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Background: Anterior communicating artery (ACOM) aneurysms are among the most common aneurysms associated with aneurysmal subarachnoid hemorrhage (International Study of Unruptured Intracranial Aneurysms I (N Engl J Med 339:1725-1733, 1998), Wiebers (Lancet 362:103-110, 2003)). Surgical clipping of posterior-superiorly projecting ACOM aneurysms can be challenging, as the ipsilateral A2 can interfere with clip trajectory and ACOM perforating vessels obstructed from view. Intraluminal coils can further increase the difficulty of the procedure. Method: The relevant surgical anatomy with illustration is presented. A video detailing our technique on an illustrative case is provided. Conclusion: Surgical clipping of posterior-superiorly projecting ACOM aneurysms can require complex clip configurations. We describe the key steps of posterior-superiorly projecting ACOM aneurysm clipping through a lateral supraorbital craniotomy and fenestrated tandem clipping. [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]

Background Surgical clipping has been a gold standard procedure for management of intracranial aneurysms. Outcome studies of surgical clipping at institutional level are important to identify modifiable factors and further improve the results. These are even more important in areas where resources are limited, and patient presents late due to ignorance and lack of education. This study is a review of our institutional experience in microsurgical clipping of ruptured intracranial aneurysms.

Unruptured posterior communicating artery (Pcom) aneurysms cause oculomotor nerve palsy (ONP). However, the time course of recovery after aneurysm repair remains unclear. We aimed to evaluate the ONP course after clipping and coiling for unruptured Pcom aneurysms. We retrospectively reviewed the medical records of 25 consecutive patients with ONP due to unruptured Pcom aneurysms, undergoing aneurysm repair at our institution during 2010–2022. We analyzed the clinical data, angiographic results, and surgical complications. The time to ONP recovery was evaluated using the Kaplan–Meier method. This study included 14 patients undergoing surgical clipping and 11 undergoing endovascular coiling. The two groups exhibited no significant differences in complete or partial ONP percentage or in symptom presentation (ptosis, diplopia, ocular paralysis, pupillary light reflex disorder, or mydriasis). All patients achieved complete or partial recovery during the follow-up period. The median time to partial or complete improvement in ONP was significantly shorter for clipping compared to coiling (2 days vs. 33 days; P = 0.009). Preoperative partial and complete ONP were stratified; clipping improved significantly earlier than coiling in the complete ONP group (P = 0.010). In the early treatment group (based on the median duration of treatment), clipping resulted in earlier improvement than coiling (P = 0.014). In the small aneurysm group (based on the median of the aneurysm maximum diameter), clipping resulted in earlier improvement than coiling (P = 0.005). In ONP caused by an unruptured Pcom aneurysm, clipping may provide faster recovery than coiling, particularly in cases of early onset, complete palsy, and small aneurysms. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to describe the effectiveness and evaluation of open surgical treatment of basilar artery aneurysms in the context of interventional therapy era, including surgical clipping and blood reconstruction, by retrospectively analyzing the clinical data of basilar artery aneurysms in our center. Methods: Patients with basilar artery aneurysms who were treated at our center were retrospectively included according to the inclusion and exclusion criteria. The basic clinical data, surgical approach, clinical follow-up and prognosis of the enrolled patients were analyzed in detail. In this study, the mRS score was applied to assess the neurological prognosis of the patients, and the relevant data were statistically analyzed using SPSS. Results: A total of 104 eligible patients treated at our center from January 2010 to August 2023 were included in this study, of which 67 were treated by open surgery and 37 by bypass. For the 67 patients with open surgical clipping, the mean age was 60.0 (52.0, 65.0) years. The maximum diameter of the aneurysms ranged from 2.0 mm to 54.0 mm, with a mean of 13.9 (10.0, 19.0) mm. The mean follow-up time was 38 (20, 58) months. At the last follow-up, 61 (91.0%) completely obliterated aneurysms and 6 (9.0%) incompletely obliterated aneurysms were found. The prognosis was good in 59 (88.1%) patients and poor in 8 (11.9%). After surgical clipping, the difference between complete and incomplete postoperative aneurysm elimination was statistically significant between the favorable and poor prognosis groups (P < 0.001). For the 37 bypass group patients, the mean age was 52.0 (45.5, 59.0) years. The maximum diameter of the aneurysm ranged from 10.5 mm to 55.0 mm, with a mean of 28.55 ± 12.08 mm. Bypass combined with proximal occlusion was performed in 18 (48.6%) patients, and bypass only was performed in 19 (51.4%) patients. Clinical follow-up was 19.0 (10.5, 43.0) months. There were 19 (51.4%) patients with complete elimination of the aneurysm, 13 (35.1%) with incomplete elimination of the aneurysm, and 5 (13.5%) with aneurysm stabilization. The prognosis was good in 32 (86.5%) patients and poor in 5 (13.5%) patients. Conclusion: Treatment of basilar artery aneurysms is challenging. In the context of the rapidly evolving interventional therapy era, open surgery including surgical clipping and bypass is an ideal option for complex basilar artery aneurysms not amenable to intervention. [ABSTRACT FROM AUTHOR]

Background Surgical clipping has been a gold standard procedure for management of intracranial aneurysms. Outcome studies of surgical clipping at institutional level are important to identify modifiable factors and further improve the results. These are even more important in areas where resources are limited, and patient presents late due to ignorance and lack of education. This study is a review of our institutional experience in microsurgical clipping of ruptured intracranial aneurysms. Methods A retrospective study of patients who underwent surgical clipping for ruptured intracranial aneurysms from January 2014 to February 2020. The medical records of patients were reviewed for demographic data, clinical presentation, radiological investigations, surgery performed and neurological outcome. Outcome at discharge and outcome at follow-up were measured by modified Rankin scale (mRS). Results In this study of 289 patients, 194 patients (67.13%) had good outcome at discharge (mRS0–2), while 95 patients (32.87%) had poor outcome at discharge (mRS 3–6) and 50 patients (17.30%) expired during hospital stay. Out of 289 patients, 208 patients (71.97%) were admitted after more than 3 days of ictus. Significant factors affecting outcome were neurological status determined by Glasgow coma scale (GCS) score, World Federation of Neurosurgical Societies (WFNS) grade or Hunt and Hess Grade, time interval from onset of subarachnoid hemorrhage to admission, and time interval from admission to surgery. Conclusion The present study identifies factors for improving outcome in patients of ruptured aneurysm at institutional and community level. Time from ictus to admission and admission to surgery are important modifiable factors in our study. [ABSTRACT FROM AUTHOR]

AbstractPurposeMethodsResultsConclusionThe study aims to investigate the effect of prognostic nutritional index (PNI) on the outcome of patients with SAH undergone endovascular occlusion or surgical clipping.Clinical data of consecutive patients with SAH patients who were managed in the neurosurgical department of Kanuni Research and Training Hospital in Trabzon from January 2020 to June 2022 was analyzed. The primary endpoint was early mortality in one month. The prognostic role of PNI was investigated.Of the 46 patients, 17 were male and 29 were female. The median age was 57.3 (33–89). the last status according to the PNI values of the patients was statistically significant (p = 0.023 < 0.=5). When the patients were divided into two groups according to Glasgow Coma Score as group 1 (the patient’s GCS was lower than 12) and Group 2 (GCS score whose GCS score was between 12-15, the non-parametric Mann-Whitney U test showed a statistical significant between this two group.This study indicates that PNI was correlated with the outcome in patients with SAH. Preoperative impaired nutritional status based on PNI can be accepted as a predictor of affecting the outcome in aneurysmal SAH patients undergoing endovascular occlusion or surgical clipping. [ABSTRACT FROM AUTHOR]

Objective: Treatment modality for ruptured and unruptured intracranial aneurysms has shifted during the last two decades from microsurgical treatment towards endovascular treatment. We present how this transition happened in a large European neurovascular center. Methods: We conducted a retrospective observational study consecutive patients treated for an unruptured or ruptured intracranial aneurysm at Helsinki University Hospital during 2012–2022. We used Poisson regression analysis to report age-adjusted treatment trends by aneurysm location and rupture status. Results: A total of 2491 patients with intracranial aneurysms were treated (44% ruptured, 56% unruptured): 1421 (57%) surgically and 1070 (43%) endovascularly. A general trend towards fewer treated aneurysms was noted. The proportion of patients treated surgically decreased from 90% in 2012 to 20% in 2022. The age-adjusted decrease of surgical versus endovascular treatment was 6.9%/year for all aneurysms, 6.8% for ruptured aneurysms, and 6.8% for unruptured aneurysms. The decrease of surgical treatment was most evident in unruptured vertebrobasilar aneurysms (10.8%/year), unruptured communicating artery aneurysms (10.1%/year), ruptured communicating artery aneurysms (10.0%/year), and ruptured internal carotid aneurysms (9.0%/year). There was no change in treatment modality for middle cerebral artery aneurysms, of which 85% were still surgically treated in 2022. A trend towards an increasing size for treated ruptured aneurysms was found (p = 0.033). Conclusion: A significant shift of the treatment modality from surgical to endovascular treatment occurred for all aneurysm locations except for middle cerebral artery aneurysms. Whether this shift has affected long-term safety and patient outcomes should be assessed in the future. [ABSTRACT FROM AUTHOR]

Background: The concept of aneurysm "complexity" has undergone significant changes in recent years, with advancements in endovascular treatments. However, surgical clipping remains a relevant option for middle cerebral artery (MCA) aneurysms. Hence, the classical criteria used to define surgically complex MCA aneurysms require updating. Our objective is to review our institutional series, considering the impacts of various complexity features, and provide a treatment strategy algorithm. Methods: We conducted a retrospective review of our institutional experience with "complex MCA" aneurysms and analyzed single aneurysmal-related factors influencing treatment decisions. Results: We identified 14 complex cases, each exhibiting at least two complexity criteria, including fusiform shape (57%), large size (35%), giant size (21%), vessel branching from the sac (50%), intrasaccular thrombi (35%), and previous clipping/coiling (14%). In 92% of cases, the aneurysm had a wide neck, and 28% exhibited tortuosity or stenosis of proximal vessels. Conclusions: The optimal management of complex MCA aneurysms depends on a decision-making algorithm that considers various complexity criteria. In a modern medical setting, this process helps clarify the choice of treatment strategy, which should be tailored to factors such as aneurysm morphology and patient characteristics, including a combination of endovascular and surgical techniques. [ABSTRACT FROM AUTHOR]

Intracranial aneurysms represent a major global health burden. Rupture of an intracranial aneurysm is a catastrophic event. Without access to treatment, the fatality rate is 50% in the first 30 days. Over the last three decades, treatment approaches for intracranial aneurysms have changed dramatically. There have been improvements in the medical management of aneurysmal subarachnoid haemorrhage, and there has been an evolution of treatment strategies. Endovascular therapy is now the mainstay of the treatment of ruptured intracranial aneurysms based on robust randomised controlled trial data. There is now an expansion of treatment indications for unruptured intracranial aneurysms to prevent rupture with both microsurgical clipping and endovascular treatment. Both microsurgical and endovascular treatment modalities have evolved, in particular with the introduction of innovative endovascular treatment options including flow diversion and intra-saccular flow disruption. These novel therapies allow clinicians to treat more complex and previously untreatable aneurysms. We aim to review the evolution of treatment strategies for intracranial aneurysms over time, and discuss emerging technologies that could further improve treatment safety and functional outcomes for patients with an intracranial aneurysm.

Purpose: Persistent primitive anterior choroidal artery (PPAChA) is a rare vascular anomaly. The clinical course of internal carotid artery (ICA)-PPAChA aneurysms has not been well described. Case reports: We report two patients with an ICA-PPChA aneurysm and summarize previously reported cases. Results: Including our two, a total of 10 patients with an ICA-PPAChA aneurysm have been reported. Data were not described for one. Among the remaining nine, five patients (56%) experienced aneurysmal rupture. Five patients underwent surgical clipping and four underwent endovascular coiling. The procedure was completed in all but one patient who had a tiny branch artery adherent to the aneurysm; this patient was converted from clipping to aneurysm coating with a cotton sheet. Among the other eight patients, one who underwent coiling experienced an internal capsule infarction. The remaining seven had a satisfactory postoperative course; however, an asymptomatic occlusion of the PPAChA at its origin was noted on postoperative angiography in one. Conclusion: PPChA is associated with a high incidence of aneurysm formation and rupture. During treatment of ICA-PPAChA aneurysms, obstruction of the PPAChA and any surrounding perforating arteries should be avoided to prevent ischemic stroke. [ABSTRACT FROM AUTHOR]

Intracranial aneurysms represent a major global health burden. Rupture of an intracranial aneurysm is a catastrophic event. Without access to treatment, the fatality rate is 50% in the first 30 days. Over the last three decades, treatment approaches for intracranial aneurysms have changed dramatically. There have been improvements in the medical management of aneurysmal subarachnoid haemorrhage, and there has been an evolution of treatment strategies. Endovascular therapy is now the mainstay of the treatment of ruptured intracranial aneurysms based on robust randomised controlled trial data. There is now an expansion of treatment indications for unruptured intracranial aneurysms to prevent rupture with both microsurgical clipping and endovascular treatment. Both microsurgical and endovascular treatment modalities have evolved, in particular with the introduction of innovative endovascular treatment options including flow diversion and intra-saccular flow disruption. These novel therapies allow clinicians to treat more complex and previously untreatable aneurysms. We aim to review the evolution of treatment strategies for intracranial aneurysms over time, and discuss emerging technologies that could further improve treatment safety and functional outcomes for patients with an intracranial aneurysm. [ABSTRACT FROM AUTHOR]

Background: Posterior cerebral artery (PCA) aneurysms, though rare, pose treatment challenges. Endovascular therapy is the preferred option, but microsurgery becomes necessary in certain cases. Various microsurgical approaches have been suggested for PCA aneurysms, particularly those at the P2–P3 junction. This study highlights the trans-lateral ventricular approach (TVA) for addressing these complex aneurysms. This study aims to assess the feasibility and safety of the trans-lateral ventricular approach (TVA) for treating high-located complex PCA aneurysms at the P2–P3 junction. The study evaluates both clinical outcomes and anatomical considerations. Methods: Two cases of PCA aneurysms at the P2–P3 junction were treated using TVA in 2019. Navigation-guided entry via the interparietal sulcus was planned. Ventriculostomy was performed from the cortex to the lateral ventricle's atrium. Medial atrial floor dissection exposed PCA's P2–P3 segments. Neuronavigation and ultrasound-aided guidance was used. Anatomical studies on fixed and contrast-perfused specimens refined the approach. Results: Both cases saw successful aneurysm clipping. The unruptured aneurysm patient was discharged in 6 days. The poor-grade SAH patient required extended ICU care, moving to rehabilitation with mRS = 4. The unruptured complex aneurysm case exhibited no deficits, returning to work in 3 months. Anatomical dissections validated TVA for high-located P2–P3 junction PCA aneurysms. Conclusion: While endovascular therapy remains primary, this study demonstrates the viability of navigation-guided TVA for select high-located P2–P3 junction PCA aneurysms. Successes and challenges underscore the importance of patient selection and anatomical awareness. [ABSTRACT FROM AUTHOR]

Objective To compare and analyze 2 therapeutic methods, the surgical clipping and endovascular treatment in the clinical efficacy, prognosis, neurological function outcomes, surgical complications and recurrence rate for middle cerebral artery aneurysm. Methods A retrospective cohort study was conducted on 265 patients receiving treatment for middle cerebral artery aneurysms in our hospital from January 2013 to December 2021. These patients were divided into surgical clipping group and endovascular treatment group according to the therapeutic methods they chose. Univariate analysis was used to analyze the recurrence rate in these 2 groups. Clinical prognosis, neurological function outcomes and surgical complication rates of these 2 groups were analyzed based on propensity score matching. Results A total of 162 patients underwent surgical clipping and 103 patients received endovascular treatment. Propensity score matching(PSM) was used to control the baseline characteristics, and 103 patients who received surgical clipping were matched with 103 patients who received endovascular treatment. The good clinical prognosis rate (99.03% vs 86.41%, P < 0.001) and neurological function recovery rate (88.35% vs 63.11%, P < 0.001) of endovascular treatment were higher than those in the surgical clipping group, which were statistically significant. The clipping group had a greater rate of surgical complications than that in the interventional group, with intracranial infection (24.27% vs 5.83%, P < 0.001) being the most significant. No differences were observed in vasospasm, delayed cerebral infarction, hydrocephalus, intraoperative rupture or epilepsy. The endovascular group had a higher recurrence rate than that in the surgical clipping group (3.33% vs 1.11%, P=0.560). Conclusion Endovascular treatment has better clinical prognosis and neurological function outcomes and has fewer surgical complication rates than that of surgical clipping, but surgical clipping appears to result in lower recurrence rates. Endovascular treatment is recommended when both two therapeutic methods are available.

Objective : This study compared the quality of recovery (QoR) after minicraniotomy for clipping of unruptured intracranial aneurysms (UIAs) between patients with and without scalp nerve block (SNB). Methods : Patients were randomly assigned to the SNB (SNB using ropivacaine with epinephrine, n=27) and control (SNB using normal saline, n=25) groups. SNB was performed at the end of surgery. To assess postoperative QoR, the QoR-40, a patient-reported questionnaire, was used. The QoR-40 scores were measured preoperatively, 1-3 days postoperatively, at hospital discharge, and 1 month postoperatively. Pain and intravenous patient-controlled analgesia (IV-PCA) consumption were evaluated 3, 6, 9, and 12 hours and 1-3 days postoperatively. Results : All QoR-40 scores, including those measured 1 day postoperatively (primary outcome measure; 155.0 [141.0-176.0] vs. 161.0 [140.5-179.5], p=0.464), did not significantly differ between the SNB and control groups. The SNB group had significantly less severe pain 3 (numeric rating scale [NRS]; 3.0 [2.0-4.0] vs. 5.0 [3.5-5.5], p=0.029), 9 (NRS; 3.0 [2.0-4.0] vs. 4.0 [3.0-5.0], p=0.048), and 12 (NRS; 3.0 [2.0-4.0] vs. 4.0 [3.0-5.0], p=0.035) hours postoperatively. The total amount of IV-PCA consumed was significantly less 3 hours postoperatively in the SNB group (2.0 [1.0-4.0] vs. 4.0 [2.0-5.0] mL, p=0.044). Conclusion : After minicraniotomy for clipping of UIAs, SNB reduced pain and IV-PCA consumption in the early postoperative period but did not improve the QoR-40 scores. [ABSTRACT FROM AUTHOR]

Intraoperative aneurysm rupture (IOAR) is a serious and potentially life-threatening complication that can occur during intracranial aneurysm surgery. Understanding the perioperative risk factor contributing to IOAR may help prevention and better handle if it occurs. The anesthesiologist should be familiar with the management of IOAR to facilitate bleeding control and improve perioperative outcome. There is controversy surrounding the management of IOAR. The main goal of management includes promptly securing for control of bleeding as well as maintaining adequate cerebral perfusion and providing neuroprotection. The purpose of the present article was to review the anesthetic management during IOAR. The authors focused on the hemodynamic and intracranial pressure control for optimizing cerebral perfusion, neuroprotection during temporary arterial occlusion, monitoring of cerebral ischemia, and recent techniques for controlling bleeding. [ABSTRACT FROM AUTHOR]

Abstract The incidence of multiple aneurysms was 10.7–34% of CA. Multiple associated factors were found; hypertension was the most significant one and others like advancing age and female sex were also documented. The estimated prevalence of UA is 5–10%. They include those aneurysms that did not rupture and discovered incidentally and those presented with symptoms rather than SAH, e.g., cranial nerve palsy or mass effect. Unruptured intracranial aneurysms are diagnosed with higher frequency nowadays as a result of imaging techniques improvement. The reported annual rate of rupture of UA is approximately 0.7–1%. The natural history of unruptured cerebral aneurysms cannot be extrapolated from the evaluation of individuals with ruptured aneurysms. Multiple cerebral aneurysms pose an even greater risk than a single aneurysm; the risk of rebleeding from the original aneurysm is larger and occurs sooner. The natural course of the disease has led to a consensus that all multiple unruptured aneurysms should be treated when technically viable. However, the prophylactic treatment of multiple unruptured is still controversial. Weighing the risk of intervention to the risk of observation is a mandatory pathway. Factors like age of patients, size and location of the aneurysms influence the decision-making and the type of therapy to be elected.

Intracranial aneurysms (IAs) are common cerebrovascular diseases with high rates of mortality and disability. With the development of endovascular treatment technologies, the treatment of IAs has gradually turned to endovascular methods. However, because of the complex disease characteristics and technical challenges of IA treatment, surgical clipping still plays an important role. However, no summary has been performed of the research status and future trends in IA clipping. Publications related to IA clipping from 2001 to 2021 were retrieved from the Web of Science Core Collection database. We conducted a bibliometric analysis and visualization study with the help of VOSviewer software and R program. We included 4104 articles from 90 countries. The volume of publications on IA clipping, in general, has increased. The United States, Japan, and China were the countries with the most contributions. The University of California, San Francisco, Mayo Clinic, and the Barrow Neurological Institute are the main research institutions. World Neurosurgery and the Journal of Neurosurgery were the most popular journal and most co-cited journal, respectively. These publications came from 12,506 authors, of whom Lawton, Spetzler, and Hernesniemi had reported the most studies. The reports from the past 21 years on IA clipping can generally be divided into 5 parts: (1) characteristics and technical difficulties of IA clipping; (2) perioperative management and imaging evaluation of IA clipping; (3) risk factors for subarachnoid hemorrhage caused by rupture after IA clipping; (4) outcomes, prognosis, and related clinical trials of IA clipping; and (5) endovascular management for IA clipping. "Occlusion," "experience," "internal carotid artery," "intracranial aneurysms," "management," and "subarachnoid hemorrhage" were the major keywords for future research hotspots. The results from our bibliometric study have clarified the global research status of IA clipping between 2001 and 2021. The United States contributed the most publications and citations, and World Neurosurgery and Journal of Neurosurgery can be considered landmark journals in this field. Studies regarding occlusion, experience, management, and subarachnoid hemorrhage will be the research hotspots related to IA clipping in the future. [ABSTRACT FROM AUTHOR]

The effect of surgical clipping (SC) and endovascular coiling (EC) on the incidence of delayed cerebral ischemia (DCI) in patients with aneurysmal subarachnoid hemorrhage (aSAH) has always been a controversial topic. Hence, it is necessary to reanalyze the effects of the 2 surgical methods on DCI, which determines the choice of the most favorable method for patients who are suitable for both surgical modalities. A multicenter retrospective observational cohort study was performed to evaluate all consecutive patients with aSAH admitted to 5 medical centers in China between April 2019 and June 2021. Univariable and multivariable analyses were used to confirm risk factors of DCI after aSAH. A 1:1 propensity score matching model was generated in the EC and SC groups to reduce the influence of all confounding factors on DCI. A total of 412 patients were included, and 115 patients (27.9%) developed DCI. After propensity score matching for controlling demographic information, past medical history, admission clinical status, aneurysm characteristics, and inflammatory factors associated with DCI, 133 patients with SC and 133 patients with EC treatment were matched. The results of the matched cohorts indicate a significantly lower incidence of DCI when patients received EC than SC (31.9% vs. 20%; adjusted odds ratio, 1.87; 95% confidence interval, 1.08–3.29; P = 0.027). The study found that the patients who received SC treatment had a higher incidence of DCI than did those who received EC and suggested that ruptured intracerebral aneurysm is preferentially coiled rather than clipped if the aneurysm is suitable for both surgical modalities. [ABSTRACT FROM AUTHOR]

Objective: Red blood cell (RBC) parameters are associated with outcomes following aneurysmal subarachnoid hemorrhage (aSAH), but their predictive value remains uncertain. This study aimed to detect the association between RBC parameters and functional outcome in aSAH patients undergoing surgical clipping. Methods: This retrospective observational study included aSAH patients who underwent surgical clipping at Affiliated Hospital of North Sichuan Medical College between August 2016 and September 2019. The functional outcome following aSAH was assessed by modified Rankin Scale (mRS), and mRS 3-6 was defined as poor functional outcome. Results: Out of 187 aSAH patients included (62% female, 51-66 years old), 73 patients had poor functional outcome. Multivariate logistic regression of admission parameters showed that World Federation of Neurosurgical Societies (WFNS) grade (odds ratio [95% CI]: 1.322 [1.023-1.707], p = 0.033) and white blood cell (WBC) (odds ratio [95% CI]: 1.136 [1.044-1.236], p = 0.003) were independently associated with poor functional outcome. In postoperative parameters, RBC distribution width (RDW) (odds ratio [95% CI]: 1.411 [1.095-1.818], p = 0.008), mean platelet volume (MPV, odds ratio [95% CI]: 1.253 [1.012-1.552], p = 0.039) and admission WFNS grade (odds ratio [95% CI]: 1.439 [1.119-1.850], p = 0.005) were independently associated with poor functional outcome. The predictive model including WFNS grade, admission WBC, and postoperative RDW and MPV had significantly higher predictive power compared to WFNS grade alone (0.787 [0.722-0.852] vs. 0.707 [0.630-0.784], p = 0.024). The combination of WFNS grade and WBC on admission showed the highest positive predictive value (75.5%) and postoperative RDW and MPV combined with admission WFNS grade and WBC showed the highest negative predictive value (83.7%). Conclusion: Postoperative RDW is independently associated with poor functional outcome in aSAH patients undergoing surgical clipping. A combined model containing postoperative RDW may help predict good outcome in patients with aSAH after timely aneurysm clipping. [ABSTRACT FROM AUTHOR]

Vasospasm, initial neurological damage, rebleeding, and periprocedural complications are associated prognostic factors for clinical outcomes after aneurysmal subarachnoid hemorrhage (SAH). In this study, factors related to delayed ischemic neurological deficit (DIND) are evaluated using data from our institute for the last 18 years. Data from 2001 to 2018 of patients with aneurysmal SAH who underwent surgical clipping (SC) or endovascular coiling (EC) within 7 days of onset were retrospectively analyzed. Cases of mortality within 5 days after treatment were excluded. Multivariate analysis was used to identify the risk factors for DIND. In total, 840 cases of SAH were assessed; among these cases, 384 (45.7%) and 456 (54.3%) were treated with SC and EC, respectively. The frequency of DIND in the EC group was significantly less than that in the SC group (11.8% vs. 17.7%; p = 0.016). In the results of multivariate analysis, internal carotid artery (ICA) aneurysm and hemorrhagic complications were the risk factors for DIND. Cilostazol administration and EC were significant factors for vasospasm prevention after aneurysmal SAH (odds ratio of ICA aneurysm: 1.59, hemorrhagic complications: 1.76, SC: 1.51, and cilostazol administration: 0.51, respectively). Cilostazol administration was also a significant factor in patients who were treated with EC. ICA aneurysm, treatment strategy, hemorrhagic complications, and cilostazol administration were associated with DIND. Oral administration of cilostazol and avoiding hemorrhagic complications were effective in DIND prevention. If both treatments are available for ruptured aneurysms, clinicians should choose EC on the basis of its ability to prevent DIND.

Endovascular coiling techniques have emerged as an alternative and effective approach for treating intracranial aneurysms. However, in some cases, previously coiled aneurysms may require secondary treatment with surgical clipping, presenting a more complex challenge compared with the initial intervention. 1,2 We present the case of a 39-year-old man with a residual class III Raymond-Roy occlusion partially coiled aneurysm at the left middle cerebral artery bifurcation (Video 1). Faced with the risks of rerupture, the patient underwent microsurgical treatment after providing consent. Despite successful initial microsurgical clipping, postoperative complications arose due to coil protrusion into the middle cerebral artery bifurcation, resulting in thrombotic occlusion of the frontal M2 branch. Emergency repeat microsurgical intervention and administration of a thrombolytic agent were performed to address complications, ultimately preserving blood flow. Subsequent endovascular placement of a flow-diverting stent 7 weeks after discharge confirmed complete occlusion of the aneurysm. The patient had no neurological deficit on follow-up. When planning microsurgical clipping of an aneurysm previously treated with coils, it is critical to consider coil placement, as there is a risk of prolapse if the coil is in the neck of the aneurysm. Thrombosis of the cerebral arteries is a potential complication of microsurgical clipping of partially coiled intracranial aneurysms, and injection of a fibrinolytic agent into thrombosed arterial branches may be an effective intraoperative method for treating intra-arterial thrombosis. 3 This case illustrates the challenges associated with treating partially coiled aneurysms, highlighting the significance of careful planning when considering microsurgical treatment. [ABSTRACT FROM AUTHOR]

Background: Intracranial aneurysms are rare in the pediatric population and constitute less than 2% of all cerebral aneurysms. Relative to their adult counterparts, published series have been few.The proportion of ruptured aneurysms in patients younger than 15 years is less than 1%.The occurrence of aneurysms is probably the result of an interplay between congenital factors and hemodynamic stress. Results: Our case is a 10-year-old boy suddenly presented to the emergency department complained of severe headache, diplopia and partial ptosis.There was no history of systemic upset, trauma or relevant medical or surgical history.Urgent brain CT scan and Brain MRI were performed with normal findings.The patient was admitted to pediatric ICU for ICP monitoring.Standard clinical examination and laboratory investigations were done to exclude intracranial infection, toxins and metabolic conditions.Enhanced CT angiography revealed a 5 mm saccular ICA bifurcation aneurysm on the left side.Detailed screening and imaging were done to rule out any associated conditions, such as Autosomal dominant polycystic kidney disease (ADPKD), fibro muscular dysplasia, coarctation of aorta, Ehlers syndrome, and Marfans syndrome.A multi-disciplinary team (MDT) meeting had been held and surgery was recommended after interdisciplinary decision with radiologist and two neurosurgeons.The patient underwent microsurgical clip ligation of ICA bifurcation aneurysm after 10 days of symptoms. The patient was discharged on day 7 after operation.Post-procedure CTA showed complete exclusion of the aneurysm from the circulation. Conclusion: Diagnosis of symptomatic unruptured intracranial aneurysm is challenging. The next challenge is to determine which aneurysms pose a significant risk for future rupture.The management of pediatric intracranial aneurysms is controversial. A multidisciplinary team is best able to treat such complex conditions.

Treatment of anterior choroidal artery (AchoA) aneurysms is challenging because of the risk of artery injury. The objective of the study was to evaluate the incidence and predictors of AchoA infarction in patients who underwent surgical or endovascular procedure. We included 123 patients with AchoA aneurysms treated by surgical clipping (n = 62; 50.4%) or endovascular coiling, including flow diverter placement (n = 61; 49.6%). The clinical and radiological data were retrospectively analyzed. AchoA infarction was defined as the presence of a hyperintense signal on diffusion-weighted imaging in the area of AchoA, including the posterior limb of the internal capsule. AchoA infarction was detected in 8 cases (6.5%), with similar incidence in both groups (6.5% [4/62] vs. 6.6% [4/61]). It occurred in ruptured aneurysms more frequently than in unruptured aneurysms (14.3% [6/42] vs. 2.5% [2/81], P = 0.019). In the surgical group, all 4 affected patients had a non-proximal type AchoA, whereas in the non-infarction group, 9 patients (15.5%) had a non-proximal type AchoA (P = 0.001). In the endovascular group, the incidence was higher in patients with ruptured aneurysms (17.3% [4/23] vs. 0% [0/38], P = 0.017) and lower in patients with pre-admission antiplatelet therapy (0% [0/39] vs. 18.8% [4/22], P = 0.014). Repair of an AchoA aneurysm is associated with the risk of incurring post-procedural AchoA infarction. Surgical clipping and endovascular coiling have similar complication rates, but risk factors specific to each intervention exist. Careful surgical planning to avoid these risk factors in each therapeutic modality may improve patient outcomes. [ABSTRACT FROM AUTHOR]

The objective of the study was to assess the esthetic efficacy of acellular dermal matrix (ADM) implantation to prevent frontotemporal depression (FTD) following minipterional craniotomy (MPT) to clip unruptured intracranial aneurysms. We retrospectively compared the incidence of FTD in 100 patients treated without ADM from March to July 2019 and 100 patients treated with ADM from August to December 2019. ADM was implanted in the interfascial layer to cover the temporalis muscle. The specific location and degree of FTD were analyzed by measuring the thickness and area of multiple points (P1–P12) and regions (S1–S3) through brain computed tomography preoperatively and 1 year postoperatively. In the non-ADM group, the thickness at P1, P2, P5, P6, and P9 was reduced and the area of S1 and S2 was smaller after surgery than before surgery (P < 0.05), similar to the incision and suture site of the temporalis muscle. However, in the ADM group, the preoperative and postoperative measurements were not different. FTD recognition was significantly lower in the ADM group (6.0%) than that in the non-ADM group (17.0%) (P = 0.015) and occurred in the retroorbital region through P1, P2, P5, and P6, with the area under the receiver operating characteristic curves of 0.840, 0.766, 0.811, and 0.751, respectively. ADM implantation was the only significant predictive factor for FTD recognition in multivariate logistic regression analysis (odds ratio = 0.30; 95% confidence interval: 0.11–0.79; P = 0.015). Even MPT cannot completely prevent FTD in the retroorbital region. ADM implantation in MPT can help to improve esthetic satisfaction. [ABSTRACT FROM AUTHOR]

The incidence of multiple aneurysms was 10.7–34% of CA. Multiple associated factors were found; hypertension was the most significant one and others like advancing age and female sex were also documented. The estimated prevalence of UA is 5–10%. They include those aneurysms that did not rupture and discovered incidentally and those presented with symptoms rather than SAH, e.g., cranial nerve palsy or mass effect. Unruptured intracranial aneurysms are diagnosed with higher frequency nowadays as a result of imaging techniques improvement. The reported annual rate of rupture of UA is approximately 0.7–1%. The natural history of unruptured cerebral aneurysms cannot be extrapolated from the evaluation of individuals with ruptured aneurysms. Multiple cerebral aneurysms pose an even greater risk than a single aneurysm; the risk of rebleeding from the original aneurysm is larger and occurs sooner. The natural course of the disease has led to a consensus that all multiple unruptured aneurysms should be treated when technically viable. However, the prophylactic treatment of multiple unruptured is still controversial. Weighing the risk of intervention to the risk of observation is a mandatory pathway. Factors like age of patients, size and location of the aneurysms influence the decision-making and the type of therapy to be elected. [ABSTRACT FROM AUTHOR]

Objective: The aim of the study was to investigate (1) the 30-day, 3-month, and 12-month cumulative mortalities for patients who underwent aneurysm occlusion, and (2) the causes of death, and (3) the potential risk factors for death. Methods: All patients who underwent surgical clipping or endovascular treatment of a ruptured aneurysm at Copenhagen University Hospital, during the period of January 1, 2017–December 31, 2019, were included and followed up for 12 months. Data regarding vital status, causes of death, comorbidities, treatment, and clinical presentations on admission was collected. The absolute mortality risk was estimated as a function of time with a 95% confidence interval. The associations between potential risk factors and death were estimated as odds ratios with 95% confidence intervals using logistic regression models. Results: A total of 317 patients were included. The overall cumulative mortalities after 30 days, 3 months, and 12 months were 10.7%, 12.9%, and 16.1%, respectively. The most common cause of death was severe primary hemorrhage (52.9%), followed by infections (15.7%) and rebleeding (11.8%). WFNS score > 3 and Fisher score > 3 on admission, preprocedural hydrocephalus, and preprocedural rebleeding were found significantly associated with higher risk of death. Conclusions: Considerable mortality was seen. Possible preventable causes accounted for approximately 22% of the deaths. The occurrence of both pre- and postprocedural rebleeding's indicates an opportunity of further improvement of the mortality by (1) further reduction of time from aSAH to aneurysm occlusion and (2) continuous efforts in improving methods of aneurysm occlusion. [ABSTRACT FROM AUTHOR]

Objective: There are many studies on post-operative cognitive function after surgical clipping (SC) and endovascular coiling (EC) for unruptured cerebral aneurysms, but few reports focusing on possible subclinical damage. The aim of the present study was to detect the subclinical damage after surgical intervention., Methods: Patients with anterior circulation aneurysms who underwent either SC (SC group) or EC (EC group) were recruited. Imaging studies and evaluation of cognitive function were performed within 1 month preoperatively and at 6 months and 2 years postoperatively. The ipsilateral/contralateral cerebral blood flow (CBF) ratio (I/C ratio) calculated from values in four regions of interest (ROIs) placed on N-isopropyl-p-[ 123 I] iodoamphetamine ( 123 I-IMP)-single photon emission computed tomography (SPECT) was used to detect "subclinical consequence". "Subclinical consequence" was defined as post-operative CBF reduction without abnormality in other radiological examinations and cognitive tests., Results: There were 14 patients in the SC group (mean age, 60.6±11.7 years) and 33 patients in the EC group (mean age, 67.5±7.2 years). All cognitive assessment results showed no significant reduction through the survey period. However, I/C ratios were restored by 2 years in the EC group not but in the SC group. I/C ratios at 6 months and 2 years were significantly lower in the SC group than the EC group (P<0.01)., Conclusions: 123IMP-SPECT revealed a statistically significant reduction in ipsilateral CBF in patients who had an uneventful clinical course and no cognitive problems. The subclinical consequence could persist for at least 2 years following SC, and was less pronounced following EC., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

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.

This is a case of 62-year-old patient presenting with tingling and numbness extending from the buttocks area towards the lower extremities and gait instability. Contrast Magnetic Resonance Imaging (MRI) and time-resolved imaging of contrast kinetics Magnetic Resonance Imaging (TRICKS MRI) raised suspicion for a possible dural arteriovenous fistula. Diagnostic Digital Subtraction Angiography (DSA) showed a filum terminale arterio venous fistula (AVF) fed by the left T9 from the anterior spinal artery of Adamkiewicz all the way down to the fistulous point at L5-S1. The patient underwent successful laminectomy of L5-S1 and clipping of the filum terminale arteriovenous fistula.

Cerebral aneurysms that compress cranial nerve VIII can cause hearing loss and imbalance. Hearing function that does not recover after aneurysm occlusion can signal neurological damage with the potential for permanent deafness. A 72-year-old woman presented with gradually worsening left-sided hearing loss and imbalance over a period of 10 years. She was found to have a lesion of the cerebellopontine angle, which proved to be a large fusiform vertebral artery aneurysm with mass effect on cranial nerve VIII. The patient underwent surgical clip occlusion of the vertebral artery distal to the posterior inferior cerebellar artery and proximal to the aneurysm, which no longer filled on catheter angiography. Postoperatively, the patient experienced delayed complete loss of ipsilateral hearing on the third post-operative day. Otherwise, she made a good recovery with improvement in her balance issues. At that time, we suspected that delayed occlusion of a perforating vessel had probably caused irreversible hearing loss. Ten months later, the patient awoke with significant subjective recovery of her hearing. Audiometry confirmed substantial improvement in her hearing likely due to the aneurysm shrinking away from and decompressing the cranial nerve. This case highlights the continued usefulness of vascular occlusion in the management of selected cases of intracranial aneurysms and also that neurological function may recover suddenly, even in very delayed fashion, following treatment. [ABSTRACT FROM AUTHOR]

Objective: Postoperative pneumonia (POP) is one of the major complications after aneurysmal subarachnoid hemorrhage (aSAH) associated with postoperative mortality, prolonged hospitalization, and increased medical cost. Early recognition of pneumonia and more aggressive management may improve patient outcomes. Methods: We retrospectively reviewed all patients with aSAH who were admitted to our institution between January 2015 and December 2020. Baseline clinical characteristics, imaging data, and inflammatory biomarkers were reviewed. The risk factors derived from multivariate logistic regression of surgical clipping (SC) and endovascular coiling (EC) were analyzed. The area under the receiver operating characteristic (ROC) curve (AUC) was used to calculate each independent predictor's prediction ability. Results: A total of 843 patients were enrolled. Compared with patients in the EC group, the incidence of POP was higher in the SC group [143/414 (34.54%) vs. 114/429 (26.57%), p = 0.015]. In the EC group, multivariate analysis revealed that age [ p = 0.001; odds ratio (OR) = 1.04, 95% CI = 1.02–1.07], posterior circulation aneurysms (p = 0.021; OR = 2.07, 95% CI = 1.14–3.83), higher neutrophil (NEUT; p < 0.001; OR = 1.13, 95% CI = 1.06–1.21), World Federation of Neurosurgical Societies (WFNS) grade 4 or 5 (p < 0.001; OR = 4.84, 95% CI = 2.67–8.79), modified Fisher Scale (mFS) grade 3 or 4 (p = 0.022; OR = 2.60, 95% CI = 1.15–5.89), and acute hydrocephalus (p = 0.048; OR = 1.74, 95% CI = 1.01–3.00) were independent risk factors for POP. In the SC group, multivariate analysis revealed that age (p = 0.015; OR = 1.03, 95% CI = 1.01–1.05), WFNS grade 4 or 5 (p = 0.037; OR = 1.76, 95% CI = 1.03–3.00), heart disease (p < 0.001; OR = 5.02, 95% CI = 2.03–12.45), higher white blood cell (WBC; p < 0.001; OR = 1.13, 95% CI = 1.07–1.20), and mFS grade 3 or 4 (p = 0.019; OR = 2.34, 95% CI = 1.15–4.77) were independent risk factors for POP. Conclusion: Patients treated with SC are more likely to develop POP. Comprehensive preoperative evaluation of patients may help physicians to better predict POP and implement preventive measures to improve outcomes. [ABSTRACT FROM AUTHOR]

ObjectiveTo investigate the surgical techniques and their clinical effects for ruptured basilar artery apex and posterior cerebral aneurysms via the Dolenc approach.MethodsWe retrospectively analyzed the clinical data of 14 patients with ruptured basilar artery apex and posterior cerebral aneurysms who underwent surgical clipping by the Dolenc approach from July 2017 to June 2020 in Beijing Tiantan Hospital affiliated with Capital Medical University and Lianyungang Hospital affiliated with Xuzhou Medical University. The modified Rankin scale (mRs) scores were used to evaluate the prognosis of patients.ResultsAll 14 cases of aneurysms were successfully clipped. Overall, 1, 2, and 1 cases of postoperative new-onset visual loss, oculomotor nerve palsy, and contralateral hemiplegia, respectively, were reported. Digital subtraction angiography (DSA) or computed tomography angiography (CTA) examination of the aneurysm within 2 weeks after surgery revealed that the aneurysm was completely clipped without residue. The observations during the follow-up within 12–18 months after surgery were as follows: 1 case of vision loss returned to normal, 2 cases of oculomotor nerve palsy, 1 case of return to normal, 1 case of improved, 1 case of contralateral hemiplegia improved after rehabilitation treatment, and 1 case of hydrocephalus ventriculoperitoneal shunt surgery was performed. Overall, 11, 2, and 1 case had mRs scores of 0, 1, and 2, respectively. No death was reported.ConclusionFor the small number of basilar apical and posterior cerebral aneurysms treated non-invasively, the Dolenc approach may offer advantages over other modalities.

ObjectivePostoperative pneumonia (POP) is one of the major complications after aneurysmal subarachnoid hemorrhage (aSAH) associated with postoperative mortality, prolonged hospitalization, and increased medical cost. Early recognition of pneumonia and more aggressive management may improve patient outcomes.MethodsWe retrospectively reviewed all patients with aSAH who were admitted to our institution between January 2015 and December 2020. Baseline clinical characteristics, imaging data, and inflammatory biomarkers were reviewed. The risk factors derived from multivariate logistic regression of surgical clipping (SC) and endovascular coiling (EC) were analyzed. The area under the receiver operating characteristic (ROC) curve (AUC) was used to calculate each independent predictor's prediction ability.ResultsA total of 843 patients were enrolled. Compared with patients in the EC group, the incidence of POP was higher in the SC group [143/414 (34.54%) vs. 114/429 (26.57%), p = 0.015]. In the EC group, multivariate analysis revealed that age [p = 0.001; odds ratio (OR) = 1.04, 95% CI = 1.02–1.07], posterior circulation aneurysms (p = 0.021; OR = 2.07, 95% CI = 1.14–3.83), higher neutrophil (NEUT; p < 0.001; OR = 1.13, 95% CI = 1.06–1.21), World Federation of Neurosurgical Societies (WFNS) grade 4 or 5 (p < 0.001; OR = 4.84, 95% CI = 2.67–8.79), modified Fisher Scale (mFS) grade 3 or 4 (p = 0.022; OR = 2.60, 95% CI = 1.15–5.89), and acute hydrocephalus (p = 0.048; OR = 1.74, 95% CI = 1.01–3.00) were independent risk factors for POP. In the SC group, multivariate analysis revealed that age (p = 0.015; OR = 1.03, 95% CI = 1.01–1.05), WFNS grade 4 or 5 (p = 0.037; OR = 1.76, 95% CI = 1.03–3.00), heart disease (p < 0.001; OR = 5.02, 95% CI = 2.03–12.45), higher white blood cell (WBC; p < 0.001; OR = 1.13, 95% CI = 1.07–1.20), and mFS grade 3 or 4 (p = 0.019; OR = 2.34, 95% CI = 1.15–4.77) were independent risk factors for POP.ConclusionPatients treated with SC are more likely to develop POP. Comprehensive preoperative evaluation of patients may help physicians to better predict POP and implement preventive measures to improve outcomes.

Treated cerebral aneurysms (IA) require follow-up imaging to ensure occlusion. Metal artifacts complicate radiologic assessment. Our aim was to evaluate an innovative metal-artifact-reduction (iMAR) algorithm for flat-detector computed tomography angiography (FD-CTA) regarding image quality (IQ) and detection of aneurysm residua/reperfusion in comparison to 2D digital subtraction angiography (DSA). Patients with IAs treated by endovascular coiling or clipping underwent both FD-CTA and DSA. FD-CTA datasets were postprocessed with/without iMAR algorithm (MAR+/MAR−). Evaluation of all FD-CTA and DSA datasets regarding qualitative (IQ, MAR) and quantitative (coil package diameter/CPD) parameters was performed. Aneurysm occlusion was assessed for each dataset and compared to DSA findings. In total, 40 IAs were analyzed (ncoiling = 24; nclipping = 16). All iMAR+ datasets demonstrated significantly better IQ (pIQ coiling < 0.0001; pIQ clipping < 0.0001). iMAR significantly reduced the metal-artifact burden but did not affect the CPD. iMAR significantly improved the detection of aneurysm residua/reperfusion with excellent agreement with DSA (naneurysm detection MAR+/MAR−/DSA = 22/1/26). The iMAR algorithm significantly improves IQ by effective reduction of metal artifacts in FD-CTA datasets. The proposed algorithm enables reliable detection of aneurysm residua/reperfusion with good agreement to DSA. Thus, iMAR can help to reduce the need for invasive follow-up in treated IAs. [ABSTRACT FROM AUTHOR]

• • All patients were followed up for more than 12 months and they received at least one postoperative computed tomography angiography and/or digital subtraction angiography. • •Duration of oculomotor nerve palsy before operation, oculomotor nerve palsy type and treatment modality were three independent relevant factors. • •We establish a score to assess the possibility of complete oculomotor nerve palsy recovery. To explore prognostic factors of complete recovery of oculomotor nerve palsy (ONP) induced by posterior communicating artery aneurysm (PcomAA). PcomAA patients aged 18–60 years combined with ONP who underwent surgical clipping or endovascular embolization at our institution between January 2014 and January 2020 were enrolled. Characteristics included maximum diameter of aneurysm, width of aneurysm, subarachnoid hemorrhage (SAH), duration of ONP, age, sex, ONP type, treatment method were compared. Based on the recovery of ONP, patients were separated into two groups: complete recovery group, partial and no recovery group. Analyzing by univariate and multivariate logistic regressions to identify the independent prognostics for complete ONP recovery. We established a score based on these prognostics. Receiver operating characteristics (ROC) were conducted to under the performance of the predictors and score. Finally, ONP type (OR 6.457 95% CI 1.664–25.052, p = 0.007), treatment method (OR 5.051, 95% CI 1.332–19.158, p = 0.017), and interval to treatment ≤2 weeks (OR 25.601 95% CI 6.222–105.340, p < 0.001) were independent predictors of complete ONP recovery. The score had an area under the curve (AUC) value of 0.870. We defined that the score higher than 5 points as easier to achieve complete ONP recovery, and the AUC value of this definition was 0.821. For ONP induced by PcomAA in patients aged 18–60 years, the best prognostic factor for complete ONP recovery was timely treatment. The ONP type and treatment methods were correlated with complete ONP recovery. [ABSTRACT FROM AUTHOR]

Whether the best management of middle cerebral artery (MCA) aneurysm patients is surgical or endovascular remains uncertain, with little evidence to guide decision-making. A randomized care trial offering MCA aneurysm patients a 50% chance of surgical and a 50% chance of endovascular management may optimize outcomes in the presence of uncertainty. The Middle Cerebral Artery Aneurysm Trial (MCAAT) is an investigator-initiated, multicenter, parallel group, prospective, 1:1 randomized controlled clinical trial. All adult patients with MCA aneurysms, ruptured or unruptured, amenable to surgical and endovascular treatment can be included. The composite primary outcome is "Treatment Success": (i) occlusion or exclusion of the aneurysm using the allocated treatment modality; (ii) no intracranial hemorrhage during follow-up; (iii) no retreatment of the target aneurysm during follow-up, (iv) no residual aneurysm on angiographic follow-up; and (v) independence (mRS <3) at 1 year. The trial tests 2 versions of the same hypothesis (one for ruptured and one for unruptured MCA aneurysm patients): Surgical management will lead to a 15% absolute increase in the proportion of patients reaching Treatment Success from 55% to 70% (ruptured) or from 75% to 90% (unruptured aneurysm patients) compared with endovascular treatment (any method). In this pragmatic trial, outcome evaluations are by treating physicians, except for 1-year angiographic results which will be core lab assessed. The trial will be monitored by an independent data safety monitoring committee to assure safety of participants. MCAAT is registered at clinicaltrials.gov: NCT05161377. Patients with MCA aneurysms can be optimally managed within a care trial protocol. [ABSTRACT FROM AUTHOR]

BackgroundArterial vasospasm has been ascribed as the responsible etiology of delayed cerebral infarction in patients with aneurysmal subarachnoid hemorrhage (aSAH), but other neurovascular structures may be involved. We present the protocol for a multicenter, prospective, observational study focused on analyzing morphological changes in cerebral veins of patients with aSAH.Methods and AnalysisIn a retrospective arm, we will collect head arterial and venous CT angiograms (CTA) of 50 patients with aSAH and 50 matching healthy controls at days 0–2 and 7–10, comparing morphological venous changes. A multicenter prospective observational study will follow. Patients aged ≥18 years of any gender with aSAH will be enrolled at 9 participating centers based on the predetermined eligibility criteria. A sample size of 52 aSAH patients is expected, and 52 healthy controls matched per age, gender, and comorbidities will be identified. For each patient, sequential CTA will be conducted upon admission (day 0–2), at 7–10 days, and at 14–21 days after aSAH, evaluating volumes and morphology of the cerebral deep veins and main cortical veins. One specialized image collecting center will analyze all anonymized CTA scans, performing volumetric calculation of targeted veins. Morphological venous changes over time will be evaluated using the Dice coefficient and the Jaccard index and scored using the Boeckh–Behrens system. Morphological venous changes will be correlated to clinical outcomes and compared between patients with aSAH and healthy-controls, and among groups based on surgical/endovascular treatments for aSAH.Ethics and DisseminationThis protocol has been approved by the ethics committee and institutional review board of Ethikkommission, SALK, Salzburg, Austria, and will be approved at all participating sites. The study will comply with the Declaration of Helsinki. Written informed consent will be obtained from all enrolled patients or their legal tutors. We will present our findings at academic conferences and peer-reviewed journals.Approved Protocol Version and RegistrationVersion 2, 09 June 2021.

A 59-year-old female with recurrent Anterior Choroidal Artery (AchA) aneurysm was elected for surgery at our institution through a standard pterional approach. Two thin perforating branches were found to origin from the dome of the aneurysm during operation, and therefore complete aneurysm clipping preserving these branches was not feasible. These perforating branches were temporarily occluded under motor-evoked potential (MEP) monitoring. The MEPs remained stable during 10 min of temporary clipping, and we concluded that these branches could be sacrificed, and therefore neck clipping was performed occluding these tiny AchA perforators. Although postoperative magnetic resonance imaging with diffusion-weighted images showed ischemic signs in left AchA territory after the operation, the patient remained asymptomatic and was discharged home with mRS 0. [ABSTRACT FROM AUTHOR]

Background/Aim: There is no consensus on the optimal treatment for intracranial aneurysm rupture due to subarachnoid hemorrhage (SAH). In this study, we analyzed a series of ruptured intracranial aneurysms treated with the clipping method at our center. Methods: In this retrospective cohort study; we searched our patient database for patients who developed SAH due to ruptured intracranial aneurysm treated at the Neurosurgery Clinic of Sivas Cumhuriyet University. A total of 304 patients who underwent the clipping operation due to aneurysmal SAH between 2010 and 2020 were included in the study. Cases with aneurysmal SAH who underwent endovascular coiling which is consisted of 22 patients were excluded. Results: A significant inverse correlation was found between age and Glasgow coma scores (GCS) (r=-0.137, P=0.017). Hunt-Hess and Fisher grades increased significantly with increasing age (r=0.187, P<0.001 and r=0.185, P<0.001). The mean age of men was significantly lower than that of women (P=0.005). Aneurysms located in the anterior communicating artery were significantly more frequent in men than in women (P<0.001). There was no significant difference in the distribution of other aneurysm locations by gender (P>0.05). No significant differences were observed in GCS scores and Hunt-Hess and Fisher grades between genders (P>0.05). There were no significant effects of aneurysm locations on mortality (P>0.05). Conversely, GCS scores were significantly lower and Hunt-Hess and Fisher grades were significantly higher in the surviving group than in the deceased group (P<0.001). Conclusion: Our study presented the outcomes of patients treated in our clinic with surgical clipping. Based on our findings, we believe that surgical clipping is still a safe and valid treatment method. [ABSTRACT FROM AUTHOR]

Background: It is commonly believed that after successful clipping of unruptured cerebral aneurysms patients may be considered restored to normal life. Nonetheless, some 11% may develop stroke within a year of the procedure. Therefore the question arises as to whether this group of patients can be submitted to different medical procedures, including vaccination against COVID-19, which has been reported to incidentally elicit thromboembolic events, without the necessity of special precautions. Case presentation: A contribution to this debate was presented in the case-history of a 56-year-old woman who underwent clipping of 3 unruptured cerebral aneurysms and in whom CT 8 months postsurgery did not show any abnormalities. Fourteen months post procedure she developed headache, vomiting and hand numbness coincidentally with ChAdOx1 nCoV-19 vaccination. CT revealed a small hypodense region within the territory of the right middle cerebral artery (MCA). CT angiography demonstrated a gap in contrast enhancement of the MCA and of the left anterior cerebral artery (ACA), exactly at the sites corresponding to localization of the aneurysm clips. Conclusions: Following clipping of cerebral aneurysms, patients may be prone to developing stroke coincidental with anti-COVID-19 vaccination. They may require special care during the peri-vaccinate period. [ABSTRACT FROM AUTHOR]

Abstract Background Oculomotor nerve palsy (ONP) is a common symptom of posterior communicating artery aneurysm (PcomAA) that can lead to impaired eye movement and pupil dilation. Currently, surgical clipping and endovascular embolization are the two most popular treatment methods for PcomAA-induced ONP; however, the recovery outcome between the two methods remains to be elucidated. Methods In the present study, we thoroughly compared the pretreatment factors and recovery outcome of the two treatments on 70 patients with PcomAA-induced ONP. The patients were separated into two groups based on the treatment that was received. Pretreatment factors, including age, sex, time period between ONP onset and treatment, ONP type, aneurysm diameter, status of subarachnoid hemorrhage and aneurysm rupture were recorded for each individual patient. Recovery outcome of the patients was assessed over a 12-month period. Results No significant differences were observed in any of the analyzed factors. Importantly, we revealed a significantly higher full recovery rate for the patients receiving the surgical clipping treatment than the ones that received the endovascular embolization treatment. In addition, we showed that patients’ age was negatively correlated with the recovery extent in both treatment groups. Conclusions The outcome of our study suggests that surgical clipping might be a better option to treat PcomAA-induced ONP.

Wen-qiang Xin,1 Qi-qiang Xin,2 Xin-yu Yang1 1Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, Peoples Republic of China; 2Department of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, Jiangxi 330000, Peoples Republic of ChinaCorrespondence: Xin-yu YangDepartment of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, Peoples Republic of ChinaTel +86-18622766038Fax +86-02260362062Email yangxinyu@tmu.edu.cnBackground: Endovascular coiling and surgical clipping are routinely used to treat unruptured middle cerebral artery aneurysms (MCAAs). However, the optimal treatment for unruptured MCAAs is controversial. We aimed to systematically and comprehensively compare the clinical outcomes between endovascular coiling and surgical clipping for the treatment of MCAAs.Method: This meta-analysis retrieved academic articles comparing the clinical outcomes between endovascular coiling and surgical clipping for unruptured MCAAs from the Cochrane Library, Medline, PubMed, and EMBASE databases. The reference articles of the identified studies were carefully reviewed to ensure that all available articles were represented in the study. The meta-analysis was conducted in accordance with the acknowledged the prioritized reported items for systematic review and meta-analysis (PRISMA) guidelines.Results: A total of 6 studies, which enrolled a total of 789 participants, were included in our analysis. Of these 789 patients with MCAAs, 144 were assigned to an endovascular coiling group, and 645 were assigned to a surgical clipping group. Our results demonstrated that endovascular coiling was associated with a higher rate of retreatment (OR = 104.926; 95% CI: 12.931 to 851.379; P2, infarction, or bleeding.Conclusion: Although this study has inherent limitations, surgical clipping of unruptured MCAAs resulted in significantly higher complete aneurysm occlusion and GOS≥4 rates and was associated with a lower incidence of retreatment and complication, especially for postoperative thrombus without infarction. Therefore, the effect induced by surgical clipping of unruptured MCAAs remains superior to that induced by endovascular coiling; surgical clipping should be regarded as the first choice of treatment for unruptured MCAAs.Keywords: endovascular coiling, surgical clipping, unruptured cerebral aneurysms

Background: Tentorium resection and detachment from the oculomotor nerve are sometimes required for surgical clipping of unruptured posterior communicating artery (PCoA) aneurysms. Using T2-weighted 3D images, we aimed to identify the preoperative radiological features required to determine the necessity of these additional procedures., Methods: We reviewed 30 patients with unruptured PCoA aneurysms who underwent surgical clipping and preoperative simulation using T2-weighted 3D images for measurement of the distance between the tentorium and aneurysm. Aneurysms were classified into superior type (superior to the tentorium) and inferior type (inferior to the tentorium)., Results: Seven patients (23%) underwent tentorium resection; all had the inferior type (superior vs. inferior, 0% vs. 33%, p = 0.071). In the 21 patients with the inferior type, the distance from the tentorium to the aneurysmal neck was 2.2 ± 1.1 mm and 0.0 ± 0.5 mm without and with tentorium resection (p < 0.01), respectively. An optimal cutoff value of ≤ +0.84 mm was identified for tentorium resection (area under the curve (AUC) = 0.96). Furthermore, 17 patients (57%) showed tight aneurysm attachment to the oculomotor nerve; all had the inferior type (0% vs. 81%, p < 0.01). The distance from the aneurysm tip to the tentorium was 1.1 ± 1.2 mm and -1.7 ± 1.4 mm without and with attachment (p < 0.01). The optimal cutoff value was ≤ +0.45 mm (AUC = 0.92)., Conclusions: Measurement of the distance between the tentorium and aneurysmal neck or tip with T2-weighted 3D images is effective for preoperative simulation for surgical clipping of PCoA aneurysms., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Institutional Review Board (IRB) of National Cerebral and Cardiovascular Center issued approval IRB number: M30-13. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Nagano et al.)

Objective: Anterior choroidal artery (AChA) aneurysms account for 2%-5% of all intracranial aneurysms. Treatment considerations include microsurgical clipping, flow diversion, or coiling with or without adjunctive devices. AChA aneurysms pose challenges in treatment due to the origination of the aneurysm from the origin or proximal segment of the AChA. The AChA is particularly susceptible to vasospasm and occlusion during treatment with devastating neurological deficits, including hemiparesis, hemianesthesia, lethargy, neglect, and hemianopia. In this study, the authors performed a meta-analysis to quantify the outcomes and complication rates across treatment modalities for AChA aneurysms and to identify risk factors reported in the literature., Methods: The authors performed a systematic review of AChA aneurysms treated with surgical clipping, endovascular coiling, or flow diversion and reported in the PubMed, Embase, Scopus, and Cochrane search databases. Single-arm meta-analyses of the selected outcomes were performed in RStudio., Results: Literature review yielded 25 studies that met the inclusion criteria. In total, 1627 patients were included in the analysis, with 554 males, 1009 females, and 64 unspecified. The rate of any complication in the full cohort was 11.6%, with a rate of ischemic complications of 5.5% and a favorable recovery rate of 90.3% of all patients treated. In total, 1064 patients underwent surgical clipping, 443 were treated with coiling, and 120 patients with flow diversion. In clipped patients, the rate of total surgical complications was 17.6%, with an ischemic complication rate of 9.4%. The rate of good functional recovery, defined on the basis of a Glasgow Outcome Scale score of 4-5 or modified Rankin Scale score of 0-2, was 88.0%, and complete obliteration was achieved in 84.5% of surgically clipped aneurysms. The complication rate in coiled patients was 10.3%, with an ischemic complication rate of 3.0%. Good functional recovery was achieved in 88.6% of coiled patients and complete aneurysm obliteration in 74.1%. Flow diversion resulted in a complication rate of 1.3%, with 0.7% rate of ischemic complications. Good functional recovery was achieved in 98.4% of patients and complete aneurysm obliteration in 79.0% in the flow diversion group. Aneurysm morphological features that impacted the complication rate were also identified to augment quantitative data and to help guide treatment selection for AChA aneurysms., Conclusions: Flow diversion showed significantly lower total and ischemic complications and improved outcomes compared to clipping and coiling. There may be differences in outcomes between treatment types, especially when considering the varied patient presentations that guide treatment selection.