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Purpose: Intracranial aneurysms present significant health risks, as their rupture leads to subarachnoid haemorrhage, which in turn has high morbidity and mortality rates. There are several elements affecting the complexity of an intracranial aneurysm. However, criteria for defining a complex intracranial aneurysm (CIA) in open surgery and endovascular treatment could differ, and actually there is no consensus on the definition of a "complex" aneurysm. This DELPHI study aims to assess consensus on variables defining a CIA., Methods: An international panel of 50 members, representing various specialties, was recruited to define CIAs through a three-round Delphi process. The panelists participated in surveys with Likert scale responses and open-ended questions. Consensus criteria were established to determine CIA variables, and statistical analysis evaluated consensus and stability., Results: In open surgery, CIAs were defined by fusiform or blister-like shape, dissecting aetiology, giant size (≥ 25 mm), broad neck encasing parent arteries, extensive neck surface, wall calcification, intraluminal thrombus, collateral branch from the sac, location (AICA, SCA, basilar), vasospasm context, and planned bypass (EC-IC or IC-IC). For endovascular treatment, CIAs included giant size, very wide neck (dome/neck ratio ≤ 1:1), and collateral branch from the sac., Conclusions: The definition of aneurysm complexity varies by treatment modality. Since elements related to complexity differ between open surgery and endovascular treatment, these consensus criteria of CIAs could even guide in selecting the best treatment approach., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Introduction: The recent emphasis on simulation-based training in neurosurgery has led to the development of many simulation models and training courses. We aimed to identify the currently available simulators and training courses for neurovascular surgery and endovascular interventions to assess their validity and determine their effectiveness to suggest widespread applicability in educational curricula., Evidence Acquisition: Literature research was performed on academic databases for English language articles that validate simulation or virtual reality intracranial aneurysm models. Studies for neurosurgery and interventional neuroradiology published between January 2011 and January 2021 were included. Each study was assessed according to the Medical Education Research Quality Instrument., Evidence Synthesis: Between January 2011 and January 2021, 44 articles were screened and 12 were identified to be included in our research. The study involved 177 trainers. Participant trainers' characteristics reveal sensible homogeneity between studies. All studies reported a significant improvement in technical outcomes after simulator or virtual reality training. The Medical Education Research Quality Instrument average rate from 12 studies was M=11.7 (range: 8.5-14.5)., Conclusions: Nowadays, the training of a medical doctor in the neurovascular field benefits from modern methods like simulators and virtual reality. With the advent of increasing neurosurgery simulators and training instruments, there is a need for more validity studies. More training tools incorporating full-immersion simulation are recommended to develop a standardized learning curve in neurovascular procedures.

Cotinine, the primary metabolite of nicotine, is currently regarded as the best biomarker of tobacco smoke exposure. We aim to assess whether cotinine levels are associated with (1) intracranial aneurysm and (2) intracranial aneurysm rupture., Methods: We performed a single-center case-control study. Cases were consecutive patients admitted with diagnosis of brain aneurysm (ruptured or unruptured). We randomly selected controls without intracranial aneurysm from the same source population that produced the cases. Smoking data were collected by questionnaire, and serum levels of cotinine were used as an objective measure of nicotine exposure. Logistic regression models were used to assess the relationship between cotinine levels and aneurysm rupture., Results: We included 86 patients with intracranial aneurysm and 96 controls. Smoking status (p < .001), cotinine levels (p = .009), and female sex (p = .006) were associated with diagnosis of intracranial aneurysm. In the multivariate analysis, controlling for sex, smoker status and age, levels of cotinine were independently associated with aneurysm rupture (OR 1.53, 95% CI 1.10-2.13, p = .012)., Conclusions: Our results suggest that high cotinine levels in smokers with brain aneurysm are significantly associated with high rupture risk, independently of smoker status, age, and sex., (© 2022 The Authors. Acta Neurologica Scandinavica published by John Wiley & Sons Ltd.)

The aim of this study is to compare occlusion rate, complication rate, and clinical outcome of microsurgical clipping (MC) and advanced endovascular techniques (EVT) in unruptured anterior communicating artery-complex aneurysms (ACoCAs). We reviewed the scientific literature reporting occlusion rate, time of occlusion assessment, and clinical outcome of MC and EVT in patients with unruptured ACoCAs, from January 2009 to December 2019. We included in our analysis 25 studies and 872 patients with unruptured ACoCAs (434 treated with endovascular techniques and 438 with MC). Ninety-three (10.7%), 320 (36.7%), 21 (2.4%), and 438 (50.2%) were treated with flow diverter (FD), stent-assisted coiling (SAC), endosaccular devices (ES), and microsurgical clipping (MC) respectively. FD, SAC, ES, and MC subgroups presented minor complications in 11.8%, 3.8%, 14.3%, and 7.1% of cases (p=.016), and major complications in 3.2%, 4.4%, 0%, and 7.1% (p=.136) of patients. A total occlusion rate post-treatment has been achieved in 4.3%, 87.1%, 47.6%, and 98.2% of cases (p=.000), while at 12 months' follow-up in 50%, 66%, 83.3%, and 80% of patients (p=.001). FD, SAC, ES, and MC subgroups had a good clinical outcome at 12 months in 93.5%, 90.5%, 100%, and 67.8% of cases. MC is associated with higher post-treatment total occlusion rate, but higher complication and lower good clinical outcome rates. EVT are promising in treating unruptured anterior cerebral artery aneurysms with high margin of safety and good clinical outcome, despite the lower total occlusion rate., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: The flow-diverter devices (FDDs) safety and effectiveness have been demonstrated by large series and meta-analyses. Due to the high occlusion rates and the acceptable morbidity rates of FDDs, the indications for their use are continuously expanding. We presented our Italian multicentric experience using the second generation of DERIVO® Embolization Device (DED ® ; Acandis, Pforzheim, Germany) to cure cerebral aneurysms, evaluating both middle and long-term safety and efficacy of this device., Methods: Between July 2016 and September 2017 we collected 109 consecutive aneurysms in 108 patients treated using DED ® during 109 endovascular procedures in 34 Italian centers (100/109 aneurysms were unruptured, 9/109 were ruptured). The collected data included patient demographics, aneurysm location and characteristics, baseline angiography, adverse event and serious adverse event information, morbidity and mortality rates, and pre- and post-treatment modified Rankin Scale scores. Midterm and long-term clinical, angiographic and cross-sectional CT/MR follow-up were recorded and collected until December 2018., Results: In 2/109 cases, DED ® placement was classified as technical failures. The overall mortality and morbidity rates were respectively 6.5% and 5.5%. Overall DERIVO® related mortality and morbidity rates were respectively 0% and 4.6% (5 out of 108 patients). Midterm neuroimaging follow-up showed the complete or nearly complete occlusion of the aneurysm in 90% cases, which became 93% at long-term follow-up. Aneurysmal sac shrinking was observed in 65% of assessable aneurysms., Conclusions: Our multicentric experience using DED ® for endovascular treatment of unruptured and ruptured aneurysms showed a high safety and efficacy profile, substantially equivalent or better compared to the other FDDs.

Objective: Analyzing occlusion, complications rate, and clinical results in unruptured saccular middle cerebral artery aneurysms (MCAAs) comparing clipping with the most advance and newer endovascular techniques., Methods: We conducted a literature research from January 2009 to December 2018 to evaluate the efficacy and safety of microsurgical clipping or endovascular treatment with new devices (such as Flow-diverter or Woven EndoBridge) in patients with unruptured MCAAs. We extracted data involved: study and intervention features, occlusion rate; time of occlusion assessment; and clinical outcome., Results: A total of 29 studies and 1552 patients with unruptured saccular MCAAs were included in our analysis (464 patients included in the endovascular group, 1088 patients in the surgical group). Overall, the rate of long-term complete/near-complete occlusion was 78.1% (311/405, 95% confidence interval [CI], 69%-87.1%) and 95.7% (113/118, 95% CI, 92%-99.3%) after endovascular and surgical treatments, respectively (P = 0.001). The long-term complete occlusion rate was 60% (153/405, 95% CI, 45%-74%) and 95% (112/118, 95% CI, 90%-98%) after endovascular and surgical treatments, respectively (P = 0.001). The overall rate of treatment-related complications was 5.6% (33/464, 95% CI, 3.6%-7.7%) and 2.9% (37/1088, 95% CI, 0.8%-5%) among the endovascular and surgical groups, respectively (P = 0.001). Endovascular treatments were associated with higher rates of good neurologic outcome (283/293 [97%], 95% CI, 95%-98% vs. 570/716 [84%], 95% CI, 67%-98%; P = 0.001). No difference was found for the mortality (3/464 [1.5%], 95% CI, 0.4%-2.6% vs. 1/1088, 95% CI, 0.1%-0.6%; P = 0.5)., Conclusions: Treatment-related complication and mortality are comparable among these techniques and the risk of aneurysm rupture seems very low for both strategies. The endovascular approach seems to increase the probability of good functional outcome after treatment, compared with surgery., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Intracranial pseudoaneurysm (IPA) is a rare but likely underdiagnosed cause of intracranial hemorrhage, which accounts for just 1-6% of all intracranial aneurysms. Spontaneous IPAs are exceptionally rare, and their etiology and features are not well defined. Herein, we report a case of a pediatric patient who died from massive intracranial bleeding due to the rupture of a spontaneous IPA after undergoing multiple radiological studies and neurosurgical operations. At the postmortem examination of the brain, a giant size pseudoaneurysm of the right middle cerebral artery was observed. Microscopic examination demonstrated variable wall thickness and dense fibrosis focally in the vessel wall with disruption of the media structure together with a loss and fragmentation of the elastic laminae, loss of organization of smooth muscle cells in the media, and multifocal areas of hemorrhage throughout the vessel wall, as well as direct evidence of wall dissection. Since IPAs without any traumatic or infective history are extremely uncommon, further pathologic studies should be performed to clarify spontaneous pseudoaneurysm etiology.

Aneurysms arising from the ophthalmic artery trunk (OAT) are very rare, particularly in the artery's intracranial course. The onset of a subarachnoid hemorrhage (SAH) from a ruptured OAT aneurysm in this segment is extremely rare. We present a case and discuss the anatomy, clinical significance, and therapeutic options for an aneurysm at this site. We also retrospectively analyzed the record of a patient with a ruptured aneurysm of the intracranial segment of the OAT and conducted a comprehensive and systematic review of the PubMed and Scopus databases for literature on this pathology. Only one case report of SAH from an aneurysm of the intracranial segment of the OAT was published in the literature. Only in our case was the intracranial OAT segment aneurysm discovered in the acute phase of SAH. Conventional angiography with three-dimensional acquisition may help detect aneurysms at this level. Detailed knowledge of the anatomy of the OAT is of paramount importance for both surgical and endovascular approaches. Surgical treatment is complex because of difficulties in accessing the orbital region and the risk of optic nerve and vascular injuries. Endovascular treatment, when feasible, could be a good alternative to reduce the risk of loss of vision related to surgical manipulation., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Blood blister-like aneurysms (BBA) consist of focal wall defects covered with thin fibrous tissue correlated with the marked fragility of their wall; this concept is very important for deciding the right treatment of the latter. Until 2008, it was thought that this type of aneurysm almost exclusively affected the internal carotid artery, and in particular, of its dorsal portion. Subsequently, it was discovered that the BBA may also be present on the anterior communicating artery and on the posterior cranial fossa vessels. In this article, we present a case of anterior communicating artery (AComA) BBA and discuss the unique diagnostic and therapeutic aspects of this vascular lesion. Treatment requires an experienced team of vascular and endovascular neurosurgeons to treat this hazardous group of aneurysms; endovascular stenting techniques avoid maneuvres on the aneurysm itself and should therefore be judged as the lowest risk and first-choice procedures available. We found no reports in the English-language literature of BBA that arose from the AComA treated by a Flow-diverter stent (FDS) in the acute phase. BBA constitute technically challenging lesions that may occur at the AComA. Endovascular treatment offers a lower morbidity-mortality compared with surgical approaches; FDS appear to be a promising strategy.

Background: Although flow diverters (FDs) have been widely accepted by neurointerventionists, their safety has yet to be fully defined. Stratification by aneurysm size and location is essential for correct evaluation of treatment outcomes and risks of flow diversion., Objective: To compare neurological and anatomic outcomes and evaluate the risk of complications after endovascular treatment of large or giant internal carotid artery (ICA) aneurysms with FD/FDs alone or together with coil embolization., Methods: We reviewed all patients with large or giant, ruptured or unruptured ICA aneurysms who underwent endovascular treatment with flow diversion alone (group A) or with concomitant coiling (group B) in 4 international institutions between 2010 and 2015. Anatomic outcome was evaluated using the Byrne scale on digital subtraction angiography and/or angioMRI and/or angioCT scans 3, 6, 12, and 24 months postoperatively., Results: We collected 44 patients with large or giant ICA aneurysms. Four patients (9%) presented with aneurysmal subarachnoid hemorrhage (SAH). FD/FDs were used alone in 26 patients and in combination with coil embolization in the 18 remaining patients. The mortality rate due to procedure-related and/or neurological complications was 2.2%. Twelve months after the procedure, 88.6% (n = 39) of patients had a favorable neurological outcome. One year after the procedure, the aneurysm was completely occluded in 72.7% of patients: 61.5% (16/18) in group A and 88.9% (16/26) in group B., Conclusion: Clinical outcomes and rates of intraoperative and postoperative complications did not differ significantly between the groups. Better anatomic results using FD/FDs combined with coils were documented 6 months after the procedure; this option seems to provide a higher aneurysm occlusion rate and reduce the need for retreatment., (Copyright © 2017 by the Congress of Neurological Surgeons)

Background: Intracranial carotid artery aneurysm can be treated via microsurgical or endovascular techniques. The optimal planning is the result of the careful patient selection through clinical, anatomic, and angiographic analysis., Clinical Presentation: We present a case of ruptured internal carotid artery (ICA) aneurysm that became a complex aneurysm after failure of multi-endovascular and surgery treatment. We describe complete trapping in awake craniotomy after failure of coiling, stenting, and bypassing., Conclusions: ICA aneurysms could become complex aneurysms following multi-treatment failure. Endovascular approaches to treat ICA aneurysms include coiling, stenting, flow diverter stenting, and stenting-assisted coiling technique. The role of surgery remains relevant. To avoid severe neurologic deficits, recurrence, and the need of retreatment, a multidisciplinary discussion with experienced endovascular and vascular neurosurgeons is mandatory in such complex cases., (Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Introduction: The purpose of this study is to report on a multi-center experience of ruptured intracranial aneurysms treated in acute phase with stent-assisted coil embolization, including primary success rates and midterm follow-up results., Materials and Methods: Retrospective analysis was performed on a sample of 40 patients (14 men, 26 women, mean age 59.7 years) affected by ruptured saccular aneurysms and treated by stent-assisted coiling in acute phase; double antiplatelet therapy with clopidogrel bisulphate and acetylsalicylic acid was started after the procedure. Angiographic follow-up at 1 year was recorded., Results: 20 % of the aneurysms were located in the posterior circulation, and 85 % presented a wide neck. Mean size of the sac was 7 mm (range 3-22 mm). Complete sac exclusion was obtained in 92.5 % and neck remnant in 7.5 %. The overall complications rate was 15 %. In 7.5 %, stent occlusion occurred intra-procedurally. In 12.5 %, re-bleeding was detected within 3 weeks after the procedure. Ischemic area related to the procedure was observed at follow-up in 7.5 %. Hydrocephalus developed in 15 %. 7.5 % presented with sac re-bleeding between 1 and 5 months after the procedure. In 15 %, the 3-6 months of follow-up revealed aneurysm refilling. 25 % of the patients presented vessel stenosis at the 1-year DSA of control. 33 % of the patients reported sensory-motor deficits. 82.5 % had a favorable outcome (GOS: IV-V), while 17.5 % presented a poor score (GOS: I-III)., Conclusions: Stent-assisted coil embolization is a feasible endovascular treatment option for ruptured intracranial aneurysms, which is difficult to approach with simple coiling; however, neurointerventionalists need to consider a mild increase of post-procedural complications rate.

Background and Purpose: Blister-like aneurysms are uncommon but challenging lesions. Their small size and atypical location often make the diagnosis difficult. Microsurgery and endovascular procedures have been used for their treatment, but there is no consensus on the best treatment technique. We conducted a systematic review and meta-analysis of treatments and outcomes of these vascular lesions., Materials and Methods: We reviewed English-language articles on "blood blister-like aneurysms" published between January 1997 and November 2014. All studies reporting patients with these aneurysms treated with surgery, endovascular procedures, or combined therapy with data on treatment modalities and clinical and/or angiographic outcomes were selected, including case reports and series. We performed a meta-analysis on the 2 largest treatment groups (surgery and endovascular management)., Results: Sixty studies with 334 patients met our inclusion criteria. Surgery was performed in 114 patients (34.2%), and endovascular treatment, in 199 patients (59.5%). A combined treatment was used in 19 patients (5.7%). A favorable outcome (mRS 0-2) was reported in 67.4% and 78.9% of patients treated with surgery and with endovascular therapy, respectively (P = .034)., Conclusions: Blister-like aneurysms are challenging vascular lesions. The choice of treatment method must be based on the initial clinical presentation and an analysis of the radiologic features of the lesion to select the best technique. Endovascular treatment seems to have lower morbidity and mortality and provides a better outcome compared with surgical approaches. Further prospective studies must be performed to confirm such interesting results., (© 2016 by American Journal of Neuroradiology.)

Objective: To describe the history of vascular and endovascular neurosurgery., Methods: A literature research was conducted including historical events from 2000 bc to the twenty-first century ad, and a timetable was filled with information regarding the most representative historical landmarks regarding vascular and endovascular neurosurgery., Results: Starting from approaches limited to the cervical carotid artery, vascular neurosurgery gained its way through the intracranial and finally endovascular space thanks to the introduction of both innovative and progressively less invasive procedures. With the invention of cerebral angiography in 1927, Egas Moniz paved the way for modern endovascular neurosurgery., Conclusions: Numerous pioneers have been described through this historical reconstruction. Their genius, effort, dedication, and passion brought a massive contribution to vascular and endovascular neurosurgery as we know it today., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: Basilar trunk perforator (BTP) aneurysms are rare. Treatment options traditionally considered for these uncommon lesions have included direct surgery, endovascular therapy, or conservative management. Flow diverters represent a newer therapeutic option for BTP aneurysms but pitfalls and complications are unknown. We describe three patients with BTP aneurysms treated with flow diverter stents., Methods: All three patients had ruptured BTP aneurysms and, after loading doses of dual antiplatelet agents, underwent treatment with a flow diverter alone (two patients) or in combination with an intracranial stent (one patient)., Results: Complications directly (two thromboembolic events) or indirectly (one hemorrhage at the external ventricular drain site, probably facilitated by the dual antiplatelet therapy) occurred in all three patients and resulted in permanent morbidity in one case. Imaging follow-up confirmed obliteration in all three patients, and no episodes of rebleeding from the aneurysms were observed at follow-up., Conclusions: Flow diverters are effective in obliterating BTP aneurysms. However, given the challenges and complications encountered, especially in patients with ruptured lesions, their use must be carefully weighed against other available therapeutic modalities, including observation., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objective: Blister-like aneurysms (BLAs) were originally described to arise typically along the nonbranching segment of the dorsal wall of the internal carotid artery (ICA); however, BLAs located in areas other than the dorsal ICA have been described more recently. We present a case series of "atypical" BLAs and a systematic review of the literature on this subject., Methods: We conducted a literature search using the key word "blister-like aneurysm." Studies reporting BLAs in locations other than the dorsal ICA wall were selected. Clinical presentation, treatment modality, complications, and outcomes (modified Rankin Scale for neurologic outcomes and Roy scale for radiologic outcomes) were extracted from each study. We also reviewed our single-institution experience with atypical BLAs and analyzed the topography and outcomes of all the atypical BLAs according to each specific treatment modality., Results: Atypical BLAs were observed in the anterior communicating, middle cerebral, basilar, posterior cerebral, anterior cerebral, and posterior inferior cerebellar arteries. Surgery was the treatment in 65% of patients, an endovascular approach was used in 30%, and a combined approach was used in 5%. A good outcome (modified Rankin Scale 0-1-2) was experienced by 88% and 55% of the patients in the endovascular and surgical groups, respectively. There were 4 deaths, 2 in the endovascular group and 2 in the surgical group., Conclusions: Endovascular treatment of BLAs seems to be associated with reduced morbidity and mortality and to provide a better outcome compared with surgical approaches. Further prospective studies are needed to confirm these results. It is important for clinicians to remember that BLAs may also occur in sites other than the typical ICA location., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective and Importance: To demonstrate the curative reconstruction of two giant fusiform aneurysms using a combination of flow-diverter stents and self-expanding stents for intracranial use., Clinical Presentation: Two cases that would have been difficult to manage with standard methods: one patient with deficiencies of cranial nerves VI and VII on the left, acute diplopia, and an aneurysm of the vertebrobasilar bifurcation, the other with diplopia, deficiencies of cranial nerves III and VI, and an aneurysm of the intracavernous internal carotid artery. INTERVENTION OR TECHNIQUE: Complete reconstruction was achieved using a combination of flow-diverter and self-expandable stents. Follow-up investigations at 6 months demonstrated the complete reconstruction of the arteries and angiographically determined disappearance of the aneurysms with resolution of the clinical profile. The patients' outcome was excellent (modified Rankin Scale: 0)., Conclusion: This technique enables safe and definitive treatment of lesions that would be difficult to manage with other methods. The greater metal surface does not seem to interfere with the perforating arteries originating from the segments involved., (Georg Thieme Verlag KG Stuttgart · New York.)

Blood blister-like aneurysms (BBA) were described for the first time in the 1990s, as small hemispherical bulges arising from a very fragile arterial wall. Until 2008, it was thought that this type of aneurysm almost exclusively affected the internal carotid artery, in particular, its dorsal portion. Subsequently, it was discovered that a BBA may also be present on the anterior communicating artery and on the vessels of the posterior cranial fossa. However, we found no reports in English-language literature of BBA arising from the middle cerebral artery (MCA). In this article, we present three cases of MCA BBA and discuss the unique diagnostic and therapeutic aspects of this vascular lesion. In our retrospective, multicenter review of 1330 patients with non-traumatic subarachnoid hemorrhage admitted to our services from 2000 to 2013, we found three cases (all in men) of MCA BBA. The patients' outcome was assessed using the modified Rankin scale. All three patients underwent angio-computed tomography, which did not reveal any aneurysms. Digital subtraction angiography performed within 24-48 h after admission, in all cases, demonstrated a very small aneurysm (<2 mm), with a triangular shape and abroad base, at non-branching sites of MCA. All the aneurysms were treated: one by wrapping + clipping, one by wrapping + flow-diverter stent, and one with coils. At the time of surgery, the aneurysms appeared on the surface of the parent artery without any involvement of the branches. All presented as blister-like aneurysms that were thin-walled and lacked a surgical neck. At the time of discharge, the outcome was good in one patient and poor in the other two. Our cases demonstrate that BBA can also arise from the MCA, despite the lack of previous reports of this occurrence; a BBA should be suspected, particularly in cases of non-perimesencephalic subarachnoid hemorrhage in which the presence of a MCA aneurysm is suspected but not revealed by digital subtraction angiography or angio-computed tomography.