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Background: This study aimed to evaluate the clinical course after flow diversion (FD) treatment with a focus on aneurysms with remnant sac filling, by analyzing angiographic outcomes, aneurysm volume, and clinical events., Methods: We retrospectively reviewed the medical records of 61 patients who underwent FD for intracranial aneurysms between July 2014 and June 2021., Results: The majority of aneurysms (52.5%) were located in the internal carotid artery, with a median diameter of 16.6 mm and neck size of 9.3 mm. Remnant filling was observed in 17 aneurysms (27.9%) more than 18 months after FD, 10 (16.4%) of these aneurysms underwent enlargement, which occurred only in cases with subtotal filling or entry remnant states. Eleven patients experienced major adverse events, and three exhibited unfavorable functional outcomes. The incidence of major adverse events and unfavorable functional outcomes was significantly higher in the aneurysm enlargement group than that in the no-filling or stable remnant filling groups (P < 0.001). Aneurysmal diameter and the presence of incorporated branches were independent predictors of aneurysm enlargement, while the presence of incorporated branches was the only independent predictor of persistent remnant filling., Conclusions: Aneurysm enlargement after FD is not uncommon, particularly when the aneurysm is large, has incorporated vessels, or does not undergo occlusion within 12 months, often culminating in major adverse events and unfavorable functional outcomes. In addition to investigating angiographic results, it is necessary to evaluate the changes in aneurysm size and clinical events when assessing the efficacy of FD., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: Here, we presented our early experience with flow diversion procedures using the Surpass Evolve flow diverter (SE, Stryker) and reported the feasibility and safety profile compared to those of a control group treated with other types of flow diverters., Methods: We included 31 and 53 consecutive flow diversion procedures performed using the SE and other commercial flow diverters, respectively, to treat intracranial aneurysms at our institution. We used two commercial flow diversion systems in the comparison group: the pipeline embolization device and Surpass Streamline., Results: In the SE group, technical failures occurred in three (9.7%) cases, due to either incomplete wall apposition (n = 1, 3.2%) or stent migration (n = 2, 6.5%). Major complications occurred in four (12.9%) cases: delayed rupture of the target aneurysm (n = 1, 3.2%), major ischemic stroke (n = 1, 3.2%), sudden death from an unidentified cause (n = 1, 3.2%), and parent artery occlusion with stent thrombosis (n = 1, 3.2%). Balloon angioplasty was performed in eight (25.8%) cases. On post-procedure MRI, a DWI-positive lesion was detected in three (9.7%) cases. After multivariate adjustment, the SE group was independently associated with less procedural time of ≥ 90 min (adjusted OR, 0.09; 95% CI, 0.03-0.29; p < 0.001), balloon angioplasty (adjusted OR, 0.22; 95% CI, 0.07-0.75; p = 0.015), and DWI-positive lesions (adjusted OR, 0.04; 95% CI, 0.01-0.19; p < 0.001)., Conclusion: The SE is safe and easy to deploy., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: We aimed to evaluate the efficacy and safety of single-device flow diversion in patients with aneurysms measuring ≥15 mm in diameter., Methods: For this retrospective study, we extracted medical record data for patients with unruptured intracranial aneurysms, who underwent flow diversion, at the authors' institution between July 2014 and August 2019. The primary effectiveness outcome was defined as angiographic occlusion of the target aneurysm within 18 months without major (>50%) parent artery stenosis, major adverse events, or additional treatment., Results: Thirty-five aneurysms in 35 patients were analyzed. Most aneurysms (n = 29, 82.9%) involved the anterior circulation. The median aneurysmal diameter was 18.3 mm, and the median neck size was 7.6 mm. Eleven (31.4%) aneurysms were considered giant (≥25 mm). The primary effectiveness outcome was achieved in 20 (57.1%) patients at a median of 10 months (interquartile range, 4.3-12.5) after flow diversion. Major adverse events occurred in 6 (17.1%) patients, including remote intraparenchymal hemorrhages (n = 2), a major ischemic stroke (n = 1), a delayed rupture of the target aneurysm (n = 1), and clinical deterioration caused by aggravated mass effect (n = 2). Multivariate logistic regression analysis found 2 independent predictors of the primary effectiveness outcome: the aneurysmal diameter (odds ratio, 0.71; 95% confidence interval, 0.54-0.86; P = 0.004) and the parent-vessel angle (odds ratio, 0.97; 95% confidence interval, 0.93-0.99; P = 0.017)., Conclusions: Single-device flow diversion was shown to be ineffective for large or giant intracranial aneurysms with a high parent vessel angle., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Despite its relative rarity, the potential for loss of productive years makes aneurysmal subarachnoid hemorrhage (SAH) a considerably important entity in young adult patients (20-39 years of age). This study aimed to analyze outcomes of microsurgery (MS) and endovascular treatment (EVT) for saccular intracranial aneurysms (IAs) in young adult patients., Methods: A total of 276 young adult patients with 315 IAs, treated with MS or EVT between January 2001 and December 2015, were studied. Major recurrence and treatment-related complications were the primary outcome measures. Functional outcomes in patients with SAH were also assessed., Results: Major recurrence occurred in 21 cases (6.7%). Younger age (adjusted hazard ratio [aHR], 3.77; 95% confidence interval [CI], 1.45-9.83; P = 0.007), ruptured IA (aHR, 6.44; 95% CI, 2.09-19.89; P = 0.001), size (aHR, 1.84; 95% CI, 1.06-3.18; P = 0.030), and EVT (aHR, 7.21; 95% CI, 2.44-21.35; P < 0.001) were independently related to major recurrence. Treatment-related complications occurred in 5 cases (1.6%) and did not differ between the MS and EVT groups (P > 0.999). Unfavorable outcomes (modified Rankin scale score ≥2) were identified in 30 patients (19.6%) with SAH, and only Hunt and Hess grade was independently associated with unfavorable functional outcome., Conclusions: Both MS and EVT are safe for treating IAs in young adult patients. MS showed better durability of treatment and may be preferred over EVT in young patients in view of their longer life expectancy compared with older patients., (Copyright © 2019. Published by Elsevier Inc.)

Introduction: The purpose of this study was to explore the safety and efficacy of an antiplatelet response assay and drug adjustment to prevent delayed thromboembolic events after stent-assisted coil embolization., Methods: A total of 370 patients were enrolled in this study between December 2005 and July 2014. Of these, 124 patients were placed into the drug resistance test (DRT) group with drug adjustment according to response to an antiplatelet agent, and 246 patients comprised the control group with a standard antiplatelet regimen. The response to the antiplatelet agent was evaluated with the VerifyNow Rapid Platelet Function Assay. Propensity score matching analysis was performed with one-to-multiple matching., Results: Among 370 patients, delayed thromboembolic events occurred in 28 (7.6 %) patients including 25 (10.2 %) in the control group and three (2.4 %) in the DRT group. Antiplatelet response test (p = 0.012), diabetes mellitus (DM) (p = 0.014), and hypertension (HTN) (p < 0.001) were associated with delayed infarction in multivariate analysis. In propensity score matching analysis, 331 patients were matched (control group (n = 229) vs. DRT group (n = 103)), and antiplatelet response (hazard ratio 0.247, 95 % confidence interval 0.070-0.868, p = 0.029) was correlated with delayed infarction. Conversely, the two groups were not significantly different with regard to total (p = 0.368) or major hemorrhagic complications (p = 0.108)., Conclusion: Antiplatelet drug adjustment according to the results of an antiplatelet response assay might be associated with a decreased risk of delayed thromboembolic infarction compared with the standard antiplatelet regimen.

Introduction: The purpose of this study was to evaluate morphological factors associated with rupture in anterior communicating artery (AcomA) aneurysms and to investigate the significance of AcomA fenestration as a risk factor for aneurysm rupture., Methods: The clinical and radiologic findings of 255 patients with AcomA aneurysms treated with coil embolization between January 2005 and March 2014 were retrospectively reviewed. We performed univariate and multivariate analyses to evaluate the associations between morphological variables and rupture status., Results: The number of patients with AcomA fenestration was 17 out of 255 (6.6 %). There were no statistically significant differences between the fenestration group and non-fenestration group in clinical and morphological characteristics. Multivariate logistic regression tests showed that superior direction of aneurysm dome (OR 2.802, p = 0.023), presence of a bleb (OR 5.998, p < 0.001), high aspect ratio (OR 3.138, p = 0.009), size greater than 7 mm (OR 3.356, p = 0.013), and AcomA fenestration (OR 4.135, p = 0.026) were significantly associated with AcomA aneurysm rupture., Conclusions: The results of this study demonstrated that a fenestrated AcomA is associated with risk of aneurysm rupture. Therefore, AcomA fenestration can be considered as an important morphological risk factor for rupture, along with other known risk factors such as the direction of aneurysm dome, a bleb, high aspect ratio, and size.

Recently, the treatment of intracranial aneurysms entered a new phase due to safe surgical tool such as neurophysiologic monitoring and challenged by endovascular treatment. To determine the safety of clipping surgery in the modern era, we reviewed our experiences of simple unruptured anterior circulation aneurysm surgery which is commonly performed in many places. We retrospectively reviewed 610 consecutive patients who were treated with surgical clipping under motor evoked potential (MEP) monitoring for a tiny to large anterior circulation aneurysm in a single institute between 2008 and 2012. MEP changes were identified in 40 cases (6.6 %). MEP deterioration was associated with remote site epidural hematoma (n = 1), anesthesia (n = 2), temporary clipping (n = 21), and permanent clipping (n = 16). Despite that no persistent MEP deterioration was noted after prompt corrective measures, 56 (9.2 %) patients showed symptomatic (n = 14) and asymptomatic (n = 42) radiologic abnormalities. Anterior cerebral artery (ACA) aneurysm was associated with a higher radiologic complication rate (Fisher's exact test, P < 0.05). Two (0.3 %) patients showed severe morbidity (mRS >2) at latest follow-up. MEP monitoring can be helpful in preventing postoperative motor deterioration but seems to have some limitations. Although the permanent morbidity rate was low, a significant clinical (2.3 %) or radiologic (9.2 %) abnormality rate was identified even in simple aneurysm clipping that should be taken into account when performing interdisciplinary treatment planning and patient counseling. Also, direct vascular monitoring or new neurophysiologic monitoring techniques are needed to reduce surgical complications, especially in ACA aneurysm surgery.

Objective: The Enterprise stent is used for endovascular treatment of complex intracranial aneurysms. The purpose of this study was to evaluate delayed thromboembolic events (DTEs) that developed more than 30 days after Enterprise stent-assisted embolization (SAC) and its associated risk factors., Methods: There were 125 consecutive patients (90 women and 35 men; mean age, 56.1 years) who received endovascular treatment for 126 complex intracranial aneurysms using the Enterprise stent during December 2008 to May 2011. A DTE was defined as a symptomatic or asymptomatic ischemic stroke with positive findings on brain magnetic resonance imaging in the territory of the treated aneurysm and transient ischemic attack. Asymptomatic in-stent stenosis and occlusion were excluded., Results: During a mean follow-up of 32.4 months, DTEs occurred in 10 patients (7.93%). DTEs occurred on antiplatelet therapy (dual medication, n = 2, 2 months after embolization; single medication, n = 6, 10-20 months after SAC) or after discontinuation of antiplatelet therapy (n = 2, 14 months after embolization). Multivariate analysis showed that current smoking (p = 0.005) and maximum parent artery diameter >4.5mm (p = 0.003) were associated with DTE., Conclusions: SAC with the Enterprise stent poses a considerable risk of DTE. Our results suggest that a longer duration of antiplatelet therapy and clinical follow-up may be warranted for cases with suggested risk factors. The protocol for antiplatelet therapy after SAC should be determined in a large prospective trial., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Objectives: To identify the incidence of thromboembolic complications based on magnetic resonance imaging (MRI) and to explore the potential risk factors for thromboembolism (TE) during the periprocedural period of elective coil embolization for unruptured intracranial aneurysms., Methods: We retrospectively reviewed all aneurysm cases treated with coil insertion between January 2008 and March 2011. Two hundred eighty-two coiling procedures for unruptured aneurysms were included in this study. The patients' demographic characteristics were documented and records reviewed for abnormalities in diffusion-weighted imaging (DWI) seen on post-procedure MRI, intraoperative thrombus formation, and clinical signs of stroke., Results: Overall, there were 87 (30.9 %) procedure-related complications in 282 aneurysms treated: 2 (0.7 %) procedural ruptures, 5 (1.8 %) symptomatic infarctions, and 80 (28.3 %) asymptomatic infarctions. Thromboembolic events during the procedure were observed more often in the the hyperlipidemia group (32/71 aneurysms, 45.1 %) than in the normal lipid profile group (39/196 aneurysms, 25.6 %; p = 0.002; chi-squre test). The coiling technique and size of the aneurysm were also associated with TE (p < 0.001 and p = 0.004)., Conclusion: Hyperlipidemia seems to be associated with a significant increase in the rate of thromboembolic events. In preventive procedures, modifiable risk factors should be managed to reduce complications. Although permanent deficits are rare, the high rate of thromboembolic events suggests that improvements in the technique, such as the addition of antiplatelet agents and the development of new embolic materials, are necessary.

Surgical clipping is preferred to endovascular coil embolization for the treatment of middle cerebral artery (MCA) aneurysms. The aim of this study was to describe our experience of coiling for MCA aneurysms, to analyze the reasons for choosing coiling instead of clipping, and to evaluate the appropriateness of the choice. We retrospectively reviewed data of 30 patients who had coiling for MCA aneurysms in our Institute from January 2008 to February 2011. We analyzed the morphologies, techniques, angiographic results and complications of 30 aneurysms treated with coiling, and compared the outcomes with those of 78 clipped aneurysms during the same period. The most common reason for choosing coiling instead of clipping was the short length of the M1 artery (17/30, 56.7%). Complete obliteration of the aneurysm was achieved in 28 of 30 coiling patients (93%) and in 72 of 78 clipping patients (92%). In the coiling group, two of 30 patients (6.7%) had post-procedural infarctions on radiologic evaluation, with only one infarction in clinically relevant territory. There was one intra-procedural rupture and one aneurysm recanalization requiring retreatment in the coiling group. In the clipping group, two infarctions, one subdural hygroma and two intracerebral hematomas were found as postoperative complications, with two clinical deteriorations. Endovascular coil embolization should be considered for treatment of MCA aneurysms as it has angiographic results equivalent to surgical clipping and acceptable post-procedural complications. It is particularly appropriate for patients with serious medical problems or where there is the risk of damaging perforating lenticulostriate arteries on the MCA during surgery., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Purpose: The aim of the present study was to delineate preoperative factors that may predict perforator injuries following open surgery for an unruptured middle cerebral artery (MCA) aneurysm., Methods: The authors conducted a retrospective review of 85 consecutive patients who underwent surgical clipping of 91 unruptured MCA aneurysms. In addition to demographic profiles, angiographic characteristics of aneurysms, which included the side, size, projection, height from the origin of the ophthalmic artery, and distance between the internal carotid artery (ICA) bifurcation and the aneurysm origin, were analysed and correlated with perforator injuries. Compared with the preoperative CT and/or MRI, any newly-developed infarctions in the striatocapsular area were regarded as perforator injuries even if they were very small and asymptomatic., Results: A perforator injury was found in 14 out of 91 cases (15%). Although the majority of them remained asymptomatic, neurological deterioration occurred in four patients. Of the analysed variables, both the height (from the origin of the ophthalmic artery) and the distance (between the ICA bifurcation and the aneurysm origin) were significantly associated with perforator injuries. A stepwise increment of the risk was observed as the position of aneurysms became higher or as the distance to the ICA bifurcation became shorter., Conclusions: These results would be helpful in estimating surgical risks for an unruptured MCA aneurysm, one of the most commonly encountered aneurysms in the neurosurgical field.

Background: Major artery aneurysms may be found incidentally while evaluating moyamoya disease (MMD). The purpose of this study was to delineate the prevalence and characteristics of these uncommon aneurysms with a brief mention of their management and outcomes., Methods: We conducted a retrospective review of 249 adult patients who were diagnosed with non-hemorrhagic MMD. Cerebral angiograms obtained at the time of initial diagnosis were carefully reviewed to identify incidental aneurysms located on a major intracranial artery or near its tributaries. Aneurysms originating from distal peripheral arteries or moyamoya vessels were ineligible for this study., Results: Nine patients (3.6%) were found to have 13 major artery aneurysms, 7 (54%) of which were located in the posterior circulation, especially in older patients with bilateral MMD. The sizes of all aneurysms were less than 10 mm. Surgical clipping was performed on two aneurysms, and endovascular coiling on six (five posterior circulation aneurysms). Ischemic complications occurred in two patients after clipping of an anterior communicating artery aneurysm and in one patient after the second coiling of a recanalized basilar tip aneurysm., Conclusions: Incidental major artery aneurysms can be found in 3.6% of adult patients with non-hemorrhagic MMD, an observed frequency that increases with age. About half of these aneurysms are located in the posterior circulation, particularly in older patients with bilateral MMD. Considering the risks of treatment-related complications, more information about the natural course of these aneurysms is needed to design proper management strategies both for the aneurysms and MMD.

Objective: The aim of the present study was to evaluate the usefulness of transcranial motor evoked potential (MEP) monitoring and its impact on morbidity after surgical clipping of unruptured intracranial aneurysms., Methods: Motor outcomes were compared before and after the application of MEP monitoring for a one year period. A total intravenous anesthesia was induced and maintained with a continuous infusion of vecuronium. Muscle MEPs were elicited by constant voltage stimulation via subdermal needle electrodes placed at C3 and C4 positions. A more than 50% decrement of MEP amplitudes compared with baseline recordings was regarded as a warning sign and promptly indicated to the surgeon., Results: Before the application of MEP monitoring, a new motor deficit was observed in 3 of 66 patients. However, in 98 patients operated under MEP monitoring, no new motor deficit was found except for one patient who manifested delayed hemiparesis 30 h after the operation owing to a cortical vein injury during craniotomy. MEPs deteriorated in 12 patients which were related to hypotension (n=1), temporary clipping (n=7), and permanent clipping (n=4), and recovered in all after prompt corrective measures. After surgical clipping of unruptured aneurysms, the absence of new motor deficits could be reliably anticipated by recovered MEPs as well as unchanged MEPs., Conclusions: Transcranial MEP monitoring is a simple, safe, and reliable tool for the prediction of postoperative motor functions. The ischemic complications can be reduced via prompt corrective measures taken on the basis of MEP changes during aneurysm surgery., (Copyright 2010 Elsevier B.V. All rights reserved.)

We investigated surgical results based on craniotomy sidedness in patients with superiorly projecting anterior communicating artery (ACoA) aneurysms to evaluate decision-making on the surgical approach based on the anatomical planes of both A2 vessels. Among 99 patients treated surgically, 19 (19.2%) ACoA aneurysms projected superiorly. We analyzed the associations between surgical outcomes and the planes containing both A2 vessels (anterior or posterior displacement of A2 in relation to the aneurysm). Surgery in nine patients was approached from the side of the A2 posterior displacement, while surgery for ten patients was approached from the side of anterior displacement. A higher requirement for gyrus rectus aspiration was found in patients approached from the plane of A2 anterior displacement (p=0.041). All aneurysms were successfully secured without any surgery-related complications, except in two patients. Approaches from the side of posterior displacement of A2 in patients with superiorly projecting ACoA aneurysm allowed the aneurysmal necks to be secured safely and prevented postoperative complications.

A 51-year-old female presented with bilateral accessory middle cerebral arteries (MCA) with associated ruptured aneurysm manifesting as a subarachnoid hemorrhage. Angiography demonstrated the bilateral accessory MCA and associated ruptured aneurysm at the junction of the left anterior cerebral artery and left accessory MCA. This was successfully treated by coil embolization. Magnetic resonance angiography obtained 6 months later revealed no evidence of residual or recurring aneurysm., (Copyright 2009 Elsevier Ltd. All rights reserved.)

Objective: The objective of this study is to determine the incidence, character, and outcome of headache in patients with unruptured intracranial aneurysms who had been treated to avoid the risk of rupture., Background: There are a variety of clinical manifestations associated with unruptured intracranial aneurysms. Among them, chronic headache is the most common presenting and/or accompanying symptom., Methods: Among the 137 patients with unruptured aneurysms who had been treated, we collected 81 patients excluding 30 on the basis of inclusion criteria. Twenty-six patients were lost to follow-up. We collected data by medical record review and a telephone survey. Included in the information collected was the analysis of presenting symptom, location and size of each aneurysm, location, quality, intensity and duration of headaches, associated symptoms, triggering and alleviating factors, and precipitating events., Results: Forty-nine patients (60.5%) of 81 had chronic headaches before the diagnosis of unruptured intracranial aneurysm. Forty-four patients (89.8%) answered that their headaches were improved slightly (12 patients) or markedly (32 patients) (P <.05). The clinical pattern of the headache worsened in only 1 patient and did not change in 4 patients. When the surgical group (40 patients) and the coil embolization group (41 patients) were compared, there was no significant difference observed in outcome (P >.05)., Conclusion: Either by employing the technique of clipping or by coil embolization, treatment of unruptured intracranial aneurysms resulted in relief of headaches in majority of patients who had headaches pre-operatively.

Background/Objectives: Target tetra detachable coils (TTDCs) aid in achieving effective framing during the coil embolization of small intracranial aneurysms by maintaining a tetrahedral conformation within the aneurysm sac. We aimed to report the initial experience of patients treated for intracranial aneurysms using TTDCs, with a specific focus on efficacy and safety. Methods: We retrospectively reviewed the medical records of 41 patients who underwent the coil embolization of intracranial aneurysms sized ≤10 mm with TTDCs between April and May 2023. Post-procedural angiographic and clinical results were reviewed. Results: Of the 46 aneurysms (45 unruptured and 1 ruptured), 33 (71.7%) were treated with the stent-assisted technique and 13 (28.3%) using the simple coil embolization technique. Post-procedural angiography showed complete occlusion in 41 aneurysms (89.1%), neck remnants in 1 (2.2%), and residual aneurysms in 4 (8.7%). The mean packing density was 34.7% (19.3–46.8%), with TTDC coil length comprising a mean of 88.5% of the total coil length. No major device- or procedure-related complications were observed. During the follow-up, 40 aneurysms (93.0%) demonstrated complete occlusion, while neck remnants were observed in 1 (2.3%), and residual aneurysms in 2 (4.7%). No cases of recanalization were observed. Conclusions: The TTDC is a safe and effective device for the endovascular treatment of intracranial aneurysms. Follow-up studies are required to establish long-term results. [ABSTRACT FROM AUTHOR]