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Purposes: Braided and laser-cut stents both are efficacious and safe for coiling intracranial aneurysms. The study aimed to compare outcomes following braided stent-assisted coil embolization versus laser engraved stent-assisted coil embolization in 266 patients who were diagnosed with unruptured intracranial aneurysms of different types and locations. Methods: Patients with unruptured complex intracranial aneurysms underwent braided (BSE cohort, n = 125) or laser engraved (LSE cohort, n = 141) stent-assisted embolization. Results: The deployment success rate was higher for patients of the LSE cohort than those of the BSE cohort (140 [99%] vs. 117 [94%], p = 0.0142). Seventy-one (fifty-seven percentages) and 73 (52%) were coil embolization procedure success rates of the BSE and the LSE cohorts. Periprocedural intracranial hemorrhage was higher in patients of the BSE cohort than those of the LSE cohort (8 [6%] vs. 1 [1%], p = 0.0142). Four (three percentages) patients from the LSE cohort and 3 (2%) patients from the BSE cohort had in-stent thrombosis during embolization. Permanent morbidities were higher in patients of the LSE cohort than those of the BSE cohort (8 [6%] vs. 1 [1%], p = 0.0389). Higher successful procedures (76% vs. 68%) and fewer postprocedural intracranial hemorrhage (0% vs. 5%) and mortality (0% vs. 5%) were reported for patients of the BSE cohort in posterior circulation aneurysmal location than those of the LSE cohort. Laser engraved stent has fewer problems with deployment and may have better periprocedural and follow-up outcomes after embolization. Conclusions: Braided stent-assisted embolization should be preferred when the aneurysm is present in the posterior circulation.

This is an overview of the challenges associated with screening for asymptomatic intracranial aneurysms (ICA) in children with autosomal dominant polycystic kidney disease (ADPKD). ADPKD is the most common inherited kidney disease affecting 1 in 1,000 people. ICAs are an extra-kidney manifestation of ADPKD, and while the exact pathophysiology of how they develop is unknown, we know that they more commonly occur in the adult rather than paediatric population. ICAs can be found in up to 9-11.5% of adults with ADPKD, but ICA rupture remains a rare event in adults with an incidence of 0.04 per 100 patient years. ICA size is an important factor in determining the risk of aneurysm rupture and therefore affects the decision on intervention in asymptomatic adults. For some, unruptured aneurysms cause no clinical significance, but those that rupture can be associated with devastating morbidity and mortality. Therefore, if detected, the treatment for unruptured ICAs is usually endovascular coiling, alongside recognising the importance of preventative interventions such as hypertension management. There are, however, no current guidelines for either adult or paediatric patients with ADPKD supporting regular screening for asymptomatic ICAs, although there is a suggestion for individualised practice, for example, with those with a positive family history. The UK clinical guidelines for ADPKD in children make research recommendations due to a lack of published literature, which in itself indicates that ICA rupture is an extremely rare phenomenon in children.

BackgroundThe eCLIPs bifurcation remodelling system is a non-circumferential implant that bridges the neck from outside of a bifurcation aneurysm. The goal of the multicenter, post-marketing European eCLIPs Safety, FeasIbility, and Efficacy Study (EESIS), was to present the efficacy and safety results of the eCLIPs device after 365 days of follow-up.MethodsAll patients were to receive an eCLIPs in conjunction with coils. The study was conducted according to good clinical practices and included independent adjudication of safety and efficacy outcomes.ResultsTwenty patients were enrolled at four European centers. Mean age was 60 years (range 41–74) and aneurysms were located at the basilar tip (n=19) and carotid tip (n=1). Average aneurysm dome height was 6.0 mm (range 2.0–15.0). Mean neck length was 5.1 mm (range 2.6–8.5). The technical success rate was 90% (18 of 20). No major territorial strokes or deaths occurred between the index procedure and after 365 days of follow-up. Complete occlusion was achieved in 60% of patients (12 of 20 patients) and 67% of patients with an eCLIPs device (12 of 18) after 365 days of follow-up. Adequate occlusion (complete occlusion and neck remnant) was achieved in 80% of patients (16 of 20 patients) and 89% of patients with an eCLIPs device (16 of 18 patients) after 365 days of follow-up.ConclusionIn this small series, treatment with eCLIPs was feasible, safe, and efficacious, considering the challenging nature of the aneurysms.Trial registration numberClinicalTrials.govNCT02607501.

Intracranial aneurysms at the anterior communicating artery (AcomA) are associated with a higher rupture risk and a more challenging therapy since they are supplied with blood from both sides of the anterior vasculature. Since the standard imaging modality, i.e. digital subtraction angiography, involves the contrast agent injection into a single cerebral artery, this relationship cannot be satisfactorily considered in subsequent blood flow analysis based on the single-sided segmentation. In this study, we analysed five patients harbouring multiple intracranial aneurysms including those located at the AcomA. We virtually combined the segmentations from both sides into a single model and examined the influence on blood flow simulations based on different inlets: (1) only the left internal carotid artery, (2) only the right internal carotid artery and (3) both internal carotid arteries. Our results indicate a strong influence of the blood flow simulation for AcomA aneurysms as well as large differences between left and right side of the patient’s vasculature

Background Intracranial aneurysm rupture is the main cause of subarachnoid hemorrhage, leading to high disability and mortality. This study aimed to evaluate the clinical treatment effects of multiple overlapping stent-assisted coiling for complex intracranial aneurysms. Methods We conducted a randomized, controlled, single-blinded clinical trial among 168 patients diagnosed with complex intracranial aneurysms. Treatment allocation to either single stent (SS) group or multiple stent (MS) group was randomized at 1:1 ratio using a Web-based platform. The O’Kelly–Marotta (OKM) grading scale was used to evaluate the degree of aneurysm occlusion after operation and during follow-up. Good aneurysm occlusion was defined as OKM grade C–D. The modified Rankin Scale (mRS) was used to evaluate the neurological status and the clinical outcome of patients. Results Efficacy comparative analysis demonstrated that major recurrence of aneurysms was significantly reduced in the MS group (P = 0.012). In addition, the MS group displayed significantly reduced number of patients with mRS between 3 and 6 (P = 0.007) and increased number of patients with mRS between 0 and 1 (P = 0.034). Furthermore, the MS group showed increased percentage of patients with OKM grade C–D (P = 0.041). Compared with the SS group, the MS group exhibited decreased mortality (P = 0.037) and morbidity (P = 0.035). Conclusions Multiple overlapping stent-assisted coiling significantly improved the clinical treatment effects and provided a new method for complex intracranial aneurysms., Highlights Multiple overlapping stent-assisted coiling technique reduced the major recurrence of aneurysms compared with single stent.Multiple overlapping stent-assisted coiling improved neurological status of patients with aneurysms compared with single stent.Multiple stent-assisted coiling decreased the aneurysm occlusion after operation compared with single stent.Multiple overlapping stent-assisted coiling significantly improved the clinical treatment for complex intracranial aneurysms.

Purpose Intracranial aneurysm (IA) wall enhancement on post-contrast vessel wall magnetic resonance imaging (VW-MRI) is assumed to be a biomarker for vessel wall inflammation and aneurysm instability. However, the exact factors contributing to enhancement are not yet clarified. This study investigates the relationship between luminal enhancement and intra-aneurysmal flow behaviour to assess the suitability of VW-MRI as a surrogate method for determining quantitative and qualitative flow behaviour in the aneurysm sac. Methods VW-MRI signal is measured in the lumen of three patient-specific IA flow models and compared with the intra-aneurysmal flow fields obtained using phase-contrast magnetic resonance imaging (PC-MRI) and computational fluid dynamics (CFD). The IA flow models were supplied with two different time-varying flow regimes. Results Overall, the velocity fields acquired using PC-MRI or CFD were in good agreement with the VW-MRI enhancement patterns. Generally, the regions with slow-flowing blood show higher VW-MRI signal intensities, whereas high flow leads to a suppression of the signal. For all aneurysm models, a signal value above three was associated with velocity values below three cm/s. Conclusion Regions with lower enhancements have been correlated with the slow and high flow at the same time. Thus, further factors like flow complexity and stability can contribute to flow suppression in addition to the flow magnitude. Nevertheless, VW-MRI can qualitatively assess intra-aneurysmal flow phenomena and estimate the velocity range present in the corresponding region.

A brain aneurysm is a bulge in a blood vessel in the brain caused by a weakness in the blood vessel wall. Rupture causes subarachnoid haemorrhage, a subset of stroke with a poor prognosis. To prevent rupture, brain aneurysms can be treated preventively by neurosurgical treatment (clipping) or by an endovascular approach via the groin. In the first part of this thesis, we describe the current treatment risks of preventive aneurysm treatments. With a group of international aneurysm experts we developed two risk scores to better predict the risk of neurological complications. For this study, we collected data from 10 hospitals in Europe, North America, and Asia. Based on a combination of seven patient, aneurysm and treatment characteristics, the risk scores allow for a better individual assessment of the risk of complications. The treatment risks in our study are higher than in previous studies. This can be explained by differences in definitions. Earlier studies focused on complications with severe consequences (death or dependence), while we also included treatment complications causing non-permanent neurological deterioration. The second part of this thesis describes the quality-of-life (QoL) outcomes in patients with and without a preventive aneurysm treatment in the first year after diagnosis. We found that treated patients experienced more restrictions during their recovery period, but that their QoL gradually increased afterwards. For untreated patients, the greatest improvement in QoL occurred directly after visiting the aneurysm clinic. A passive coping style is the most important predictor of poor QoL outcomes in all aneurysm patients.

Numerical simulations have been extensively used in the past two decades for the study of intracranial aneurysms (IAs), a dangerous disease that occurs in the arteries that reach the brain. They may affect up to 10 % of the world's population, with up to 50 % mortality rate, in case of rupture. Physically, the blood flow inside IAs should be modeled as a fluid-solid interaction problem. However, the large majority of those works have focused on the hemodynamics of the intra-aneurysmal flow, while ignoring the wall tissue's mechanical response entirely, through rigid-wall modeling, or using limited modeling assumptions for the tissue mechanics. One of the explanations is the scarce data on the properties of IAs walls, thus limiting the use of better modeling options. Unfortunately, this situation is still the case, thus our present study investigates the effect of different modeling approaches to simulate the motion of an IA. We used three hyperelastic laws and two different ways of modeling the wall thickness and tissue mechanical properties -- one assumed that both were uniform while the other accounted for the heterogeneity of the wall by using a "hemodynamics-driven" approach in which both thickness and material constants varied spatially with the cardiac-cycle-averaged hemodynamics. Pulsatile numerical simulations, with patient-specific vascular geometries harboring IAs, were carried out using the one-way fluid-solid interaction solution strategy, in which the blood flow is solved and applied as the driving force of the wall motion. We found that different wall morphology models yield smaller absolute differences in the mechanical response than different hyperelastic laws. Furthermore, the stretch levels of IAs walls were more sensitive to the hyperelastic and material constants than the stress. These findings could be used to guide modeling decisions on IA simulations., Preprint submitted to the Journal of the Mechanical Behavior of Biomedical Materials, with 33 pages and 10 figures

We present an analysis tool for subgroup identification in medical research based on feature analysis. Our use case is intracranial aneurysms. In the tool, an aneurysm-of-interest’s most similar aneurysms within a database are found. Similarity is defined via user-selected parameters, which can be entirely arbitrary. Different interactive outputs and visualizations include a heatmap view and a graph, which give an intuitive feedback to support researchers in the consideration of research questions, which in the present use case often relate to rupture risk analysis. The tool was evaluated with a pilot study and phantom database and received favorable results for its requirements of reliability and appropriate and clear outputs.

Objective With the development of endovascular technique and devices, large and giant intracranial aneurysms are increasingly being managed by this less invasive method. Here we discuss our experience on managing such aneurysms via endovascular technique. Methods Retrospective data on 42 patients with large and giant intracranial aneurysms managed by endovascular techniques between September 2015 to December 2017 at our neurosurgery institute were included in this analysis. Results There were a total 42 patients with 9 giant and 33 large aneurysms in this study. Eight aneurysms were treated by parent vessel occlusion, 22 aneurysms with coils and rest 12 aneurysms were treated with stent assisted coiling. Following the procedure, Raymond class I occlusion was accomplished in 31 (73.8%) patients while class Ⅱ in 9 (21.4%) and class Ⅲ in 2 (4.8%) patients. Overall morbidity and mortality were 9.5% and 14.3% respectively and favorable outcome was seen in 80.9% patients. Significant correlation was observed with clinical outcome and initial neurological status. Conclusions The study indicates that endovascular intervention is a safe and effective method in managing large and giant intracranial aneurysms with lesser morbidity and mortality.

Background and purpose Flow diverters are considered as an essential tool in the stent-based treatment of complex intracranial aneurysms. We report here a subgroup analysis of the nationwide prospective DIVERSION study to investigate the safety and efficacy of the Silk flow diverter at 12 months follow-up. Methods We performed a subgroup analysis of patients included in the DIVERSION, a national prospective cohort study including all flow diverters placement between 2012 and 2014 in France, and treated with the Silk. The primary outcome was the morbi-mortality at 12 months, including death, morbidity event and aneurysm retreatment within 12 months post-treatment. All reported serious events were adjudicated by an independent Data Safety and Monitoring Board. Satisfactory occlusion was defined as 3 or 4 on Kamran's scale by an independent imaging core laboratory during follow-up. Results A total of 102 procedures involving 101 patients (mean age ± standard deviation, 54.3 ± 13.5 years) harbouring 118 aneurysms (113/118 located in the anterior circulation; mean size 8.2 ± 7.1 mm) were included. During the 12-month follow-up, 34 (33.3%) procedures experienced at least one morbi-mortality event: 3 deaths, 27 morbidity events and 4 retreatments. Overall, 1/3 deaths and 10/27 morbidity events were related to the device and/or the procedure, leading to a specific survival rate and a specific free-morbidity survival rate at 12 months of 98.98% [95% confidence interval, 92.98%–99.86%] and 89.73% [95%CI, 81.71%–94.36%], respectively. The rate of permanent-related neurological deficit was 5.9% within 12 months. One year follow-up imaging showed satisfactory occlusion in 82.2% of cases. Conclusion Flow diversion with the Silk device has a reasonable safety and effectiveness profile for the endovascular treatment of intracranial aneurysms.

Background: The role of regional hemodynamics in the intracranial aneurysmal formation, growth, and rupture has been widely discussed based on numerical models over the past decades. Variation of the circle of Willis (CoW), which results in hemodynamic changes, is associated with the aneurysmal formation and rupture. However, such correlation has not been further clarified yet. The aim of this systematic review is to investigate whether simulated hemodynamic indices of the CoW are relevant to the formation, growth, or rupture of intracranial aneurysm. Methods: We conducted a review of MEDLINE, Web of Science, and EMBASE for studies on the correlation between hemodynamics indices of the CoW derived from numerical models and intracranial aneurysm up to December 2020 in compliance with PRISMA guidelines. Results: Three case reports out of 1046 publications met our inclusion and exclusion criteria, reporting 13 aneurysms in six patients. Eleven aneurysms were unruptured, and the state of the other two aneurysms was unknown. Wall shear stress, oscillatory shear index, von-Mises tension, flow velocity, and flow rate were reported as hemodynamic indices. Due to limited cases and significant heterogeneity between study settings, meta-analysis could not be performed. Conclusion: Numerical models can provide comprehensive information on the cerebral blood flow as well as local flow characteristics in the intracranial aneurysm. Based on only three case reports, no firm conclusion can be drawn regarding the correlation between hemodynamic parameters in the CoW derived from numerical models and aneurysmal formation or rupture. Due to the inherent nature of numerical models, more sensitive analysis and rigorous validations are required to determine its measurement error and thus extend their application into clinical practice for personalized management. Prospero registration number: CRD42021125169.

Submitted by Iago Lessa de Oliveira (iago.oliveira@unesp.br) on 2022-06-29T18:45:40Z No. of bitstreams: 1 Thesis_Iago_Oliveira_FEIS_UNESP_Corrected_ABNT.pdf: 12502168 bytes, checksum: 5bcf91d6931e3b48d8a5ce1734345159 (MD5) Approved for entry into archive by Joao Josue Barbosa (joao.barbosa@unesp.br) on 2022-06-29T19:13:13Z (GMT) No. of bitstreams: 1 oliveira_il_dr_ilha.pdf: 12502168 bytes, checksum: 5bcf91d6931e3b48d8a5ce1734345159 (MD5) Made available in DSpace on 2022-06-29T19:13:13Z (GMT). No. of bitstreams: 1 oliveira_il_dr_ilha.pdf: 12502168 bytes, checksum: 5bcf91d6931e3b48d8a5ce1734345159 (MD5) Previous issue date: 2022-06-20 Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) Os aneurismas intracranianos (AIs) são dilatações nas artérias cerebrais, que podem ocasionar grande perigo caso elas rompam, causando hemorragia intracraniana e possivelmente levando à morte do paciente — AIs apresentam uma taxa de mortalidade de até 50 %. A ruptura, porém, é difícil de prever e, atualmente, os tratamentos cirúrgicos também apresentam riscos para o paciente. Simulações numéricas do escoamento dentro de AIs têm sido amplamente utilizadas para estudá-los devido à conexão entre hemodinâmica e o início, crescimento e ruptura dos aneurismas. Embora deva ser modelado como um problema de interação fluido-sólido (IFS), a maioria desses trabalhos se concentrou exclusivamente na hemodinâmica, ignorando completamente o movimento da parede, por meio de modelagem de parede rígida, ou usando modelos bastante limitadas. Uma possível explicação é a escassez de medidas experimentais das propriedades mecânicas do tecido e também da espessura da parede, o que limita o uso de melhores modelos. Consequentemente, poucos trabalhos investigaram o impacto dos differents modelos do tecido de AIs em sua resposta mecânica, o que seria importante para tentar prever a ruptura, pois este é um evento que, teoricamente, depende dos níveis de tensão. Neste contexto, este trabalho investigou a influência de diferentes leis hiperelásticas e da heterogeneidade das propriedades mecânicas e da espessura na resposta mecânica de uma amostra de AIs rompidos e não rompidos. Simulações numéricas com geometrias vasculares reais foram realizadas usando a técnica de IFS unidirecional, implementada no solids4foam, uma extensão do OpenFOAM ® , na qual o escoamento é resolvido e aplicado como força motriz do movimento da parede. Diferentes modelos de morfologia de parede tiveram menor influência na resposta mecânica do que diferentes leis hiperelásticas. Também foi encontrado que os níveis de deformação foram mais sensíveis às leis hiperelásticas e propriedades do material do que a tensão de Cauchy, especialmente para os AIs rompidos, permitindo a identificação destes pelos níveis de deformação mais elevados ao invés da tensão. Além disso, a variável morfológica que melhor se correlacionou com regiões de alta tensão e deformação foi a curvatura da parede. Finalmente, essas descobertas podem ser usadas para orientar as decisões de modelagem em simulações com AIs e também sugerir novas métricas baseadas na curvatura da parede para prever a probabilidade de ruptura. Intracranial aneurysms (IAs) are abnormalities formed in the cerebral arteries characterized by outpouching regions of their walls. The danger with these lesions occurs if they rupture, which causes intracranial hemorrhage and possibly leads to the death of the patient, presenting a mortality rate as high as 50 %. The rupture event is hard to predict, though, and, currently, surgical treatments also pose risks to the patient. Numerical simulations of the blood flow inside IAs have been extensively used to study them because of the well-known connections between hemodynamics and their inception, growth, and rupture. Physically, although it should be modeled as a Fluid-Solid Interaction (FSI) problem, the majority of those works have solely focused on the hemodynamics while either ignoring the wall tissue motion entirely, through rigid-wall modeling, or using limited assumptions for it. One possible explanation is the scarcity of measurements of their wall mechanical properties and also its thickness, which limits the use of better modeling options. Consequently, few works have investigated the impact of tissue modeling on their mechanical response, an important endeavor to try to predict the likelihood of rupture, because it is a wall-exclusive event that theoretically depends on the level of stress. In this context, this work investigated the influence of different hyperelastic laws and the material properties and thickness heterogeneity on the wall mechanics of IAs, given their rupture status. Pulsatile numerical simulations with patient-specific vascular geometries harboring IAs were carried out using the one-way fluid-solid interaction solution strategy implemented in solids4foam, an extension of OpenFOAM®, in which the blood flow is solved and applied as the driving force of the wall motion. First, it was found that different wall morphology models yielded smaller absolute differences in the mechanical response than different hyperelastic laws. Second, the stretch levels of IAs walls were more sensitive to the hyperelastic laws and material constants than the stress, especially for ruptured IAs, allowing the identification of these by the higher stretch levels instead of stress levels. Additionally, the morphology variable that best correlated with regions of high stress and stretch was the wall curvature. Finally, these findings could be used to guide modeling decisions on IA simulations and also suggest new metrics based on the wall curvature to predict the likelihood of rupture. FAPESP: 2017/18514-1 FAPESP: 2019/19098-7

Previous case series have described the safety and efficacy of different stent models for stent-assisted aneurysm coiling (SAC), but comparative analyses of procedural results are limited. This study investigates the procedural outcome and safety of three different stent models (Atlas™, LEO+™ (Baby) and Enterprise™) in the setting of elective SAC treated at a tertiary neuro-endovascular center. We retrospectively reviewed all consecutively treated patients that received endovascular SAC for intracranial aneurysms between 1 July 2013 and 31 March 2020, excluding all emergency angiographies for acute subarachnoid hemorrhage. The primary procedural outcome was the occlusion rate evaluated with the Raymond–Roy occlusion classification (RROC) assessed on digital subtraction angiography (DSA) at 6- and 12-month follow-up. Safety assessment included periprocedural adverse events (i.e., symptomatic ischemic complications, symptomatic intracerebral hemorrhage, iatrogenic perforation, dissection, or aneurysm rupture and in-stent thrombosis) and in-house mortality. Uni- and multivariable logistic regression analyses were performed to identify patient baseline and aneurysm characteristics that were associated with complete aneurysm obliteration at follow-up. A total of 156 patients undergoing endovascular treatment via SAC met the inclusion criteria. The median age was 62 years (IQR, 55–71), and 73.7% (115) of patients were female. At first follow-up (6-month) and last available follow-up (12 and 18 months), complete aneurysm occlusion was observed in 78.3% (90) and 76.9% (102) of patients, respectively. There were no differences regarding the occlusion rates stratified by stent model. Multivariable logistic analysis revealed increasing dome/neck ratio (adjusted odds ratio (aOR), 0.26.; 95% CI, 0.11–0.64; p = 0.003), increasing neck size (aOR, 0.70; 95% CI, 0.51–0.96; p = 0.027), and female sex (aOR, 4.37; 95% CI, 1.68–11.36; p = 0.002) as independently associated with treatment success. This study showed comparable rates of complete long-term aneurysm obliteration and safety following SAC for intracranial aneurysm with three different stent-models highlighting the procedural feasibility of this treatment strategy with currently available stent-models. Increased neck size and a higher dome/neck ratio were independent variables associated with less frequent complete aneurysm obliteration.

Objectives The number of original scientific researches on intracranial aneurysms has risen over the last 30 years. Despite the rise in the number of articles, there is no up-to-date exhaustive bibliometric research in the literature. This study aimed to contribute to the literature via a bibliometric analysis of the original scientific researches on intracranial aneurysms published over the last 30 years. Methods The literature review was done using the Web of Science. All articles and its citations containing aneurysm keywords were analyzed in the "title" section of articles published in the research areas: Neurosciences Neurology during 1980–2019. Correlation analyses between the number of articles produced by the countries and their economic and development indicators of gross domestic product, and Human Development Index were analyzed using the Spearman correlation coefficient. Linear regression analysis was utilized to estimate the number of articles to be published in the future. Results There were a total of 21,673 publications on intracranial aneurysms. Of these publications, 13,371 (61.7%) were articles. The three countries that produced the most articles were the USA (4098), Japan (2668), and China (937). A statistically significant correlation was found between the development indicators of world countries and publication productivity ( pConclusion This bibliometric study provides a collection of data that will help design future research on intracranial aneurysms more efficiently and make innovations at greater speed.

Peng Qi,1 Xin Feng,2 Jun Lu,1 Junjie Wang,1 Shen Hu,1 Daming Wang2 1Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China; 2Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China; Graduate School of Peking Union Medical College, Beijing, People’s Republic of ChinaCorrespondence: Daming WangGraduate School of Peking Union Medical College, No. 9 Dongdansantiao, Dongcheng District, Beijing, 100730, People’s Republic of ChinaTel +86 10-85136281Fax +86 10-85132621Email daming2000@263.comObjective: It remains unclear whether irregular morphological features of intracranial aneurysms (IAs) are associated with atherosclerosis. We investigated the effect of cerebrovascular atherosclerosis stenosis (CAS) on irregular morphology of IAs.Patients and Methods: This single-center case-control study included consecutive patients with IAs at our institution from September 2011 to September 2018. Cases were patients with irregular IAs, and age- and location-matched controls were patients with regular IAs. Conditional logistic regression models were used to assess the relationship between angiographic variables of CAS and aneurysmal irregularity.Results: A total of 140 cases of irregular IAs and 140 controls were included in the analysis. Sixteen patients with irregular IAs (11.4%) and eleven patients with regular IAs (7.9%) had > 50% parent artery stenosis; however, the differences were not statistically significant between these two groups. In addition, no significant between-group differences were observed in distributions of the cerebrovascular stenosis, number of arterial stenoses, and location of the stenosis. In the final adjusted conditional logistic regression model, only aneurysm size (≥ 7 mm) was significantly associated with irregular IA morphology (P = 0.022). Moreover, 89 cases of irregular IAs and 89 controls were included in the analysis of unruptured IAs (UIAs). In the final adjusted conditional logistic regression model, only aneurysm size (≥ 7 mm) was significantly associated with irregular UIA morphology (P = 0.020).Conclusion: Our findings indicate that the morphological irregularity of unruptured intracranial aneurysms is more related with aneurysm size rather than cerebrovascular atherosclerosis. Further studies are needed to use prospective data to identify causative factors responsible for aneurysmal irregularity.Keywords: atherosclerotic stenosis, intracranial aneurysms, irregular morphology, risk factors, aneurysm size

Peng Qi,1 Xin Feng,2 Jun Lu,1 Junjie Wang,1 Shen Hu,1 Daming Wang2 1Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China; 2Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China; Graduate School of Peking Union Medical College, Beijing, People’s Republic of ChinaCorrespondence: Daming WangGraduate School of Peking Union Medical College, No. 9 Dongdansantiao, Dongcheng District, Beijing, 100730, People’s Republic of ChinaTel +86 10-85136281Fax +86 10-85132621Email daming2000@263.comObjective: It remains unclear whether irregular morphological features of intracranial aneurysms (IAs) are associated with atherosclerosis. We investigated the effect of cerebrovascular atherosclerosis stenosis (CAS) on irregular morphology of IAs.Patients and Methods: This single-center case-control study included consecutive patients with IAs at our institution from September 2011 to September 2018. Cases were patients with irregular IAs, and age- and location-matched controls were patients with regular IAs. Conditional logistic regression models were used to assess the relationship between angiographic variables of CAS and aneurysmal irregularity.Results: A total of 140 cases of irregular IAs and 140 controls were included in the analysis. Sixteen patients with irregular IAs (11.4%) and eleven patients with regular IAs (7.9%) had > 50% parent artery stenosis; however, the differences were not statistically significant between these two groups. In addition, no significant between-group differences were observed in distributions of the cerebrovascular stenosis, number of arterial stenoses, and location of the stenosis. In the final adjusted conditional logistic regression model, only aneurysm size (≥ 7 mm) was significantly associated with irregular IA morphology (P = 0.022). Moreover, 89 cases of irregular IAs and 89 controls were included in the analysis of unruptured IAs (UIAs). In the final adjusted conditional logistic regression model, only aneurysm size (≥ 7 mm) was significantly associated with irregular UIA morphology (P = 0.020).Conclusion: Our findings indicate that the morphological irregularity of unruptured intracranial aneurysms is more related with aneurysm size rather than cerebrovascular atherosclerosis. Further studies are needed to use prospective data to identify causative factors responsible for aneurysmal irregularity.Keywords: atherosclerotic stenosis, intracranial aneurysms, irregular morphology, risk factors, aneurysm size

Purpose For the evaluation and rupture risk assessment of intracranial aneurysms, clinical, morphological and hemodynamic parameters are analyzed. The reliability of intracranial hemodynamic simulations strongly depends on the underlying models. Due to the missing information about the intracranial vessel wall, the patient-specific wall thickness is often neglected as well as the specific physiological and pathological properties of the vessel wall. Methods In this work, we present a model for structural simulations with patient-specific wall thickness including different tissue types based on postmortem histologic image data. Images of histologic 2D slices from intracranial aneurysms were manually segmented in nine tissue classes. After virtual inflation, they were combined into 3D models. This approach yields multiple 3D models of the inner and outer wall and different tissue parts as a prerequisite for subsequent simulations. Result We presented a pipeline to generate 3D models of aneurysms with respect to the different tissue textures occurring in the wall. First experiments show that including the variance of the tissue in the structural simulation affect the simulation result. Especially at the interfaces between neighboring tissue classes, the larger influence of stiffer components on the stability equilibrium became obvious. Conclusion The presented approach enables the creation of a geometric model with differentiated wall tissue. This information can be used for different applications, like hemodynamic simulations, to increase the modeling accuracy.

Background and purpose Flow diverters are increasingly used to treat intracranial aneurysms. We report the safety and efficacy of the p64 flow diverter, a resheathable and detachable device for intracranial aneurysms. Materials and methods We retrospectively reviewed 108 patients with 109 aneurysms treated with the p64 between March 2014 and July 2019. There were 87 women and 21 men, mean age 57 years. Of 109 aneurysms, 74 were discovered incidentally, 12 were symptomatic, 18 were previously treated, and five were ruptured dissection aneurysms. A total of 10 aneurysms were located in the posterior circulation. The mean aneurysm or remnant size was 8.1 mm. Results Hemorrhage by perforation with the distal guidewire occurred in two patients with permanent neurological deficits in one. In one patient, acute in-stent occlusion caused infarction with a permanent deficit. Permanent morbidity was 1.9% (2 of 108, 95%CI 0.1–6.9%); there was no mortality. During follow-up, three in-stent occlusions occurred, all asymptomatic. There were no delayed hemorrhagic complications. At six months, 77 of 96 aneurysms (80.2%) were completely occluded, and at last follow-up, this increased to 93 of 96 aneurysms (96.9%). In-stent stenosis at any degree occurred in 11 patients, progressing to asymptomatic complete occlusion in one. In the other patients, stenosis resolved or improved at further follow-up. Conclusion The p64 offers an effective and safe treatment option. Aneurysm occlusion rate was 97% at last follow-up, mostly achieved with a single device. There were no delayed hemorrhagic complications. Delayed in-stent stenosis infrequently progresses to occlusion but remains a matter of concern.

Blood blister-like aneurysms (BBAs) are rare and usually appear at nonbranching sites in the supraclinoid portion of the internal carotid artery (ICA). Because it is difficult to obtain histological specimens of the aneurysm wall and because experimental models are challenging to establish, the pathogenesis of BBAs remains uncertain. In this paper, we reviewed the diagnostic, radiological, and pathophysiological characteristics of patients with BBAs. We also summarized the existing evidence and potential mechanisms related to the causes of BBAs. Current evidence indicates that atherosclerosis and dissection are the main prerequisites for the formation of BBAs. Hemodynamics may play a role in the process of BBA formation due to the unique vascular anatomy of the supraclinoid ICA. Further research on histopathology and hemodynamics is warranted in this field.

Testosterone is often used to improve the physiological function. But increased testosterone levels affect blood lipids and cause inflammation and oxidative stress, which are risk factors for vascular diseases. This study aimed at investigating the effects of testosterone on cerebral vascular injury using an established intracranial aneurysm (IA) model. Sixteen-week-old female C57Bl/6 mice were subcutaneously infused with testosterone propionate (TP; 5 mg/kg day) or plain soybean oil (controls) for 6 weeks. After 2 weeks of treatment, mice were given angiotensin II-elastase for another 4 weeks. The results showed that TP significantly increased cell apoptosis and reactive oxygen species production in cerebral artery, together with increases in plasma tumor necrosis factor-α (TNF-α) levels and in urinary 8-isoprostane levels. Plasma assays showed that 2 weeks after TP or soybean oil administration, the high-density lipoprotein (HDL) level was higher in the TP group than in controls. In vitro studies showed that testosterone increased TNF-α and monocyte chemotactic protein-1 mRNA and protein expression levels in RAW 264.7 macrophages. In summary, by reducing the HDL level, TP aggravates cerebral artery injury by increasing cell apoptosis, inflammation, and oxidative stress.

Background: The role of regional hemodynamics in the intracranial aneurysmal formation, growth, and rupture has been widely discussed based on numerical models over the past decades. Variation of the circle of Willis (CoW), which results in hemodynamic changes, is associated with the aneurysmal formation and rupture. However, such correlation has not been further clarified yet. The aim of this systematic review is to investigate whether simulated hemodynamic indices of the CoW are relevant to the formation, growth, or rupture of intracranial aneurysm. Methods: We conducted a review of MEDLINE, Web of Science, and EMBASE for studies on the correlation between hemodynamics indices of the CoW derived from numerical models and intracranial aneurysm up to December 2020 in compliance with PRISMA guidelines. Results: Three case reports out of 1046 publications met our inclusion and exclusion criteria, reporting 13 aneurysms in six patients. Eleven aneurysms were unruptured, and the state of the other two aneurysms was unknown. Wall shear stress, oscillatory shear index, von-Mises tension, flow velocity, and flow rate were reported as hemodynamic indices. Due to limited cases and significant heterogeneity between study settings, meta-analysis could not be performed. Conclusion: Numerical models can provide comprehensive information on the cerebral blood flow as well as local flow characteristics in the intracranial aneurysm. Based on only three case reports, no firm conclusion can be drawn regarding the correlation between hemodynamic parameters in the CoW derived from numerical models and aneurysmal formation or rupture. Due to the inherent nature of numerical models, more sensitive analysis and rigorous validations are required to determine its measurement error and thus extend their application into clinical practice for personalized management. Prospero registration number: CRD42021125169.

Background The novel low-profile p48 flow diverter has been designed to treat aneurysms on small vessels of 1.75–3mm. We report our first clinical experiences. Methods Between March 2018–January 2020, 22 patients with 25 aneurysms were treated with the p48 in 3 centers. One patient had 3 aneurysms covered by one p48 and one patient had 2 aneurysms. There were 5 men, 17 women, with a mean age of 55 years (median 59, range 29–73 years). Results In 25 aneurysms, 24 p48 flow diverters were placed. In 1 patient additional coils were placed in the aneurysm. Procedural vessel rupture by the micro guidewire occurred in 2 patients and vessel rupture during p48 balloon dilatation occurred in 1 patient. Overall, the permanent morbidity rate was 13.6% (3 of 22, 95%CI 3.9–34.2%) and mortality was 4.5% (1 of 22, 95%CI Conclusions Treatment of aneurysms in small-caliber vessels with the p48 is feasible and effective but is not without complications. More data is needed to establish indications, safety, and efficacy more accurately.

Intracranial aneurysms rapture is a common cause of mortality or morbidity worldwide. For this reason, in case of rupture, early treatment of the aneurysm is mandatory. The evaluation of unruptured intracranial aneurysms continue to increased due to the improvements in invasive and non-invasive neuroimaging. Securing of this life-threatening condition, considering all demographical and procedural factors is necessary for improving treatment results and patients outcome. The endovascular treatment has become frontline therapy of cerebral aneurysms treatment during the last 20 years, and without a doubt its recent advances shifted this boundary even further. Nowadays endovascular armamentarium continues to grow rapidly. Neuro-interventional procedures have tremendously improved their efficiency and continue to improve device’s safety. However some types of aneurysms are not really easy to treat with ordinary endovascular technique as it can result in devastating consequence, Firstly, it is not always applicable to complex aneurysms or very large neck aneurysms. Secondly, durability of the of the aneurysm occlusion is not guaranteed in all cases even after usage of the remodeling technique or regular stenting. New devices are introduced to decrease these limits. Two new innovative techniques that are increasingly used for endovacular occlusion of the complex aneurysms are flow diversion and intrasaccular flow disruption. The objective of this review is to provide a comprehensive overview of novel paradigms and latest research of flow diversion and intrasaccular flow disruption devices, its current application, limitation and future prospective. The obvious advantages of these new technologies proved progressive expansion of their utilization to the extent that they will ultimately replace standard coiling in an increasing number of cases going forward. The future of the endovascular treatment of intracranial aneurysms is bright. Fast gro-wing improvement in vascular access, treatment modalities and device delivery continue to increase number of patients with intracranial aneurysms treated with endovascular approach versus surgical clipping.

Background The present study aims to investigate the complete long non-coding RNA (lncRNA) and messenger RNA (mRNA) expression profiles in Intracranial aneurysm (IA) patients and controls by RNA sequencing, which reveals the lncRNA with predictive value for IA risk. Methods The comprehensive lncRNA and mRNA expression profiles were detected by RNA-Seq in human IA walls and superficial temporal arteries (STAs), followed by bioinformatics analyses, such as GO analysis, KEGG pathway analysis, and CNC network construction. Subsequently, qRT-PCR was used to profile the expression levels of selected lncRNA (lncRNA ENST000000576153, lncRNA ENST00000607042, lncRNA ENST00000471220, lncRNA ENST00000478738, lncRNA MALAT1, lncRNA ENST00000508090 and lncRNA ENST00000579688) in 30 (small) or 130 (large) peripheral blood leukocytes, respectively. Multivariate logistic regression was utilized to analyze the effects of lncRNA on IA. Receiver operating characteristic (ROC) curve was further drawn to explore the value of lncRNA in predicting IA. Results Totally 900 up-regulated and 293 down-regulated lncRNAs, as well as 1297 up-regulated and 831 down-regulated mRNAs were discovered in sequencing. Enrichment analyses revealed that they were actively involved in immune/inflammatory response and cell adhesion/extracellular matrix. Co-expression analysis and further enrichment analyses showed that five candidate lncRNAs might participate in IA’s inflammatory response. Besides, after controlling other conventional risk factors, multivariate logistic regression analysis disclosed that low expression of lncRNA ENST00000607042, lncRNA ENST00000471220, lncRNA ENST00000478738, lncRNA MALAT1 in peripheral blood leukocytes were independent risk factors for IA. LncRNA ENST00000607042 has superior diagnostic value for IA. Conclusions This study reveals the complete lncRNAs expression profiles in IA. The inflammatory response was closely related to IA. Besides, lncRNA ENST00000607042 might be a novel biomarker for IA risk.

Background and purpose The PHASES score was formulated to predict the 5-year risk of rupture for intracranial aneurysms. We retrospectively analyzed all patients treated in our institution for aneurysmal SAH and applied the PHASES score to estimate the probable predicted risk of bleeding in this group of patients. Methods Between February 2015 and August 2018, all patients with aneurysmal SAH were retrospectively analyzed and the PHASES score was applied. A total of 155 patients were included with a mean age of 53.8 years, including 60 males and 95 females. Results Of our patients 110 (70.9%) had a PHASES score of below or equal to 5, with a hemorrhagic risk of up to 1.3% over 5 years. If we analyze the patients with a risk of below 2% this figure increases to 122 patients (78.7%). Of these 99.3% were European and 0.6% were Japanese (1 patient). In 86 patients (55.4%), the aneurysm was smaller than 5 mm and in 10 patients (6.4%) the aneurysm was located in the posterior circulation. Conclusion Of our patients 78.7% had less than a 2% 5-year rupture risk based on their PHASES score, highlighting the discrepancy of the rupture risk calculated with the PHASES score when hypothetically applied to this group of patients. In the hypothetical scenario that our patients had unruptured aneurysms, our retrospective analysis shows that the PHASES score may only provide a weak tool for clinicians to use in the decision-making process as to whether or not to treat these aneurysms.

Purpose Medical case-based reasoning solves problems by applying experience gained from the outcome of previous treatments of the same kind. Particularly for complex treatment decisions, for example, incidentally found intracranial aneurysms (IAs), it can support the medical expert. IAs bear the risk of rupture and may lead to subarachnoidal hemorrhages. Treatment needs to be considered carefully, since it may entail unnecessary complications for IAs with low rupture risk. With a rupture risk prediction based on previous cases, the treatment decision can be supported. Methods We present an interactive visual exploration tool for the case-based reasoning of IAs. In presence of a new aneurysm of interest, our application provides visual analytics techniques to identify the most similar cases with respect to morphology. The clinical expert can obtain the treatment, including the treatment outcome, for these cases and transfer it to the aneurysm of interest. Our application comprises a heatmap visualization, an adapted scatterplot matrix and fully or partially directed graphs with a circle- or force-directed layout to guide the interactive selection process. To fit the demands of clinical applications, we further integrated an interactive identification of outlier cases as well as an interactive attribute selection for the similarity calculation. A questionnaire evaluation with six trained physicians was used. Result Our application allows for case-based reasoning of IAs based on a reference data set. Three classifiers summarize the rupture state of the most similar cases. Medical experts positively evaluated the application. Conclusion Our case-based reasoning application combined with visual analytic techniques allows for representation of similar IAs to support the clinician. The graphical representation was rated very useful and provides visual information of the similarity of the k most similar cases.

Intracranial aneurysms (IAs) are most commonly found at the branch points of large arteries that form the circle of Willis. The prevalence of IAs in the adult population is 1–5%. IAs rupture is associated with subarachnoid haemorrhage (SAH) in 6–8 cases per 100 000 population, causing mortality in 40–50%. Aneurysm treatment is used to prevent rupture or rebleeding (for ruptured IAs). Randomised trials demonstrated the superiority of endovascular treatment (EVT) of ruptured aneurysms with coil systems over surgery. The objective of the study was to evaluate the effectiveness of the Barricade coil system in the treatment of intracranial aneurysms. Detachable platinum coils, since their introduction 25 years ago, have become the first choice EVT method for ruptured and unruptured IAs and have shown acceptable mortality (~2%). The retrospective study of intracranial aneurysms treated with the Barricade coil system at Pauls Stradiņš Clinical University Hospital (Rīga, Latvia) conducted in a 20-month period included 95 patients and 97 IAs. Thirty-one (32.6%) males and 64 (67.4%) females with median age 56 ± 15 years underwent endovascular treatment. The minority, 22 (23.16%) patients, were asymptomatic, while 73 (76.84%) patients had neurological symptoms directly associated with aneurysm progression and SAH development. Preoperatively, 52 (53.6%) aneurysms were ruptured, causing SAH, and 24 (25.26%) patients with unruptured IAs had neurological symptoms. Sixty-four (66.0%) IAs were treated using coils without neurovascular stent implantation or balloon assistance, 22 (22.7%) — with coils and stent implantation, and 11(11.3%) aneurysms were embolised with balloon-assisted coiling. The immediate anatomical result of endovascular treatment of IAs and technical success of aneurysm coiling was evaluated using the simplified Raymond scale. In the majority of cases, complete occlusion of the aneurysm was achieved while residual neck of the aneurysm or aneurysm remnant was uncommon. Immediate clinical results were evaluated using the modified Rankin scale (mRs). The majority of patients had favourable immediate clinical outcome (mRs 0–2), but four (4.21%) patients died in 1–6 days after the procedure as a consequence of SAH. In 72 (75.79%), patients no new neurological pathological symptoms developed 2–3 days after endovascular procedure and they were discharged from the hospital. Intraprocedural complications occurred in 4 (4.21%) cases. Technical issues occurred in two (2.1%) patients. In 19 (20%) patients, neurological symptoms remained even after the procedure, six (6.32%) patients had clinical worsening, and we had one case of procedural related mortality. Six-month follow-up evaluation was performed for 58 (61.0%) patients (59 IAs). In the majority of cases, complete occlusion of the aneurysm and favourable clinical outcome (mRs 0–2) was observed. Our experience showed that the treatment of ruptured and unruptured intracranial aneurysms with the Barricade coil system is feasible, effective, clinically safe and has a low risk of intraprocedural complications.

Coil embolization has become a well-established option for the treatment of intracranial aneurysms. Yet, wide-neck bifurcation aneurysms (WNBAs) remain a challenge. The pCONUS is the first generation of a stent-like implant for the bridging of WNBAs to enable coiling. The pToWin study was a prospective, single-arm, multicenter study conducted to analyze the safety and efficacy of the pCONUS in the treatment of WNBAs. The primary effectiveness endpoint was the rate of adequate occlusion of the aneurysm at 3–6 and 7–12 months. The primary safety endpoint was the occurrence of major ipsilateral stroke or neurological death during the follow-up. A total of 115 patients were included. Aneurysm locations were the middle cerebral artery in 52 (45.2%), the anterior communicating artery in 35 (30.4%), the basilar artery in 23 (20%), the internal carotid artery terminus in three (2.6%), and the pericallosal artery in two (1.7%) patients. Treatment was successfully performed in all but one patient. The morbi-mortality rate was 1.9% and 2.3% at 3–6 and 7–12 months, respectively. Of the aneurysms, 75.0% and 65.6% showed adequate occlusion at 3–6 and 7–12 months, respectively. pCONUS offers a safe and reasonably effective treatment of WNBAs, demonstrated by acceptable adequate aneurysm occlusion and low rates of adverse neurologic events.

Despite facing technical issues (e.g., overfitting, vanishing and exploding gradients), deep neural networks have the potential to capture complex patterns in data. Understanding how depth impacts neural networks performance is vital to the advancement of novel deep learning architectures. By varying hyperparameters on two sets of architectures with different depths, this thesis aims to examine if there are any potential benefits from developing deep networks for segmenting intracranial aneurysms from 3D TOF-MRA scans in the ADAM dataset. Master of Science With the technologies we have today, people are constantly generating data. In this pool of information, gaining insight into the data proves to be extremely valuable. Deep learning is one method that allows for automatic pattern recognition by iteratively improving the disparity between its prediction and the ground truth. Complex models can learn complex patterns, and such models introduce challenges. This thesis explores the potential benefits of deep neural networks whether they stand to gain improvement despite the challenges. The models will be trained to segment intracranial aneurysms from volumetric images.

Background: To investigate the safety and efficacy of endovascular embolization of very tiny (≤2 mm) intracranial aneurysms with single coil and summarize experience. Methods: A retrospective analysis was performed for 15 consecutive patients with very tiny aneurysms treated by coil embolization alone or stent-assisted coil embolization between January 2017 and January 2020. 15 patients with six unruptured aneurysms and nine ruptured aneurysms were included in this study. There were eight males and seven females with a mean age of 50.0 ± 5.2 years (range 41 to 57 years old). Intraoperative complications, imaging outcomes, clinical outcomes and follow-up data were analyzed. Results: All aneurysms were embolized with a single coil. Lvis stents were used in all coil assisted embolizations. The embolization success rate was 100%. The average volume embolization ratio (VER) of aneurysm embolization was 53.7 ± 25.5%. An intraoperative aneurysm re-rupture complication occurred in one patient (6.7%). 11 patients (73.3%) had immediate complete occlusion after embolization. After a mean follow-up period of 6.7 ± 1.4 months, 13 patients (86.7%) had complete occlusion. No patients had aneurysm re-rupture, an ischemic event or recurrence during follow-up. All patients achieved favorable clinical outcomes with a modified rankin scale (MRS) of 0–2. Conclusions: This study demonstrates that endovascular embolization of very tiny intracranial aneurysms with a single coil is safe and effective. However, the follow-up period was not long enough and studies with larger numbers of patients are required. The summary of experience reported here is expected to provide significant patient benefits.

IntroductionWhile intracranial aneurysms are common lesions affecting between 1 and 5% of the general population, the prevalence in professional athletes remains unknown. The result is uncertainty and lack of guidelines on appropriate treatment of these patients.Case PresentationA 29-year-old professional soccer player presented in our hospital with an incidentally found intracranial aneurysm. After detailed depiction of the aneurysm and interdisciplinary discussion, endovascular treatment using a flow diverter was chosen to be the best treatment modality. Postinterventional medication consisted of dual antiplatelet therapy with aspirin and clopidogrel. The main challenge in managing the case of our patient was the combination of the dual antiplatelet treatment regime with his professional career in a contact sport.ConclusionDue to lack of literature or similar reports regarding the management of professional athletes with intracranial aneurysms, the optimal treatment strategy remains unclear. Even though decisions should be made dynamically and case-adapted to each situation, developing a registry could help provide guidance and new ideas for similar cases in the future.

Spontaneous subarachnoid hemorrhage (SAH) can occur unexpectedly and independently of the classic risk factors. Several different factors could affect intracranial aneurysm (IA) rupture, such as morphological and hemodynamic factors. The aim of this study was to establish the potential association of meteorological data such as temperature, atmospheric pressure, and humidity, and the onset of clinical symptoms preceding hospital admission of patients with acute SAH due to IA rupture. This retrospective study included 130 consecutive patients admitted for non-traumatic SAH with a determinable onset of SAH symptoms. The effects of meteorological parameters of atmospheric pressure, ambient temperature, and relative air humidity on the day of acute SAH onset and 24 hours prior to the onset of symptoms were recorded and analyzed in each patient. Spearman rank correlation analysis was used to assess the risks of incident SAH on the basis of daily meteorological data. Seasonal incidence of acute SAH showed the peak incidence in winter and a trough in summer, with monthly incidence peak in January and December. The circadian rhythm analysis showed the peak incidence of SAH in the forenoon, followed by the evening. Acute SAH incidence showed moderate positive association with daily atmospheric pressure (p, Spontano subarahnoidno krvarenje (SAH) može nastati neočekivano i neovisno o klasičnim čimbenicima rizika. Nekoliko različitih čimbenika može utjecati na rupturu intrakranijske aneurizme (IA), poput morfoloških i hemodinamskih čimbenika. Cilj ovoga istraživanja bio je utvrditi potencijalnu povezanost meteoroloških podataka kao što su temperatura, atmosferski tlak i vlažnost te pojave kliničkih simptoma prije prijma u bolnicu bolesnika s akutnim SAH-om zbog rupture IA. Ova retrospektivna studija uključila je 130 uzastopnih bolesnika primljenih zbog netraumatskog SAH-a s vidljivim početkom simptoma SAH-a. Za svakog bolesnika zabilježeni su i analizirani učinci meteoroloških parametara atmosferskog tlaka, temperature okoline i relativne vlažnosti zraka na dan nastanka akutnog SAH-a i 24 sata prije pojave simptoma. Korelacijska Spearmanova analiza primijenjena je za procjenu rizika od incidentnog SAH-a na temelju dnevnih meteoroloških podataka. Sezonska incidencija akutnog SAH-a pokazala je vrhunac incidencije zimi i pad ljeti, s mjesečnim vrhom incidencije u siječnju i prosincu. Analiza cirkadijanog ritma pokazala je vrhunac incidencije SAH-a u prijepodnevnim satima, a zatim navečer. Učestalost akutnog SAH-a pokazala je umjereno pozitivnu povezanost s dnevnim atmosferskim tlakom (p

Despite the devastating consequences of aneurysmal subarachnoid hemorrhage (SAH), the mechanisms underlying the formation, progression, and rupture of intracranial aneurysms (IAs) are complex and not yet fully clear. In a real-world situation, continuously observing the process of aneurysm development in humans appears unrealistic, which also present challenges for the understanding of the underlying mechanism. We reported the relatively complete course of IA development in two real patients. On this basis, computational fluid dynamics simulation (CFD) was performed to evaluate the changes in hemodynamics and analyze the mechanism underlying the formation, progression, and rupture of IAs. Our results suggested that the formation and progression of IAs can be a dynamic process, with constantly changing hemodynamic characteristics. CFD analysis based on medical imaging provides the opportunity to study the hemodynamic conditions over time. From these two rare cases, we found that concentrated high-velocity inflow jets, flows with vortex structures, extremely high WSS, and a very steep WSSG were correlated with the formation of IAs. Complex multi-vortex flows are possibly related to IAs prior to growth, and the rupture of IAs is possibly related to low WSS, extreme instability and complexity of flow patterns. Our findings provide unique insight into the theoretical hemodynamic mechanism underlying the formation and progression of IAs. Given the small sample size the findings of this study have to be considered preliminary and exploratory.

Background Autosomal dominant polycystic kidney disease (ADPKD) is associated with an increased risk for developing intracranial aneurysms (IAs). We aimed to evaluate the frequency of diagnosis of IAs in the cross-sectional, population-based, Genkyst cohort, to describe ADPKD-associated IAs and to analyse the risk factors associated with the occurrence of IAs in ADPKD patients. Methods A cross-sectional study was performed in 26 nephrology centres from the western part of France. All patients underwent genetic testing for PKD1/PKD2 and other cystogenes. Results Among the 2449 Genkyst participants, 114 (4.65%) had a previous diagnosis of ruptured or unruptured IAs at inclusion, and ∼47% of them had a positive familial history for IAs. Most aneurysms were small and saccular and located in the anterior circulation; 26.3% of the patients had multiple IAs. The cumulative probabilities of a previous diagnosis of IAs were 3.9%, 6.2% and 8.1% at 50, 60 and 70 years, respectively. While this risk appeared to be similar in male and female individuals 2-fold higher in PKD1 compared with PKD2, with no influence of PKD1 mutation type or location. In multivariate analysis, female sex, hypertension Conclusions This study presents epidemiological data reflecting real-life clinical practice. The increased risk for IAs in postmenopausal women suggests a possible protective role of oestrogen.

ObjectiveThe treatment of unruptured small intracranial aneurysms remains controversial. A distinguishing characteristic of A1 segment aneurysms is that they tend to rupture when they are small, which may be related to their distinctive morphology and hemodynamics. Our study sought to investigate the rupture risk factors of A1 segment aneurysms by analyzing the clinical risk factors, morphology, and hemodynamic characteristics of A1 segment aneurysms.MethodsWe retrospectively enrolled 49 (23 ruptured, 26 unruptured) consecutive patients presenting to our institute with A1 segment aneurysms between January 2010 and March 2020. Independent risk factors associated with the rupture of A1 segment aneurysms were analyzed by multivariate regression analysis in the ruptured group and unruptured group.ResultsClinical risk factors, including age, sex, hypertension, smoking history, and SAH family history revealed no difference between the ruptured and unruptured groups. The ruptured group presented a significantly larger size (Size, P = 0.007), aspect ratio (AR, P = 0.002), size ratio (SR, P = 0.001), bottleneck index (BN, P = 0.016), dome-to-neck ratio (DN, P = 0.001), and oscillatory shear index (OSI) (P = 0.001) than the unruptured group. The normalized wall shear stress (NWSS) of the ruptured aneurysms was lower than the unruptured group (P = 0.001). In the multivariate regression analysis, only SR (OR = 3.672, P = 0.003) and NWSS (OR = 0.474, P = 0.01) were independent risk factors in the A1 segment aneurysm rupture.ConclusionA higher SR and lower NWSS revealed a close connection with the rupture of A1 segment aneurysms in our study, thus providing a reference for clinical decision-making in treating A1 segment unruptured aneurysms.

La aparición de aneurismas cerebrales está dada por la debilidad de la pared arterial, y su ruptura podría desencadenar una hemorragia subaracnoidea con una alta morbimortalidad lo cual hace mandatorio considerar su tratamiento, idealmente previo a dicha ruptura. Los dispositivos diversores de flujo son un stent de implantación intra-arterial considerados como una alternativa de tratamiento mínimamente invasiva que se posicionan rodeando internamente la pared del endotelio arterial con el propósito de modificar el patrón del flujo de la arteria afectada. Lo anterior, con el objetivo de reducir la entrada de sangre al aneurisma llevándolo progresivamente a su trombosis, oclusión y posteriormente disminución de tamaño permitiendo una nueva endotelización del vaso. Esta técnica endovascular es considerada actualmente a nivel mundial como la estrategia numero uno para el manejo de aneurismas carotideos complejos no rotos. Sin embargo, aún existe controversia sobre su rendimiento terapéutico debido a que se trata de una técnica reciente que requiere de una pericia y tecnología especificas. En nuestro país no existe un estudio o registro que documente dicho rendimiento en términos de eficacia y seguridad para el manejo endovascular de esta enfermedad con esta tecnología. Por lo anterior es el objetivo de los investigadores documentar los resultados de esta conducta terapéutica en la institución y la región, para establecer un referente nacional; y que permita comparar los resultados con los pioneros internacionales en el manejo de esta condición médica. Se recolectará información de todos los pacientes tratados con diversores de flujo en la institución desde el inicio de su uso en 2014 hasta 2020 con el propósito de evaluar la oclusión al año de los aneurismas tratados (eficacia) y el resultado neurológico y clínico de los pacientes (seguridad) según la escala de Rankin modificada (mRS) como desenlaces primarios de análisis de la investigación. RESUMEN _______________________________________________________6 ABSTRACT_______________________________________________________7 1. INTRODUCCIÓN___________________________________________________8 2. DESCRIPCIÓN DEL PROYECTO……………………………...…………………...….9 2.1. PLANTEAMIENTO DEL PROBLEMA ……………………………………...…............9 2.2. JUSTIFICACIÓN .…………………………………………………………………….…12 3. MARCO TEÓRICO ……………………………………………………………………...13 4. ESTADO DEL ARTE…………………………………………………………………….23 5. PREGUNTA DE INVESTIGACIÓN…………………………………………………….28 6. HIPÓTESIS ..………………………………………………………...…………………..28 7. OBJETIVOS ..………………………………………………………...………………....29 7.1. Objetivo general..………………………………………………………………………...29 7.2. Objetivos específicos ..……………………………………………………….…...........29 8. METODOLOGÍA...……………………………………………….……………………...30 8.1 Diseño o tipo de estudio...………………………………………………………..…….30 8.2 Población y muestra.……………………………………………….…………………...31 8.3 Criterios de selección...………………………………………………………………....31 8.3.1 Criterios de inclusión...……………………………………………….….…..................31 8.3.2 Criterios de exclusión...……………………………………….……..............................31 8.4 Variables: definición y operacionalización..………………….……………………......32 8.5 Recolección de la información..………………….…………......................................32 8.6 Plan de análisis………………….…………..............................................................35 9. CONSIDERACIONES ÉTICAS ...…………….…………………………….…………37 10. RESULTADOS Y PRODUCTOS ESPERADOS ...………………….…….………..39 11. CRONOGRAMA DE ACTIVIDADES...…………….………………………………….41 12. PRESUPUESTO ...…………….………………………………………………………..42 13. REFERENCIAS BIBLIOGRÁFICAS…………………………………………….…….43 Especialización The appearance of cerebral aneurysms is given by the weakness of the arterial wall, and their rupture could trigger subarachnoid hemorrhage with high morbidity and mortality, which makes it mandatory to consider their treatment, ideally prior to said rupture. Flow diverter devices are an intra-arterial implantation stent considered as a minimally invasive treatment alternative that are positioned internally surrounding the wall of the arterial endothelium with the purpose of modifying the flow pattern of the affected artery. The foregoing, with the aim of reducing the inflow of blood to the aneurysm, progressively leading it to thrombosis, occlusion and subsequently a reduction in size, allowing a new endothelialization of the vessel. This endovascular technique is currently considered worldwide as the number one strategy for the management of complex unruptured carotid aneurysms. However, there is still controversy about its therapeutic performance because it is a recent technique that requires specific expertise and technology. In our country there is no study or registry that documents this performance in terms of efficacy and safety for the endovascular management of this disease with this technology. Therefore, it is the objective of the researchers to document the results of this therapeutic behavior in the institution and the region, to establish a national reference; and that allows comparing the results with the international pioneers in the management of this medical condition. Information will be collected from all patients treated with flow diverters in the institution from the start of its use in 2014 to 2020 with the purpose of evaluating the occlusion of the treated aneurysms at one year (efficacy) and the neurological and clinical outcome of the patients. (safety) according to the modified Rankin scale (mRS) as primary outcomes of research analysis.

Intracranial aneurysms (IAs) are localized enlargements of cerebral blood vessels that cause substantial rates of mortality and morbidity in humans. The rupture possibility of these aneurysms is a critical medical challenge for physicians during treatment planning. This treatment planning while assessing the rupture potential of aneurysms becomes more complicated when they are constrained by an adjacent structure such as optic nerve tissues or bones, which is not widely studied yet. In this work, we considered and studied a constitutive model to investigate the bio-mechanical response of image-based patient-specific IA data using cardiovascular structural mechanics equations. We performed biomechanical modeling and simulations of four different patient-specific aneurysms’ data (three middle cerebral arteries and one internal carotid artery) to assess the rupture potential of those aneurysms under a plane contact constraint. Our results suggest that aneurysms with plane contact constraints produce less or almost similar maximum wall effective stress compared to aneurysms with no contact constraints. In our research findings, we observed that a plane contact constraint on top of an internal carotid artery might work as a protective wall due to the 16.6% reduction in maximum wall effective stress than that for the case where there is no contact on top of the aneurysm.

False lumen thrombosis (FLT) in typeBaortic dissection has been associated with the progression of dissection and treatment outcome. Existing computational models mostly assume rigid wall behavior which ignores the effect of flap motion on flow and thrombus formation within the FL. In this study, we have combined a fully coupled fluid–structure interaction (FSI) approach with a shear-driven thrombosis model described by a series of convection–diffusion reaction equations. The integrated FSI-thrombosis model has been applied to an idealized dissection geometry to investigate the interaction between vessel wall motion and growing thrombus. Our simulation results show that wall compliance and flap motion can influence the progression of FLT. The main difference between the rigid and FSI models is the continuous development of vortices near the tears caused by drastic flap motion up to 4.45 mm. Flap-induced high shear stress and shear rates around tears help to transport activated platelets further to the neighboring region, thus speeding up thrombus formation during the accelerated phase in the FSI models. Reducing flap mobility by increasing the Young’s modulus of the flap slows down the thrombus growth. Compared to the rigid model, the predicted thrombus volume is 25% larger using the FSI-thrombosis model with a relatively mobile flap. Furthermore, our FSI-thrombosis model can capture the gradual effect of thrombus growth on the flow field, leading to flow obstruction in the FL, increased blood viscosity and reduced flap motion. This model is a step closer toward simulating realistic thrombus growth in aortic dissection, by taking into account the effect of intimal flap and vessel wall motion.

Background Despite psychiatric traits were associated with intracranial aneurysms (IAs) in observational studies, their causal relationships remain largely undefined. We aimed to assess the causality between psychiatric traits and IAs.Methods We firstly collected the genome-wide association statistics of IAs (sample size, n = 79,429) and ten psychiatric traits from Europeans, including insomnia (n = 1,331,010), mood instability (n = 363,705), anxiety disorder (n = 83,566), major depressive disorder (MDD) (n = 480,359), subjective wellbeing (n = 388,538), attention deficit/hyperactivity disorder (ADHD) (n = 53,293), autism spectrum disorder (ASD) (n = 46,350), bipolar disorder (BIP) (n = 51,710), schizophrenia (SCZ) (n = 105,318), and neuroticism (n = 168,105). We then conducted a series of bi-directional two-sample Mendelian randomization (MR) analyses, of which the Robust Adjusted Profile Score (RAPS) was the primary method to estimate the causal effects between these psychiatric traits and IAs.Results We found that insomnia exhibited a significant risk effect on IAs with the odds ratio (OR) being 1.22 (95% CI: 1.11–1.34, p = 4.61 × 10–5) from the RAPS method. There was suggestive evidence for risk effect of mood instability on IAs (RAPS, OR = 4.16, 95% CI: 1.02–17.00, p = 0.047). However, no clear evidence of causal effects on IAs for the rest eight psychiatric traits (anxiety disorder, MDD, subjective wellbeing, ADHD, ASD, BIP, SCZ, and neuroticism) was identified. In the reverse MR analyses, no causal effects of IAs on psychiatric traits were found.Conclusions Our findings provide strong evidence for a causal risk effect of insomnia on IAs and suggestive evidence for mood instability as a causal risk effect on IAs. These results could inform the prevention and clinical intervention of IAs.

Background The development of flow diverters (FDs) has provided neurointerventionalists with an additional option for the treatment of intracranial aneurysms. These devices lead to aneurysm occlusion by triggering intra-aneurysmal thrombosis through their potential to disrupt blood flow into the aneurysm sac and by inducing intimal hyperplasia. This enables the complete exclusion of the aneurysm from circulation, but it is also responsible for in-stent stenosis. Case description A 68-year-old latin woman with a medical history of irregular treated arterial hypertension and a 40 year history of smoking habit was diagnosed with an unruptured intracranial saccular aneurysm in the left internal carotid artery and then referred to be treated with a Flow Diverter stent. At the 6 mont follow-up angiography, a severe in-stent stenosis (>75%) was observed at the distal portion of the stent. The patient was otherwise asymptomatic and no distal flow limitation was observed. It was decided to maintain the dual antiplatelet regimen and a 12 month follow-up angiography was performed, being noticed substantial improvement, with a mild intra-stent stenosis of approximately 25% at the same site. Conclusion Severe in-stent stenosis in an uncommon finding after aneurysmal treatment with flow diverter devices, but usually with later asymptomatic improvement without any other intervention, being of great importance its knowledge by neurointerventionalists.

A 76-year-old man presented to the emergency department with a 2-month history of progressive headache, nausea, vomiting, irritability, and left focal seizures beginning as paresthesia´s and tonic clonic movements of the left lower limb subsequently spreading to the left upper limb. His medical history was notable for untreated hypertension and hyperlipidemia. He had been an active smoker for more than 20 years, and his father had died suddenly at 62 years of age from an unknown cause. There was no fever and no weight loss. At the time of admission her glasgow coma score (GCS) was 15 and there was no focal neurological deficit. The patient´s blood pressure was 160/80mmHg. Three hours later a brutal neurological fall-down was noticed after with a severe left sided hemiparesis. His blood test results, including complete blood count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) level were in the normal range. Brain computed tomography scan discovered a bilobed and bihemispheric huge mass (60 and 52 mm in diameter) of both frontal lobes with diffuse intraventricular hemorrhage necessitating emergent placement of an external ventricular drain, and the patient was admitted to the intermediate care unit.

Background The aim of this study was to comprehensively evaluate the risk factors of periprocedural ischemic stroke associated with endovascular treatment of intracranial aneurysms using a real-world database. Methods From August 2016 to March 2017, 167 patients were enrolled. Univariate analysis and multivariate logistic regression analysis were used to examine the risk factors for periprocedural ischemic stroke. Results Among the 167 cases, periprocedural ischemic stroke occurred in 20 cases (11.98%). After univariate analysis, the ischemic group had a higher proportion of large (≥ 10 mm) aneurysms than the control group (45.0% vs. 23.1%, p = 0.036). The incidence of periprocedural ischemic stroke was higher in cases treated by flow diverter (21.6%) or stent-assisted coiling (11.8%) than in cases treated by coiling only (2.7%), and the differences were statistically significant (p = 0.043). After multivariate logistic regression analysis, treatment modality was the independent risk factor for periprocedural ischemic stroke. Compared with the coiling-only procedure, flow diverter therapy was associated with a significantly higher rate of periprocedural ischemic stroke (OR 9.931; 95% CI 1.174–84.038; p = 0.035). Conclusions Aneurysm size and treatment modality were associated with periprocedural ischemic stroke. Larger aneurysms were associated with increased risk of periprocedural ischemic stroke. Flow diverter therapy was associated with significantly more periprocedural ischemic stroke than the coiling procedure alone.

Background and Aims: It has recently emerged the concept of “obesity paradox,” a term used to describe an inverse association between obesity and clinical outcomes in cardiovascular diseases and stroke. The purpose of this study was to investigate the association between body mass index (BMI) and the risk of intracranial aneurysm rupture.Methods: In this study, we conducted a retrospective analysis of a prospectively maintained database of patients with intracranial aneurysms from 21 medical centers in China. A total of 3,965 patients with 4,632 saccular intracranial aneurysms were enrolled. Patients were separated into unruptured (n = 1,977) and ruptured groups (n = 1,988). Univariable and multivariable logistic regression analyses were performed to determine the association between BMI and intracranial aneurysm rupture.Results: Compared to the patients with normal BMI (18.5 to < 24.0 kg/m2), the odds of intracranial aneurysm rupture were significantly lower in patients with BMI 24.0 to < 28.0 kg/m2 (OR = 0.745, 95% CI = 0.638–0.868, P = 0.000) and patients with BMI ≥ 28.0 kg/m2 (OR = 0.628, 95% CI = 0.443–0.890, P = 0.009). Low BMI (2) was not associated with intracranial aneurysm rupture (OR = 0.894, 95% CI = 0.483–1.657, P = 0.505). For males, both the BMI 24.0 to < 28.0 kg/m2 (OR = 0.606, 95% CI = 0.469–0.784, P = 0.000) and the BMI ≥ 28.0 kg/m2 (OR = 0.384, 95% CI = 0.224–0.658, P = 0.001) were associated with a lower rupture risk, whereas the inverse association was not observed in females. Both the BMI 24.0 to < 28.0 kg/m2 (OR = 0.722 for aged 50–60y, 95% CI = 0.554–0.938, P = 0.015; OR = 0.737 for aged >60y, 95% CI = 0.586–0.928, P = 0.009) and the BMI ≥ 28.0 kg/m2 (OR = 0.517 for aged 50–60y, 95% CI = 0.281–0.950, P = 0.0034; OR = 0.535 for aged >60y, 95% CI = 0.318–0.899, P = 0.0018) was associated with a lower rupture risk in patients aged ≥50 years, whereas the association was not significant in patients aged Conclusions: Increased BMI is significantly and inversely associated with saccular intracranial aneurysm rupture in males and patients aged ≥50 years.

At present, the energy loss (EL) mechanism of intracranial aneurysm (IA) rupture is explored based on the global EL calculated by Bernoulli equation, but the details of EL are still unclear. This study aimed to explore the temporal and spatial characteristics of EL of IAs and reveal its mechanism. A novel method for calculating the EL of IAs based on dissipation function (DF) was proposed. DF was derived from the differential form of the energy equation and reflected the irreversible conversion from mechanical energy to internal energy caused by the friction between the fluid micelles. Eight sidewall IAs located at the posterior communicating segment of the internal carotid artery were collected; the three-dimensional (3D) geometric models of IAs were established employing image segmentation and 3D reconstruction. Computational fluid dynamics was applied to obtain hemodynamic parameters of IAs. The temporal and spatial characteristics of EL of IAs were achieved utilizing our proposed method. The simulation results indicated that EL occurred mainly in the boundary layer and the region adjacent to high-velocity inflow jet, EL increased rapidly during cardiac systole and reached its maximum at end-systolic phase and then decreased gradually during diastole until the end of cardiac cycle. The proposed method achieved some improvements over the traditional Bernoulli equation–based method by acquiring the temporal and spatial characteristics of EL, and it could provide insights into the EL of IAs and contribute to further rupture mechanism investigation.

Background We investigated whether periodontal diseases, specifically, periodontitis and gingivitis, could be risk factors of the incidence of intracranial aneurysms (IAs). Methods We performed a case–control study to compare the differences in the periodontal disease parameters of 281 cases that were divided into the IAs group and non-IAs group. All cases underwent complete radiographic examination for IAs and examination for periodontal health. Results Comparing with those in the non-IAs group, the cases in the IAs group were older (53.95 ± 8.56 vs 47.79 ± 12.33, p < 0.001) and had a higher incidence of hypertension (76 vs 34, p = 0.006). Univariate logistic regression analysis revealed that age (> 50 years) and hypertension were predictive risk factors of aneurysm formation (odds ratio [OR] 1.047, 95% confidence interval [95% CI] 1.022–1.073, p < 0.001 and OR 2.047, 95% CI 1.232–3.401, p = 0.006). In addition, univariate and multivariate logistic regression analyses showed that the parameters of periodontal diseases, including gingival index, plaque index, clinical attachment loss, and alveolar bone loss, were significantly associated with the occurrence of IAs (all p < 0.05). For further statistical investigation, the parameters of periodontal diseases were divided into four layers based on the quartered data. Poorer periodontal health condition (especially gingival index > 1.1 and plaque index > 1.5) had the correlation with IAs formation (p = 0.007 and p < 0.001). Conclusion Severe gingivitis or periodontitis, combining with hypertension, is significantly associated with the incidence of IAs.

Purpose To investigate the long-term clinical and angiographic outcomes and their related predictors in endovascular treatment (EVT) of small (

Background: When inserting coils under stent deployment, a jailed microcatheter technique is typically applied as a first line approach. However, the trans cell approach might be required to achieve satisfactory complete occlusion. The trans cell approach occasionally ends in failure because the catheter cannot safely follow a proceeding guidewire into the aneurysm. Here, we report the new wireless trans cell approach (WTA), which allows feasible and safe catheter navigation through the stent strut into the aneurysm, without a proceeding guidewire. Methods: A straight tip microcatheter was used, and the tip was shaped as a very small bend of approximately 45°. The side aspect of the catheter tip exhibited a right angled edge, while the front aspect showed a round curve in the advancing direction. We compared the 45° microcatheter with a straight tip microcatheter using a silicon vascular model and then applied the WTA in a case of an unruptured basilar apex aneurysm. Results: Catheter navigation through the stent strut was smoother with the WTA than the conventional wire assisted approach. Our case of a basilar apex aneurysm was successfully treated with the dual catheter technique, which involved a jailed catheter and navigation using the WTA. After stent deployment from the right posterior cerebral artery to the basilar artery through the 45° microcatheter, the WTA was applied using the same catheter. No stress was detected during catheter navigation through the stent strut into the aneurysm. Conclusions: The WTA is associated with smoother catheter navigation compared with the conventional wire assisted approach in cases of a terminal type aneurysm.

Delayed ischemic neurologic deficit (DIND) is the main preventable cause of poor outcomes in aneurysmal subarachnoid hemorrhage (SAH) patients. Of 50% of survivors from a SAH, approximately 30% of patients will present clinical vasospasm (VS). The cornerstone of the DIND management comprises prevention and early identification. Several diagnostic methods have been proposed differing in efficacy, invasiveness, and costs. Serial neurological examination is the most reliable method to detect a new neurological deficit. On the other hand, comatose patients require advanced monitoring methods which identify changes in the microcirculatory environment, brain autoregulation, and spreading depolarization. Multimodality monitoring with continuous electroencephalography, microdialysis, and intracranial pressure monitoring represents altogether the current state-of-art technology for the intensive care of SAH patients. Moreover, advances in genetic biomarkers to predict clinical VS have shown consistent accuracy which may in the near future allow the early prediction of DIND through a simple blood test. Several clinical trials have tested drugs with theoretical effects on DIND prevention or treatment. Nevertheless, nimodipine remains the Holy Grail in the prevention of clinical VS. Among rescue therapies, the endovascular treatment through intra-arterial vasodilator (verapamil or nicardipine) infusion is the most employed method for DIND reversal; however, there is no good quality evidence comparing results of intra-arterial infusion of vasodilators versus balloon angioplasty. Although we have addressed the most refined technology in the management of SAH and DIND, the clinical experience and strict follow-up in neurointensive care will be determinant for favorable long-term outcomes.

Background Posterior circulation intracranial aneurysm (IA) treatment remains challenging, due to the anatomy of the area and the high rupture possibility. Endovascular treatment seems to be more suitable for these aneurysms, but studies focused on endovascular treatment demonstrate a high rate of re-intervention needing. A meta-analysis might offer a clearer view, being useful in a more effective treatment planning. Methods A systematic search was performed, using the PubMed database platform. The final article pool contained 20 articles. Studied parameters were operative mortality, late mortality, permanent neurologic deficit (PND), and the need for re-intervention (Re-int). We divided patients into two subgroups, those with ruptured and those with unruptured aneurysm. Statistical analysis was performed using appropriate software. Results In the total population (645 patients), there was a superiority of coiling over clipping in terms of PND and of coiling in terms of Re-int. As regards mortality, there was no clear superiority of one method over the other. Conclusions The current study came to the conclusion that there is a superiority of coiling over clipping in terms of PND. On the other hand, clipping seems to be superior to coiling in terms of the need for re-intervention. As regards mortality (both operative and late), there is no clear superiority of one method over the other. Studying subgroups of patients (ruptured and unruptured posterior circulation IAs), in terms of PND, there is no superiority of one method over the other. The same goes for Op-Mo on ruptured aneurysms.