fees from Cerenovus. DF reports consultant/speakers bureau for Stryker, Siemens, Penumbra, and Scientia; and serves on the SNIS board of directors. LLP is a Principal Biostatistician employed at Stryker Neurovascular and holds stock in Stryker. SWH reports core lab services for Stryker, Route 92; is an Imperative Care consultant; is a stockholder for Filtro and ThrombX; and serves on the SNIS board of directors. OOZ reports research grants from Stryker, Medtronic, Cerenovus, Penumbra, and Genentech; he is a consultant and speaker for Cerenovus, Stryker, Penumbra, and Medtronic; data safety monitoring board for Premier; has an ownership interest in Galaxy Therapeutics Inc.; and serves on SVIN committees. The other authors report no conflicts of interest., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: We compared the outcomes of wide necked aneurysms (WNA) treated with the Neuroform Atlas with those treated with the low profile visualized intraluminal stent (LVIS) or the Woven EndoBridge (WEB)., Methods: Objective, prospectively collected, core laboratory adjudicated data from published trials for the Neuroform Atlas, LVIS, and WEB devices were reviewed. ATLAS (Safety and Effectiveness of the Treatment of Wide Neck, Saccular Intracranial Aneurysms With the Neuroform Atlas Stent System) study patients were included if they met other studies' inclusion criteria. Outcomes included (1) primary effectiveness (complete aneurysmal occlusion without retreatment/>50% parent vessel stenosis), (2) primary safety, (3) complete aneurysmal occlusion, and (4) retreatment rates (outcomes evaluated at the 12 month follow-up). Matching adjusted indirect comparison analysis was used to compare outcomes., Results: Analytical samples included 141 ATLAS subjects meeting WEB-IT (Woven EndoBridge Intrasaccular Therapy Study) criteria (ATLAS/WEB-IT) and 241 meeting LVIS (Pivotal Study of the Low Profile Visualized Intraluminal Support) criteria (ATLAS/LVIS). ATLAS/WEB-IT exhibited significantly higher rates of primary effectiveness and complete occlusion versus WEB (86.6% vs 53.9 %, P<0.0001, and 90.3% vs 53.9%, P<0.0001, respectively). For LVIS, there was no significant differences in primary effectiveness rates between ATLAS and LVIS (84.2% vs 77.7%, respectively, P=0.12). However, ATLAS/LVIS had a significantly higher proportion of patients achieving complete occlusion than LVIS (88.1 vs 79.1, P=0.03). Retreatment rates and primary safety outcomes were not significantly different (P>0.05) for the Atlas versus other devices except for a lower retreatment rate for ATLAS/WEB-IT versus WEB-IT (2.4% vs 9.8%, P=0.01)., Conclusion: The Neuroform Atlas provided higher occlusion rates and similar retreatment rates in comparable datasets compared with LVIS and WEB devices when treating WNA., Competing Interests: Competing interests: BJ and OOZ are national co-PIs of the ATLAS trial. LLP is a senior clinical statistician at Stryker Neurovascular., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Intracavernous carotid aneurysms (ICCAs) are rare, frequently asymptomatic, with a low rupture risk, which, however, can lead to life-threatening epistaxis. The aim of this study was to assess the effect of the treatment of asymptomatic ICCAs with flow diverters (FD) on sphenoid bone erosion or dehiscence in a selected cohort of patients., Methods: We retrospectively reviewed all asymptomatic ICCAs with sphenoid bone erosion or dehiscence detected on cone beam CT (CBCT) and treated with FD between December 2018 and December 2022. Patients were followed-up with CBCT and bone reconstruction was blindly evaluated by two interventional neuroradiologists and classified as unchanged, partial, or complete., Results: A total of 10 patients (women: 90%, mean age 58 years) treated with an FD for an asymptomatic ICCA with associated sphenoid bone erosion or dehiscence were included in this cohort. Sphenoid bone erosion was present in seven patients and dehiscence was observed in the remaining three. After treatment with FD, complete reconstruction of the sphenoid sinus wall occurred in seven cases, and partial reconstruction in two cases. Sphenoid bone erosion remained unchanged after treatment in only one patient., Conclusions: The decision to treat asymptomatic and unruptured ICCAs remains challenging due to their benign natural history and low hemorrhagic risk. The presence of sphenoid sinus erosion or dehiscence should not be overlooked since it could be considered as an indication for prophylactic treatment of life-threatening epistaxis. The mechanisms of bone erosion by the aneurysm and of reconstruction after treatment are still to be fully elucidated., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The Pipeline Vantage Embolization Device (PEDV) is the fourth-generation pipeline flow diverter for intracranial aneurysm treatment. There are no outcome studies for the second PEDV version. We aimed to evaluate safety and efficacy outcomes. Primary and secondary objectives were to determine outcomes for unruptured and ruptured cohorts, respectively., Methods: In this multicenter retrospective and prospective study, we analyzed outcome data from eight centers using core laboratory assessments. We determined 30-day and ≥3-month mortality and morbidity rates, and 6- and 18-month radiographic aneurysm occlusion rates for procedures performed during the period July 2021-March 2023., Results: We included 121 consecutive patients with 131 aneurysms. The adequate occlusion rate for the unruptured cohort at short-term and medium-term follow up, and also for the ruptured cohort at short-term follow up, was >90%. Two aneurysms (1.5%) underwent retreatment. When mortality attributed to a palliative case in the unruptured cohort, or subarachnoid hemorrhage in the ruptured cohort, was excluded then the overall major adverse event rate in respective cohorts was 7.5% and 23.5%, with 0% mortality rates for each. When all event causes were included on an intention-to-treat basis, the major adverse event rates in respective cohorts were 8.3% and 40.9%, with 0.9% and 22.7% mortality rates., Conclusions: For unruptured aneurysm treatment, the second PEDV version appears to have a superior efficacy and similar safety profile to previous-generation PEDs. These are acceptable outcomes in this pragmatic and non-industry-sponsored study. Analysis of ruptured aneurysm outcomes is limited by cohort size. Further prospective studies, particularly for ruptured aneurysms, are needed., Competing Interests: Competing interests: Microvention core laboratory for neurointerventional study: payment to TCB. Siemens Healthineers Speakers Bureau Educational lecture on brain tumours, not related to aneurysms: payment to TCB. Medtronic Speakers Bureau Educational lecture on an independent non-industry-sponsored study published in AJNR 2019 on Pipeline Flow Diverter device: payment to TCB. Bayer Speakers Bureau Educational lecture on Explainability in AI, not related to aneurysms: payment to TCB. Consulting and proctoring agreement with Medtronic, Stryker, Balt, and Cerenovus: payment to TP. Microvention, Balt, and Medtronic support to attend meetings: payment to TM., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Endovascular treatment has been acknowledged as an effective treatment for intracranial aneurysms, showcasing favorable clinical outcomes and providing robust protection against rebleeding and rupture. Notably, during the endovascular procedure, significant complications include intraprocedural aneurysmal rupture (IAR) induced by microcatheters, microguidewires, or spring coils, along with thromboembolic events, significantly escalating patient mortality and disability. Current approaches against for IARs involve various strategies such as heparin reversal, compression of the common carotid artery or upstream soft guidewire to mitigate blood flow, management of intracranial pressure and blood pressure, and balloon-assisted or unassisted rapid dense embolization of the aneurysm. Nevertheless, these measures may prove insufficient in halting hemorrhage, especially in scenarios where additional coils cannot be added for dense embolization due to inherent limitations. In this context, we introduce a novel strategy for the prompt, safe, and effective cessation of aneurysm bleeding, which involves injecting an appropriate quantity of Onyx into the aneurysm through a microcatheter while safeguarded by an aneurysm-carrying arterial braided stent. Initially, we attempted dense embolization by filling multiple coils. However, in cases where continued coil filling proved unfeasible or failed to sufficiently prevent contrast agent extravasation, we opted for Onyx injection into the aneurysm. Utilizing Onyx effectively prevented further blood extravasation without adversely impacting the aneurysm-carrying artery or distal vessels, leading to favorable prognoses for all patients. This article delineates our embolization strategy, highlighting the efficacy and safety of Onyx injection as an alternative or complementary measure in managing complications arising from endovascular coil embolization., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Current approaches for localized intravascular treatments rely on using solid implants, such as metallic coils for embolizing aneurysms, or on direct injection of a therapeutic agent that can disperse from the required site of action. Here, we present a fluid-based strategy for localizing intravascular therapeutics that leverages surface tension and immiscible fluid interactions, to allow confined and focal treatment at brain aneurysm sites. We first show, computationally and experimentally, that an immiscible phase can be robustly positioned at the neck of human aneurysm models to seal and isolate the aneurysm's cavity for further treatment, including in wide-neck aneurysms. We then demonstrate localized delivery and confined treatment, by selective staining of cell nuclei within the aneurysm cavity as well as by hydrogel-based embolization in patient-specific aneurysm models. Altogether, our interfacial flow-driven strategy offers a potential approach for intravascular localized treatment of cardiovascular and other diseases.

Background and Purpose: The Pipeline Embolization Device is a safe and effective treatment option for intracranial aneurysms. The newer Pipeline generations have received structural refinements and a surface modification to improve deliverability, procedural safety, and angiographic outcomes. This multicenter study evaluated the clinical safety and efficacy of the 2 surface-modified Pipeline iterations, Pipeline Vantage and Pipeline Flex with Shield Technology (PFS)., Materials and Methods: Consecutive patients treated between 2017 and 2023 were retrospectively reviewed for aneurysm characteristics, procedural details, complications, and angiographic outcomes. The safety end point was the rate of procedural and postprocedural major neurologic events occurring during the hospital stay. The efficacy end point was the rate of complete occlusion at last follow-up., Results: One hundred forty-one patients underwent 112 Pipeline Vantage procedures and 32 PFS procedures for 147 aneurysms with a mean size of 8.0 (SD, 5.9) mm (11% ruptured, 16% posterior circulation, 18% nonsaccular morphology). All procedures were technically successful with a mean of 1.2 devices implanted. Balloon angioplasty was required in 20/144 (13.9%) procedures. Major neurologic adverse events occurred in 6/144 (4.2%) procedures (all ischemic stroke), resulting in death in 2 (1.4%) patients. There were no hemorrhagic complications. At a mean of 11 months, complete occlusion was achieved in 85/112 (75.9%) aneurysms, 15/112 (13.4%) had an entry remnant, and 12/112 (10.7%) had an aneurysm remnant., Conclusions: The results demonstrate high feasibility, procedural safety, and efficacy of the surface-modified Pipeline flow diverters., (© 2024 by American Journal of Neuroradiology.)

Purpose: Although stent-assisted technique is expected to help provide a scaffold for neointima formation at the orifice of the aneurysm, not all aneurysms treated with stent-assisted technique develop complete neointima formation. The white-collar sign (WCS) indicates neointimal tissue formation at the aneurysm neck that prevents aneurysm recanalization. The aim of this study was to explore factors related to WCS appearance after stent-assisted coil embolization of unruptured intracranial aneurysms (UIAs)., Methods: A total of 59 UIAs treated with a Neuroform Atlas stent were retrospectively analyzed. The WCS was identified on digital subtraction angiography (DSA) 1 year after coil embolization. The cohort was divided into WCS-positive and WCS-negative groups, and possible predictors of the WCS were explored using logistic regression analysis., Results: The WCS appeared in 20 aneurysms (33.9%). In the WCS-positive group, neck size was significantly smaller (4.2 (interquartile range (IQR): 3.8-4.6) versus 5.4 (IQR: 4.2-6.8) mm, p = .006), the VER was significantly higher (31.8% (IQR: 28.6%-38.4%) versus 27.6% (IQR: 23.6%-33.8%), p = .02), and the rate of RROC class 1 immediately after treatment was significantly higher (70% vs 20.5%, p < .001) than in the WCS-negative group. On multivariate analysis, neck size (odds ratio (OR): 0.542, 95% confidence interval (CI): 0.308-0.954; p = .03) and RROC class 1 immediately after treatment (OR: 6.99, 95% CI: 1.769-27.55; p = .006) were independent predictors of WCS appearance., Conclusions: Smaller neck size and complete occlusion immediately after treatment were significant factors related to WCS appearance in stent-assisted coil embolization for UIAs using the Neuroform Atlas stent., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Aneurysms occurring along the basilar artery (BA) account for <1% of all intracranial aneurysms. Endovascular treatment (EVT) in particular is recommended for large unruptured BA aneurysms and ruptured BA aneurysms. Given that EVT techniques vary, a detailed review of EVT for BA aneurysms is necessary. In this review, the following issues were discussed: the anatomy and anomalies of the BA, the classification of BA aneurysms, the natural history of BA aneurysms, the status of open surgery, the use of EVT for various types of BA aneurysms and the deployment of new devices. According to the findings of this review and based on our experience in treating BA aneurysms, traditional coiling EVT is still the optimal therapy for most BA aneurysms. However, in some BA aneurysms, flow diverter (FD) deployment can be used. In addition, there are also some new devices, such as intrasaccular flow disruptors and stent-like devices that can be used to treat BA aneurysms. In general, EVT can yield good clinical and angiographic outcomes for patients with BA aneurysms. In addition, recent new devices and techniques, such as new-generation FDs generated via surface modification and virtual reality simulation techniques, show promise for EVT for BA aneurysms. These devices and techniques may further improve EVT outcomes for BA aneurysms., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Abstract: BACKGROUND: This study aimed to identify the impact of illness uncertainty on physical and mental health-related quality of life (HRQoL) in patients with unruptured intracranial aneurysms (UIAs) after coil embolization. METHODS: A cross-sectional study was conducted and HRQoL was evaluated using the Short Form-12 Health Survey Questionnaire, which assesses physical and mental HRQoL. RESULTS: The participants had a mean age of 56.4 years, and among them, 190 (71.2%) were women. Physical and mental HRQoL were negatively correlated with physical symptoms, anxiety, depression, and illness uncertainty. Mental HRQoL was positively correlated with social support. Physical HRQoL was significantly influenced by depression (β = -0.26, P = .004) and was not influenced by illness uncertainty (β = -0.10, P = .101). Mental HRQoL was significantly influenced by anxiety (β = -0.45, P < .001), depression (β = -0.19, P = .003), social support (β = 0.14, P = .004), and illness uncertainty (β = -0.14, P = .005). The finding that illness uncertainty influences HRQoL suggests a basis for interventions aimed at improving mental HRQoL by reducing illness uncertainty in patients with UIAs. CONCLUSION: The physical and mental HRQoL in patients with UIAs after coil embolization is negatively influenced by depression, whereas mental HRQoL is also affected by anxiety, illness uncertainty, and social support. These results may serve as reference data for the design and development of interventions to improve HRQoL in patients with UIAs after coil embolization., Competing Interests: The authors declare no conflicts of interests., (Copyright © 2024 American Association of Neuroscience Nurses.)

Introduction: Wide-necked bifurcation aneurysms pose significant challenges for endovascular treatment. A recent innovation, the stent plus balloon-assisted coiling technique, combines a stent and a balloon to address these aneurysms effectively., Purpose: To evaluate the safety and efficacy of the stent plus balloon-assisted coiling for the treatment of wide-necked bifurcation aneurysms., Methods: We conducted a retrospective review of our endovascular database to identify patients who were treated with this technique and had a satisfactory angiographic follow-up of at least 24 months. Technical success, initial clinical and angiographic outcomes, procedural complications, and follow-up results were analyzed. Angiographic and clinical outcomes were assessed using Modified Raymond-Roy Classification and Modified Rankin Scale, respectively., Results: Our study included 37 aneurysms in 36 patients (26 females) with a mean age of 56.6 years. Mean aneurysm and neck sizes were 7.3 ± 3.5 mm and 3.7 ± 1.0 mm, respectively. Technical success reached 97.2%, with an immediate occlusion rate of 65.7%. At a mean follow-up of 36.5 ± 9.7 months, final angiographic follow-up showed a 91.9% complete occlusion rate. Three aneurysms did not achieve complete occlusion; however, none required retreatment. Complications developed in 32.4% of the procedures. Mortality and morbidity rates were 5.4% and 2.7%, respectively. A good clinical outcome was observed in 91.9% of patients., Conclusion: Our results showed that stent plus balloon-assisted coiling technique allows good angiographic outcomes for wide-necked bifurcation aneurysms. However, overall complication rate is high. Subgroup analysis indicated promising safety and efficacy for MCA bifurcation aneurysms, suggesting this technique could be a valuable option for select aneurysms., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The Woven EndoBridge (WEB) device is a minimally invasive endovascular treatment option for patients with cerebral aneurysms. Transradial access (TRA) is a technique that involves accessing the arterial system through the radial artery in the wrist rather than the femoral artery in the groin. Several studies have investigated the use of TRA for WEB device deployment in treating intracranial aneurysms., Methods: A systematic review was conducted to evaluate the TRA for WEB device deployment in treating intracranial aneurysms. The databases PubMed, Cochrane, Embase, Scopus, and Web of Science were searched. To reduce the risk of bias, this systematic review only included studies reporting on using TRA in WEB device deployment for intracranial aneurysm treatment with a minimum of four patients., Results: In this systematic review, 186 patients were included across five studies, with TRA used in 183 cases analyzed. The study population had a higher proportion of females ( n = 118%-69%) than males, with a mean age of 62 years old. Among the aneurysms treated, 46 were ruptured, and 119 were located at bifurcation sites, with a mean maximum diameter/width of 6.6 mm and mean height of 5.9 mm. Adjunctive coiling was used in three cases, and adjunctive stenting was used in nine cases. In two cases, conversion to a femoral artery access was necessary., Conclusion: The available results suggest TRA with the WEB device is a safe and effective alternative. However, using TRA versus TFA should be individualized based on patient factors and operator experience., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: The Derivo 2 Heal Embolization Device (D2HED) is a novel flow diverter (FD) providing a fibrin-/heparin-based surface coating aiming at lower thrombogenicity. We evaluate periprocedural aspects and preliminary aneurysm occlusion efficacy for intracranial aneurysm treatment., Methods: Thirty-four D2HEDs deployments (34 aneurysms, 32 patients) between 04/2021 and 10/2023 were analyzed. All patients were under dual antiplatelet therapy (dAPT). Periprocedural details, adverse events, and follow-up (FU) imaging were reviewed by consultant-level neuroradiologists. Complication rates and aneurysm occlusion efficacy are compared with performance data of other FDs based on literature research., Results: Each intervention succeeded in the deployment of one D2HED. Significant and/or increased intraaneurysmal contrast stagnation immediately after D2HED deployment was seen in 73.5% of cases according to O'Kelly-Marotta (OKM) grading scale. Clinically relevant early adverse events occurred in three patients: Among them two cases with fusiform aneurysms in the posterior circulation (ischemic events, early in-stent-thrombosis) and one patient (ischemic event) out of the majority of 31 treated internal carotid artery aneurysms (3,2%). Regarding mid-term FU (> 165 days), one aneurysm did not show progressive occlusion presumably caused by a prominent A1 segment arising from the terminal ICA aneurysm itself. Apart from that, mid-term complete / partial occlusion rates of 80% / 20% could be demonstrated., Conclusion: Our case series - although suffering from restricted sample size - suggests a potential effectiveness of D2HED in managing intracranial aneurysms. Further studies with larger samples are warranted to quantify long-term occlusion efficacy and the impact of antithrombogenic surface coating on the necessary (d)APT., (© 2024. The Author(s).)

Intracranial aneurysm is a common cerebrovascular disease with high morbidity and mortality. Endovascular interventional therapy has advantages of high efficiency and minimally invasive. In this paper, the technical development of intracranial aneurysm interventional therapy Instruments was introduced, by interpreting the design mechanism of various types of coil, comparing the clinical benefits of braided and cut stents for assisting coil deployment, as well as analyzing the design principle and the optimization direction of currently the most eye-catching flow diverter, and thus the development and application of various interventional devices were discussed.

Parent artery occlusion for large or giant internal carotid artery aneurysms remains a necessary procedure in the era of flow diverters. Endovascular parent artery occlusion is currently performed using detachable balloons or coils, which are difficult to obtain or costly. At our institution, we have devised a technique for combining n-butyl-2-cyanoacrylate and coils with flow control to solve this problem. Patients who underwent parent artery occlusion for large or giant internal carotid artery aneurysms with a follow-up period of more than 12 months were included. Imaging outcomes were evaluated for complete or incomplete aneurysmal occlusion and with or without aneurysmal shrinkage. The clinical outcome was based on changes in the modified Rankin Scale. Ten patients (ten aneurysms) were included. Their average age and average follow-up period were 68.4 years and 36 months, respectively. Complete occlusion and favorable clinical outcome were observed in all cases. The parent artery occlusion using a combination of coils and n-butyl-2-cyanoacrylate with flow control technique is effective for both imaging and clinical outcomes.

Aneurysmal subarachnoid hemorrhage (aSAH) is a critical condition with high in-hospital mortality rates. Delayed cerebral ischemia (DCI), a secondary complication associated with aSAH, can also contribute to morbidity and mortality. Although draining the hematoma from the subarachnoid space has been considered effective in preventing DCI, the placement of a drainage system could increase the risk of bacterial meningitis and ventriculitis. This study aimed to examine the association between meningitis following aSAH and the occurrence of DCI, focusing on the role of cerebral vasospasm. Patients who underwent endovascular coiling or surgical clipping for aSAH from April 2001 to March 2022 were included in this study, while those who did not undergo postoperative drainage were excluded. The patient's clinical characteristics, treatment modalities, and outcomes were then analyzed, after which logistic regression was used to assess the odds ratios (OR) for DCI. A total of 810 patients with aSAH were included in this study. Meningitis following aSAH was identified as an independent factor associated with DCI (odds ratio 5.0 [95% confidence intervals (CI) 2.3-11]). Other significant factors were female sex (odds ratio 1.5 [95% CI 0.89-2.5]) and surgical clipping (odds ratio 2.1 [95% CI 1.3-3.4]). This study demonstrated a significant association between meningitis following aSAH and the development of DCI, suggesting that the inflammatory environment associated with meningitis may contribute to cerebral vasospasm. Early recognition and treatment of meningitis in patients with aSAH could reduce the risk of DCI and improve patient outcomes.

Background : Using two case reports of adult women with moyamoya disease presenting with intracranial hemorrhage from ruptured aneurysms on moyamoya collateral vessels, we aim to demonstrate the potential for effective endovascular treatment navigated by CT angiography, digital subtraction angiography, and flat panel CT. Case 1 Presentation : A 45-year-old female patient with sudden onset of headache, followed by somnolency. CT scan showed a four-ventricle hematocephalus caused by a 27 × 31 × 17 mm hematoma located in the left basal ganglia. Angiography revealed a 3 mm aneurysm on hypertrophic lenticulostriate artery bridging the M1 occlusion. Selective catheterization and distal embolisation with acrylic glue was done. Case 2 Presentation : A 47-year-old woman was admitted for a sudden onset of severe headache, CT scan showed four-ventricle hematocephalus. A 4 mm aneurysm on the collateral vessel-anterior chorioidal artery bridging the closure of the terminal segment of the internal carotid artery was diagnosed as the source of bleeding. Selective catheterization and distal embolisation with acrylic glue was done. Conclusions : Selective embolisation of ruptured aneurysms on moya moya collaterals is a simple, effective, and safe procedure when relevant microcatheters are used with imaging software navigation such as 3D DSA, 3D road map and flat-panel CT.

This study aimed to evaluate the radiation doses (peak skin dose (PSD) and bilateral lens dose) for each interventional neuroradiology procedure. A direct measurement system consisting of small radiophotoluminescence glass dosimeter chips and a dosimetry cap made of thin stretchable polyester was used for radiation dosimetry. The mean PSDs for each procedure were 1565 ± 590 mGy (simple technique coil embolization (STCE) cases), 1851 ± 825 mGy (balloon-assisted coil embolization (BACE) cases), 2583 ± 967 mGy (stent-assisted coil embolization (SACE) cases), 1690 ± 597 mGy (simple flow-diverter stenting (FDS) cases), and 2214 ± 726 mGy (FDS + coiling cases). The mean PSD was higher in SACE cases than in STCE, BACE, and simple FDS cases. Moreover, the PSD exceeded 2000 mGy and 3000 mGy in 46 (67.6%) and 19 (27.9%) SACE cases, respectively. The left lens doses for each procedure were 126 ± 111 mGy (STCE cases), 163 ± 152 mGy (BACE cases), 184 ± 148 mGy (SACE cases), 144 ± 60 mGy (simple FDS cases), and 242 ± 178 mGy (FDS + coiling cases). The left lens dose in SACE cases was higher than that in STCE cases and exceeded 500 mGy in 3 (4.4%) patients. In FDS + coiling cases, the mean PSD and left lens dose were 2214 ± 726 mGy and 242 ± 178 mGy, respectively. The left lens dose was higher than that in the STCE and BACE cases, with two (15.4%) patients receiving doses >500 mGy in FDS + coiling cases. The detailed data obtained in this study are expected to contribute to the promotion of radiation dose optimization., (© 2024 Society for Radiological Protection. Published on behalf of SRP by IOP Publishing Limited. All rights, including for text and data mining, AI training, and similar technologies, are reserved.)

Background and Purpose: Material-specific reconstructions of dual-energy CTA (DECTA) can highlight iodinated contrast, subtract predefined materials, and reduce metal artifact. We present a technique to improve detection of residual aneurysms after endovascular coiling by which iodine-map DECTA (IM-DECTA) reconstructions subtract platinum coil artifacts in MIP images (MIP IM-DECTA) and assess if IM-DECTA offers improved detection over conventional CTA (CCTA) or monoenergetic DECTA., Materials and Methods: We included consecutive patients who underwent endovascular aneurysm coiling with follow-up DECTA and DSA within 24 months. DECTA was performed at 80- and 150-kVp tube voltages on a rapid kV-switching single-source Revolution scanner. CCTA and IM-DECTA series were reconstructed. Reference-standard DSA was compared with CCTA, 50- and 70-keV virtual monochromatic DECTA, IM-DECTA, and MIP IM-DECTA. Blinded to DSA data, cross-section images were reviewed in consensus by 3 neurointerventionalists for residual aneurysms and assigned modified Raymond-Roy classifications (mRRC). Sensitivity, specificity, and accuracy of each series is reported relative to DSA, and single-factor ANOVA and pair-wise Spearman correlation coefficients compared the accuracy of each series. Readers provided ROI measurements of HU deviation adjacent to the aneurysm neck for quantitative noise assessment and qualitatively scored each series on a 3-point Likert-style scale ranging from uninterpretable to excellent image quality., Results: Twenty-one patients with 25 coiled aneurysms were included. Mean time from DECTA to DSA was 286 ± 212 days. IM-DECTA and MIP IM-DECTA most sensitively (89% and 90%) and specifically (93% and 93%) detected residual aneurysms relative to CCTA (6% and 86%). Relative to DSA, IM-DECTA and MIP IM-DECTA most accurately detected (92% versus 28% for CCTA) and classified residual aneurysms by mRRC (ρ C-CTA = -0.08; ρ IM = 0.50; ρ IM-MIP = 0.55; P  < .001). Reader consensus reported the best image quality at the aneurysm neck with IM-DECTA and MIP IM-DECTA, with 56% of CCTAs considered uninterpretable versus 0% of IM-DECTAs, and image noise was significantly lower for IM-DECTA (27.9 ± 3.6 HU) or MIP IM-DECTA (26.8 ± 3.5 HU) than CCTA (103.2 ± 13.3 HU; P  < .001)., Conclusions: MIP IM-DECTA can subtract coil mass artifact and is more sensitive and specific than CCTA for the detection of residual aneurysms after endovascular coiling., (© 2024 by American Journal of Neuroradiology.)

The role of a low-profile visualized intraluminal support stent (LVIS) and Enterprise in the treatment of unruptured intracranial aneurysms is well established. Although previous studies have investigated one single type of stent for the treatment of ruptured intracranial aneurysms (RIA), the safety and efficacy between the two types of stents has not been fully explored. Herein we conducted a study to compare the outcomes of the two stents for treatment of RIA. This is a prospective registry database of aneurysmal subarachnoid hemorrhage (aSAH) patients admitted to a single institution between 2018 and 2021. We collected patient baseline information, secondary complications, follow-up angiographic data, long-term prognostic outcomes, and conducted propensity score matching (PSM) analysis with 1:1 ratio and a multivariable logistic regression to compare the outcomes of the two types of stents. A total of 231 patients with RIAs were included in this study, with 108 treated using the LVIS device and 123 treated using the Enterprise device. Before PSM analysis, only the incidence of poor prognosis after 12 months was higher in the Enterprise group comparing to the LVIS group (20% vs. 10%, P = 0.049). After PSM analysis, there was a higher occurrence of delayed cerebral ischemia (DCI) in the Enterprise group compared to the LVIS group (odds ratio [OR] 3.95, 95% confidence interval [CI] [1.20-13.01], P = 0.024). However, no significant difference in prognosis was observed after PSM adjustment. Furthermore, subgroup analysis revealed that patients with female (P = 0.019), hypertension (P = 0.048), and anterior circulation aneurysms (P = 0.019) receiving the Enterprise device had a higher risk of DCI. The overall efficacy of LVIS and Enterprise in the treatment of RIA is comparable, while the incidence of DCI in the LVIS group is lower than that in the Enterprise group after PSM analysis. Registration number: NCT05738083 ( https://clinicaltrials.gov/ )., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

For treating ruptured cerebral aneurysms, it is important to understand the setup and basic technique of coil embolization. Safe and effective embolization relies on preoperative considerations that determine the treatment strategy, guide the optimization of the therapeutic environment, and help in the selection of appropriate device systems. Moreover, during aneurysmal embolization, basic techniques for microcatheter shaping and navigation, safe coil introduction, and precise use of occlusion balloons are indispensable. Microcatheter shaping should be based on three-dimensional digital subtraction angiography findings as well as the axes of the parent artery and aneurysm. The operator must understand the advantages and disadvantages of the two methods for navigating the microcatheter into the aneurysm. Furthermore, it is essential to preoperatively simulate and understand the approaches for managing aneurysmal embolization-related complications, such as intraoperative aneurysmal rupture and thromboembolism. Mastery of these steps is mandatory before undertaking embolization of ruptured cerebral aneurysms.

Despite advancements in neurosurgical techniques, subarachnoid hemorrhage(SAH) caused by the rupture of a partially thrombosed intracranial giant aneurysm remains a challenging clinical entity. This report describes the successful treatment of an 80-year-old male patient with SAH due to a ruptured, partially thrombosed intracranial giant aneurysm. The patient underwent a staged endovascular strategy using a flow diverter. The patient presented with SAH secondary to a ruptured, partially thrombosed intracranial giant aneurysm located at the C2 portion of the internal carotid artery and involving the origin of the posterior communicating artery(Pcom). Imaging revealed a dorsomedial rupture point on the aneurysm. A two-stage endovascular intervention(IVR) was performed. The first stage involved coil embolization aimed at covering the rupture point. Following the resolution of the vasospasm and the acute phase of SAH, the second stage involved the deployment of a pipeline embolization device. Digital subtraction angiography performed one month after the second stage IVR demonstrated a significant reduction in aneurysm filling, with preserved flow to the Pcom artery. We will discuss the technical details and rationale behind the staged endovascular approach in this complex case.

Introduction: The recurrent artery of Heubner (RAH), also known as the medial striate artery, is the most clinically important perforator of the anterior cerebral artery. RAH aneurysm is relatively rare, with 11 cases found in the present literature review, but poses significant clinical challenges due to potential impact on cognitive and motor functions. This systematic review explored available case reports to comprehensively understand clinical presentation, diagnosis, management and outcome in RAH aneurysm., Materials and Methods: Following PRISMA guidelines, this systematic review extensively explored RAH aneurysms, covering demographics, symptoms, diagnosis, treatments and outcomes. Comprehensive searches on PubMed, Scopus, Google Scholar, and Science Direct employed keywords such as "recurrent artery of Heubner aneurysm" and "Heubner's artery.", Results: After extensive screening, 9 qualifying studies were identified, with 11 patients diagnosed with rare RAH aneurysm. Median age was 55 years (standard deviation, 15.3 years), with 54.5% males. 45.5% of patients presented risk factors, including Moyamoya disease in 2 patients. The majority were classified as grade I/II on the Hunt and Hess (H&H) and World Federation of Neurological Societies (WFNS) systems. Aneurysms were predominantly located in the A1 segment, with a mean size of 4.7 mm. Treatments varied, with clipping being the most frequent (63.6%). The mortality rate was 18.2%. Clipping was associated with favorable outcomes but higher rates of infarction., Conclusion: This analysis highlighted the various symptoms, therapy methods and outcomes of RAH aneurysm, with A1 being the predominant origin. Future research should explore potential genetic predisposition factors and novel therapeutic interventions to address gaps in our knowledge., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Stent-assisted coiling is a main treatment modality for intracranial aneurysms (IAs) in clinics, but critical challenges remain to be overcome, such as exogenous implant-induced stenosis and reliance on antiplatelet agents. Herein, an endovascular approach is reported for IA therapy without stent grafting or microcatheter shaping, enabled by active delivery of thrombin (Th) to target aneurysms using innovative phase-change material (PCM)-coated magnetite-thrombin (Fe 3 O 4 -Th@PCM) FTP nanorobots. The nanorobots are controlled by an integrated actuation system of dynamic torque-force hybrid magnetic fields. With robust intravascular navigation guided by real-time ultrasound imaging, nanorobotic collectives can effectively accumulate and retain in model aneurysms constructed in vivo, followed by controlled release of the encapsulated Th for rapid occlusion of the aneurysm upon melting the protective PCM (thermally responsive in a tunable manner) through focused magnetic hyperthermia. Complete and stable aneurysm embolization is confirmed by postoperative examination and 2-week postembolization follow-up using digital subtraction angiography (DSA), contrast-enhanced ultrasound (CEUS), and histological analysis. The safety of the embolization therapy is assessed through biocompatibility evaluation and histopathology assays. This strategy, seamlessly integrating secure drug packaging, agile magnetic actuation, and clinical interventional imaging, avoids possible exogenous implant rejection, circumvents cumbersome microcatheter shaping, and offers a promising option for IA therapy., (© 2024 Wiley‐VCH GmbH.)

Flow-diverter stents offer clinicians an effective solution for treating intracranial aneurysms, especially in cases where other devices may be unsuitable. However, strongly deviating success rates among different centres, manufacturers, and aneurysm phenotypes highlight the need for better in-situ studies of these devices. To support research in this area, virtual stenting algorithms have been proposed that, combined with computational fluid dynamics, provide insights into the hemodynamic alterations induced by the device. Yet, many existing algorithms rely on uncertain parameters, such as the forces applied during operation, fail to predict the length of the device after deployment, or lack robust validation steps, raising concerns about their reliability. Therefore, we developed a robust deployment technique that builds upon the geometrical features of the vessel and includes advancements from previous works. The algorithm is detailed and validated against literature examples, in-vitro experiments, and patient data, achieving a mean angular error below 5° in the latter. Furthermore, we describe and demonstrate how the deployed device can be embedded in a computational mesh using open-source tools and anisotropic meshing routines., Competing Interests: Declaration of competing interest None declared., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Catheter shaping is vital in cerebral aneurysm coil embolization; however, understanding three-dimensional (3D) vascular structures on two-dimensional screens is challenging. Although 3D-printed vascular models are helpful, they demand time, effort, and sterility. This study explores whether mixed-reality (MR) devices displaying 3D computer graphics (3D-CG) can address these issues., Methods: This study focused on magnetic resonance imaging (MRI) of seven cases of cerebral aneurysms. Head-mounted display (HMD) and spatial reality display (SRD) MR devices were used, and applications for 3D-CG display at a 1:1 scale and a 3D-CG control panel were developed. Catheters shaped using a 3D printer, HMD, and SRD were inserted into hollow models to assess their accessibility and positioning., Results: The concordance rate of the 3D printer and HMD groups in terms of accessibility to the aneurysm was 71.4 %, while that of the 3D printer and SRD group was 85.7 %, and that of the HMD and SRD group was 85.7 %. The concordance rates of positioning in the 3D printer and HMD groups, 3D printer and SRD groups, and HMD and SRD groups were 85.7 %, 85.7 %, and 100 %, respectively., Conclusions: MR devices facilitate catheter shaping in cerebral aneurysm coil embolization and offer a time-efficient, precise, and sterile alternative to traditional 3D printing methods., Competing Interests: Declaration of Competing Interest None, (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Pediatric spontaneous intracranial dissecting aneurysms are rare, but systematic studies comparing hemorrhagic and ischemic presentations are lacking. This study addresses gaps in understanding their epidemiology, clinical presentation, management, and outcome., Methods: A retrospective analysis of 23 pediatric patients with nontraumatic intracranial dissecting aneurysms treated between July 2018 and December 2023 was conducted. Patients were divided into 2 groups based on presentation: hemorrhagic (n = 16) and ischemic (n = 7). Clinical data were analyzed, including demographics, radiologic findings, treatment modalities, and outcomes., Results: Clinical presentations varied, with limb weakness being more prevalent in hemorrhagic cases (P = 0.014), while headache and seizures were more common in ischemic cases. Angiographic analysis revealed distinct patterns, with hemorrhagic cases showing more distal involvement on vessel segments with stenosis and dilatation (pearl string sign). At the same time, the ischemic group exhibited the double-lumen sign. Various treatments, including microsurgery and endovascular techniques, were utilized, with perioperative complications observed, including one mortality in a hemorrhagic case. Multiple regression analysis identified significant risk factors for perioperative complications, namely, the configuration of the dissecting aneurysm (P = 0.016) and the type of presentation (P = 0.0006). Long-term Glasgow Outcome Scores were comparable, but patients with hemorrhagic manifestations experienced prolonged hospital and ICU stays (P = 0.001)., Conclusions: Pediatric intracranial dissecting aneurysms, particularly hemorrhagic cases, are associated with severe neurologic deficits and higher perioperative complications. Despite similar long-term outcomes, hemorrhagic cases require prolonged hospitalization, increasing treatment costs. Optimizing management strategies for pediatric intracranial dissecting aneurysms, especially those with hemorrhagic features, is essential to improve outcomes and reduce healthcare expenditures., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To investigate the safety and efficacy of LVIS Jr stent-assisted coiling (SAC) of intracranial aneurysms (IAs) in small-diameter parent arteries and determine the factors influencing incomplete aneurysm occlusion., Material and Methods: Clinical and imaging data of 130 patients with IAs in small-diameter parent arteries that were treated with LVIS Jr SAC were retrospectively analyzed. Stent apposition was evaluated by high-resolution flat detector CT, and aneurysm embolization density was evaluated using 2D-DSA. Perioperative complications were recorded. Multivariate logistic regression analyses were performed to determine possible factors for incomplete aneurysm occlusion., Results: In this study, 130 patients (60 and 70 patients with ruptured and unruptured aneurysms, respectively) were successfully treated with LVIS Jr SAC. Immediate digital subtraction angiography (DSA) showed that the aneurysm occlusion was Raymond-Roy class I, II, IIIa, and IIIb in 93 (71.5%), 24 (18.5%), 8 (6.2%), and 5 (3.8%) cases, respectively. There were three cases of acute in-stent thrombosis and two cases of severe vasospasm observed during the perioperative period. The 6‑month follow-up angiograms indicated that complete aneurysm occlusion in 122 patients was 79.5% (97/122). Multivariate logistic regression analyses showed that an aneurysm size > 10.0 mm, parent artery mean diameter < 2.0 mm, and incomplete stent apposition at the aneurysm neck were possible risk factors for incomplete aneurysm occlusion., Conclusion: The LVIS Jr SAC is effective for managing IAs in small-diameter parent arteries. An aneurysm size > 10.0 mm, parent artery mean diameter < 2.0 mm, and incomplete stent apposition at the aneurysm neck are possible risk factors for incomplete aneurysm occlusion., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Purpose: To measure changes in quantitative tortuosity descriptors of the internal carotid artery (ICA) after intracranial aneurysm embolization, and to determine possible factors associated with changes in tortuosity., Materials and Methods: An analysis of 52 patients with embolized intracranial aneurysms was performed. ICA tortuosity was assessed by digital subtraction angiograms obtained prior to the embolization and after the first follow-up examination. For each patient, tortuosity descriptors were calculated: relative length (RL), sum of angle metrics (SOAM), triangular index, product of angle distance (PAD), and inflection count metric (ICM). To represent changes in tortuosity for each descriptor, delta (Δ) value was defined as value of the descriptor prior to embolization minus value of the descriptor on follow-up examination., Results: In a median follow-up of 14 months, no statistically significant changes in tortuosity were observed on the nonembolized side. On the embolized side, SOAM (2.89 [SD ± 0.92] vs 2.38 [SD ± 0.94]; P < .001), PAD (5.01 [SD ± 1.83] vs 3.95 [SD ± 1.72]; P < .001), and ICM (12.18 [SD ± 4.55] vs 9.76 [SD ± 4.04]; P = .006) were significantly higher after embolization than before embolization. Median ΔRL (-0.02 [-0.045 to 0.002] vs -0.01 [-0.02 to 0.003]; P = .003), ΔPAD (0.84 [0.30-1.82] vs 0.10 [-0.001 to 1.10]; P < .001), and ΔICM (2.05 [0.42-3.50] vs 0.27 [0.02-2.16]; P = .004) were significantly higher on the embolized side. Tortuosity correlated with elapsed time after embolization., Conclusions: Tortuosity of the ipsilateral ICA increased after intracranial aneurysm embolization., (Copyright © 2024. Published by Elsevier Inc.)

Background: When it comes to intracranial aneurysms, the quest for more effective treatments is ongoing. Flow diversion represents a growing advancement in this field. This review seeks to compare 2 variants of the endovascular flow diversion method: the Flow Re-Direction Endoluminal Device (FRED) and the Pipeline Embolization Device (PED)., Methods: A systematic review was conducted according to the PRISMA guideline using PubMed, Scopus, Web of Science, and Embase, using appropriate terms to compare PED and FRED in double-arm studies from conception until October 8th, 2023., Results: The meta-analysis encompassed 1769 patients, with a predominance of females (75.5%), among whom 973 patients underwent FRED procedures, while 651 received PED interventions. At 6 months, complete occlusion rates were 0.62 for FRED and 0.68 for PED (P = 0.68). At 1 year and the last follow-up, no significant differences were observed between FRED and PED, respectively. Adequate occlusion rates were similar between FRED and PED (0.82 vs. 0.79, P = 0.68). FRED showed a statistically significant higher rate of good mRS scores at follow-up (1.00 vs. 0.97, P = 0.03). Hemorrhage and re-treatment rates were higher in PED (P < 0.01) without considering the rupture status of the aneurysms due to the lack of data., Conclusions: This meta-analysis suggests comparable efficacy but different safety profiles between FRED and PED in treating intracranial aneurysms. FRED demonstrated a higher rate of good modified Rankin scores, while PED showed increased hemorrhage and re-treatment rates. Understanding these differences is crucial for informed decision-making in clinical practice., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Despite their asymptomatic occurrence, unruptured intracranial aneurysms (UIAs) account for a significant proportion of hospital charges and healthcare resource utilization in the United States. Hospital length of stay (LOS) is a reimbursement metric utilized to incentivize value-based care. Our study identifies predictors of extended LOS (eLOS) after elective treatment of UIAs., Methods: This was a retrospective study of 525 patients who underwent elective treatment of an UIA at a single institution. Data were collected with regard to demographics, clinical presentation, treatment characteristics, and postoperative outcomes. The primary outcome, eLOS, was defined as hospital stay in the upper quartile of the median (≥75th percentile). Univariate and multivariate analyses were performed to identify factors predictive of eLOS in this cohort., Results: The average age of the cohort was 61.40, standard deviation=11.41. 77.3% of the cohort was female. The median duration of LOS was 2 days (interquartile range: 1-5). 11.6% experienced eLOS (≥5 days). Multivariate logistic regression identified age (OR: 1.04, 95% confidence interval [CI]: 1.01-1.07), coexistent vascular pathology (OR: 21.33, 95% CI: 8.06-56.39), open surgery (OR: 3.93, 95% CI: 1.85-8.34), and postoperative stroke (OR: 11.72, 95% CI: 3.18-43.18) as independent predictors of eLOS., Conclusions: Our study identified predictors of eLOS that could help promote risk stratification prior to treatment of UIAs. Future research that identifies predictors of long-term outcomes based on treatment modality could help identify ways to improve healthcare resource utilization in this cohort., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background and Importance: Despite technological advances, ruptured wide-necked aneurysms continue to pose a challenge for endovascular management. Comaneci (Rapid Medical) is a relatively new temporary aneurysm neck bridging device to assist in coiling of wide-necked aneurysms without the need for dual antiplatelet therapy or parent vessel flow interruption. Y configuration is often necessary to prevent coil migration in cases of wide-necked aneurysms. Thus far, there have been no reports of using Comaneci device in Y configuration to aid anterior circulation aneurysm treatment., Clinical Presentation: A 60-year-old man presented with a Hunt-Hess grade 5, modified Fisher grade 4 subarachnoid hemorrhage from a ruptured wide-necked anterior communicating artery aneurysm with a dome-to-neck ratio of 1:2. Two Comaneci devices were used in a Y configuration to prevent coil prolapse into the contralateral A2 branch. After successful coiling of the aneurysm, both Comaneci devices were collapsed and removed without incident; the coil catheter was also removed without incident. Follow-up angiogram demonstrated successful occlusion of the wide-necked anterior communicating artery aneurysm without the use of a permanent stent or balloon assistance., Conclusion: This case represents a first-time report of successfully using 2 Comaneci devices in a Y configuration for the treatment of a ruptured wide-necked anterior circulation aneurysm. This knowledge can potentially further expand the use of double Comaneci devices in Y configuration for the treatment of both anterior and posterior circulation aneurysms., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Purpose: The high efficacy of flow diverters (FD) in the case of wide-neck aneurysms is well demonstrated, yet new challenges have arisen because of reported posttreatment failures and the growing number of new generation of devices. Our aim is to present a measurement-supported in silico workflow that automates the virtual deployment and subsequent hemodynamic analysis of FDs. In this work, the objective is to analyze the effects of FD deployment variability of two manufacturers on posttreatment flow reduction., Methods: The virtual deployment procedure is based on detailed mechanical calibration of the flow diverters, while the flow representation is based on hydrodynamic resistance (HR) measurements. Computational fluid dynamic simulations resulted in 5 untreated and 80 virtually treated scenarios, including 2 FD designs in nominal and oversized deployment states. The simulated aneurysmal velocity reduction (AMVR) is correlated with the HR values and deployment scenarios., Results: The linear HR coefficient and AMVR revealed a power-law relationship considering all 80 deployments. In nominal deployment scenarios, a significantly larger average AMVR was obtained (60.3%) for the 64-wire FDs than for 48-wire FDs (51.9%). In oversized deployments, the average AMVR was almost the same for 64-wire and 48-wire device types, 27.5% and 25.7%, respectively., Conclusion: The applicability of our numerical workflow was demonstrated, also in large-scale hemodynamic investigations. The study revealed a robust power-law relationship between a HR coefficient and AMVR. Furthermore, the 64 wire configurations in nominal sizing produced a significantly higher posttreatment flow reduction, replicating the results of other in vitro studies., (© 2024. The Author(s).)

The safety and feasibility of using staged flow diverter (FD) for ruptured cerebral aneurysms, in which coil embolization is performed in the acute phase and FD is deployed in the subacute phase, has recently been reported. This strategy requires assuming the rupture point and performing coil embolization. Although vessel wall magnetic resonance imaging (VW-MRI) has been reported to be useful in predicting the rupture point of aneurysms, its use with staged FD has not yet been reported. We report the first case of staged FD with preoperative contrast-enhanced VW-MRI to predict the rupture point for partially thrombosed vertebral artery dissecting large aneurysm involving posterior inferior cerebellar artery (PICA) origin. This approach achieved a very good outcome, not only completely occluding the aneurysm, but also reconstructing the parent artery while maintaining the patency of the PICA., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Akira Ishii—Payment for educational lectures and advisory board: Medtronic.

Background: Recurrent intracranial aneurysms present a significant clinical challenge, demanding innovative and effective treatment approaches. The Woven EndoBridge (WEB) device has emerged as a promising endovascular solution for managing these intricate cases. This study aims to assess the safety and efficacy of the WEB device in treating recurrent intracranial aneurysms., Methods: We conducted a comprehensive search across multiple databases, including PubMed, Scopus, Embase, and Web of Science, from inception to June 5, 2023. Eligible studies focused on evaluating WEB device performance and included a minimum of five patients with recurrent intracranial aneurysms. The complete and adequate occlusion rates, neck remnant rates, and periprocedural complication rates were pooled using SATA V.17., Results: Our analysis included five studies collectively enrolling 73 participants. Participant ages ranged from 52.9 to 65 years, with 64.4% being female. Aneurysms were wide-necked and predominantly located in the middle cerebral artery, basilar artery, and anterior cerebral artery. Previous treatments encompassed coiling, clipping, and the use of WEB devices. Our study found an overall adequate occlusion rate of 0.80 (95% CI 0.71-0.89), a complete occlusion rate of 0.39 (95% CI 0.28-0.50), and a neck remnant rate of 0.38 (95% CI 0.27-0.48). Periprocedural complications were reported at a rate of 0%, although heterogeneity was observed in this data. Notably, evidence of publication bias was identified in the reporting of periprocedural complication rates., Conclusion: Our findings suggest that the WEB device is associated with favorable outcomes for treating recurrent wide-neck intracranial aneurysms., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Intraprocedural rupture (IPR) of an intracranial aneurysm is the most feared complication of primary and stent-assisted coiling because it carries a high risk of morbidity and mortality. The endovascular strategy applied to control IPR depends on the cause of the rupture and stage of the procedure. Rupture during primary or stent-assisted coiling is traditionally managed with the use of continued packing, balloon microcatheter placement, or in rare cases, with parent artery sacrifice. In this technical note, we describe the use of temporary coiling of the parent artery to control IPR in three cases. Temporary parent artery coiling creates a subocclusive state, resulting in aneurysmal blood flow reduction without interruption of blood flow to the distal territory. Flow reduction combined with the thrombogenicity of the previously deployed coils results in hemostasis. In the cases presented here, IPR occurred during the late stage of coiling. In each case, parent artery coiling was performed along with heparin reversal. After confirmation of hemostasis, the coils were retrieved to restore normal blood flow. We demonstrate that the technique of temporary parent artery coiling may be a safe and effective option for the management of IPR during primary or stent-assisted coiling.