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Background: Cerebral aneurysm rupture is associated with high rates of morbidity and mortality. Detecting aneurysms at high risk of rupture is critical in management decision making. Rupture risk has traditionally been associated with size-measured as a maximum dimension. However, aneurysms are morphologically dynamic, a characteristic ignored by large prospective aneurysm risk studies. Manual measurement is challenging and fraught with error. We used an artificial intelligence (AI) measurement tool to study aneurysms that ruptured during conservative management to detect changes in size not appreciated by manual linear measurement., Methods: A single practice database with >5000 aneurysms was queried. Patients followed conservatively for an unruptured aneurysm were identified using appropriate diagnosis codes. This cohort was screened for subsequent rupture using procedure codes. Only patients with two vascular imaging studies before rupture were included., Results: Five patients met the criteria. All patients had aneurysm enlargement, two of which were not detected from manual linear measurements, including adjudication and analysis, during a multidisciplinary neurovascular conference in a high volume practice. Maximum dimension increased at a minimum of 1.8% (range 1.8-63.3%) from the first scan to the last, and aneurysm volume increased at a minimum of 5.9% (5.9-385.5%), highlighting the importance of volumetric measurement., Conclusions: AI-enabled volumetric measurements are more sensitive to changes in size and detected enlargement in all aneurysms that ruptured during conservative management. This finding has major implications for clinical practice and methods used for interval aneurysm measurement in patients being conservatively followed., Competing Interests: Competing interests: DHS: consultant for Medtronic, Microvention and Phenox, grant from Microvention, payment or honoraria for lectures from Medtronic and Microvention, support for attending meetings from Microvention and Medtronic. DPG: data support and consultant for iSchemaView. KA: consultant for Medtronic., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Importance: Indocyanine green angiography (ICGA) has become a useful intraoperative tool during aneurysm surgery to determine parent, branching, and perforator vessel patency. Although extremely useful, ICGA is limited to the evaluation of vessels that are in direct view in the surgical field., Clinical Presentation: We present 2 cases of patients who underwent a craniotomy for clipping of unruptured posterior communicating artery aneurysms. A Yaşargil movable mirror was used as an adjuvant to ICGA to visualize the ventromedial posterior communicating vessels after clip placement to determine vessel patency., Conclusion: Although ICGA can be very useful during aneurysm surgery, it is limited to vessels directly visualized in the surgical field. A Yaşargil movable mirror can be used during ICGA to visualize elusive vessels, in these cases on the ventromedial surface of the internal carotid artery.

Objective: Intraoperative rupture (IOR) of an aneurysm is a known risk in the surgical management of intracranial aneurysms. The purpose of this study was to determine the incidence of IOR in a modern surgical series and to assess which factors bear upon it., Methods: This study retrospectively examined 1269 patients with saccular aneurysms treated surgically between 1986 and 1998. Three vascular neurosurgeons performed 1435 operations on 1694 aneurysms. Multiple factors, including the magnitude and time of occurrence of IOR, aneurysm location, subarachnoid hemorrhage, timing of surgery, and use of temporary occlusion, were analyzed., Results: There were 113 instances of IOR (7.9% per surgery; 6.7% per aneurysm; 8.9% per patient). If the 59 "minor leaks" are excluded (as in previously published reports), the incidence becomes 3.8% per surgery, 3.2% per aneurysm, and 4.3% per patient. Posteroinferior cerebellar artery and anterior and posterior communicating artery aneurysms were more liable to rupture intraoperatively. The IOR rate was greater in ruptured than unruptured aneurysms (10.7 versus 1.2%, P < 0.0001). There was a lower rate of IOR in operations using temporary arterial occlusion (3.1 versus 8.6%, P < 0.0001). The occurrence of IOR for early surgery was not significantly higher than for surgery performed more than 3 days after subarachnoid hemorrhage (11.1 versus 10.0%, P = 0.6234)., Conclusion: The rate of significant IOR can be kept low. Aneurysm location, subarachnoid hemorrhage, and temporary arterial occlusion seem to be important factors affecting the incidence of IOR.

Unlabelled: The benefit of using intraoperative angiography (IA) during aneurysm surgery is still uncertain., Object: In this prospective study, the authors evaluate the radiographically demonstrated success of surgical treatment in 151 consecutive patients harboring 173 aneurysms who selectively underwent IA examination. The authors also assess the frequency with which IA led to repositioning of the aneurysm clip., Methods: Intraoperative angiography was used selectively in this series, based on the surgeon's concern about the potential for residual aneurysm, distal branch occlusion, or parent vessel stenosis. Specific variables were analyzed to determine their impact on the incidence of clip repositioning and the accuracy of IA was evaluated by direct comparison with postoperative angiography (PA) in 90% of the cases in which IA was used., Conclusions: The selective use of IA led to successful treatment as shown by PA, with a low incidence of unexpected residual aneurysm (3.2%), distal branch occlusion (1.9%), and parent vessel stenosis (0%). Intraoperative angiography led to immediate repositioning of the aneurysm clip in 27% of the cases. Anterior cerebral artery aneurysms required clip repositioning less often and superior hypophyseal artery aneurysms required repositioning more often than aneurysms in other locations. Large and giant aneurysms required clip repositioning more often than small aneurysms; however, they were also more likely to display false success on IA as determined by PA. Aneurysms arising along the internal carotid artery were more likely to display successful clipping on IA, as determined by PA, than were aneurysms in other locations. The results of this series support the selective use of IA in the treatment of complex aneurysms, particularly large and giant aneurysms as well as superior hypophyseal artery aneurysms. As measured by PA, IA will improve the outcome of these patients.