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Background: Cerebral angiography through the transradial approach (TRA) is associated with a low risk of complications, but in rare cases, these complications can be life-threatening., Case Presentation: A 56-year-old female patient was admitted for transradial cerebral angiography due to the complaint of right limb weakness and the diagnosis of cerebral infarction and cerebral artery stenosis. During the procedure, the patient coughed with expectoration and complained of throat discomfort, palpitations, and pains in the right shoulder and back. Emergency CT scan indicated hematoma in the middle mediastinum and the right thoracic cavity, and perforation of a branch of the subclavian artery was highly suspected. Subclavian artery angiography was conducted immediately, which revealed a patchy contrast medium overflow in a branch of the right costocervical trunk. Selective endovascular occlusion therapy was performed successfully with gelfoam particles and placement of 2 microcoils. At 12 days after cerebral angiography, the patient recovered well and was discharged from the hospital., Conclusion: Mediastinal and thoracic hematoma may occur due to vessel perforation during TRA cerebral angiography, in which guidewire advancement must be cautious. Early detection and appropriate countermeasures can reduce the severity of vascular perforation and subsequent hematoma., (© 2024. The Author(s).)

Rationale: Acute pulmonary embolism (PE), which can lead to cardiac and respiratory arrest, is a rare complication of cerebral angiography. However, neurologists do not pay attention to this., Patient Concerns: A 47-year-old male with a history of type 2 diabetes was admitted to our hospital for evaluation of surgical indications for unruptured ophthalmic aneurysms. After cerebral angiography, a fatal PE occurred. Through rapid identification and effective drug treatment, the patient recovered and was discharged., Diagnoses: A diagnosis of fatal PE was made based on the bedside ultrasonography and blood d-dimer level., Interventions: Cardiopulmonary resuscitation and intravenous thrombolysis of "50 mg alteplase" for continuous intravenous drip for 2 hours., Outcomes: The patient was recovered and no special discomfort was reported., Lessons: PE is a rare complication of cerebral angiography, but the fatality rate is very high. Neurologists must not only early identify and effectively treat this complication, but more importantly, pay attention to this complication, prevent it in advance, and reduce the occurrence of catastrophic events., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: We aimed to investigate the radiation dose to the eye lens (lens dose) during cerebral angiography and to evaluate the effectiveness of the lens dose reduction protocol for 3-dimensional rotational angiography (3D-RA) in reducing overall lens dose exposure., Methods: We conducted a randomized, controlled clinical trial at a tertiary hospital with patients undergoing cerebral angiography. The lens dose reduction protocol in 3D-RA involved raising the table to position the patient's eye lens away from the rotation axis. The lens dose was estimated by measuring the entrance surface air kerma using a photoluminescent glass dosimeter. The lens doses of 3D-RA, overall examination, and image quality were analyzed and compared between the two groups., Results: A total of 20 participants (mean age, 58±9.4 years; including 12 men [60%]) were enrolled and randomly assigned to either the conventional group or the dose reduction group. The median lens dose in 3D-RA was significantly lower in the dose reduction group compared with the conventional group (1.1 mGy vs 4.5 mGy, p<0.001). The total dose was significantly lower in the dose reduction group (median of 7.5 mGy vs 10.2 mGy, p=0.003). In the conventional group, 3D-RA accounted for 46% of the total lens dose, while in the dose reduction group, its proportion decreased to 16%. No significant differences were observed in the image quality between the groups., Conclusion: The lens dose reduction protocol resulted in a significant reduction in the lens dose of the 3D-RA as well as entire cerebral angiography, while maintaining the image quality., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: To assess the frequency, imaging appearances, and risk factors of brain microemboli following pediatric neuroangiography, as assessed by early diffusion-weighted MRI imaging (DWI)., Methods: This single-center, retrospective analysis investigated early DWI post-pediatric neuroangiography. Patients aged 0-18 years who had diagnostic neuroangiography and DWI within a week postprocedure were included. Data on clinical and procedural parameters and MRI findings were recorded. Univariate and multivariate analyses were performed on the following risk factors: age, weight, vasculopathy, antiplatelet drug use, access type, intraprocedural heparin, procedure duration, neck arteries catheterized, and angiographic runs. A p-value<0.05 indicated statistical significance., Results: Eighty-two children were included (40.2% female), mean age 10.1±4.5 years (range: 7 months-17 years). There were no intraprocedural thromboembolic complications recognized. DWI positivity was seen following 3.6% (3/82) procedures: two with transient symptoms, and one instance of silent microemboli. There were no territorial infarcts or clinical stroke. Children with underlying vasculopathy had a higher risk of microemboli from angiography than children without vasculopathy (OR 31.6, p=0.02), and the OR of microemboli following transradial angiography was 79.1 (p=0.005) as compared with transfemoral angiography. Univariate and multivariate analysis showed a significant association between microemboli and number of angiographic runs (p=0.004). Follow-up MRI in all three patients showed no residual abnormal signal., Conclusions: Cerebral microemboli are unusual following uncomplicated neuroangiography in children. However, in the presence of underlying vasculopathy and with transradial technique, the incidence approaches that reported in the adult literature. An increased association with the number of angiographic runs is an important and controllable factor., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Trans-radial (TRA) access has become increasingly prevalent in neurointervention. Nonetheless, mediastinal hematoma after TRA is an infrequent yet grave complication associated with a notably elevated mortality rate. While our review found no reported mediastinal hematoma cases managed conservatively within neuro-interventional literature, similar complications are documented in cardiac and vascular interventional radiology, indicating its potential occurrence across disciplines., Case Presentation: Carotid computed tomography angiography (CTA) showed calcified plaques with stenosis (Left: Severe, Right: Moderate) in the bilateral internal carotid arteries (ICAs) of an 81-year-old male presented with paroxysmal weakness in the right upper limb. Dual antiplatelet therapy with aspirin and clopidogrel was administered. On day 7, DSA of the bilateral ICAs was performed via TRA. Post-DSA, the patient experienced transient loss of consciousness, chest tightness, and other symptoms without ECG or MRI abnormalities. Hemoglobin level decreased from 110 g/L to 92 g/L. Iodinated contrast-induced laryngeal edema was suspected, and the patient was treated with intravenous methylprednisolone. Neck CT indicated a possible mediastinal hemorrhage, which chest CTA confirmed. The patient's treatment plan involved discontinuing antiplatelet medication as a precautionary measure against the potential occurrence of an ischemic stroke instead of the utilization of a covered stent graft and surgical intervention. Serial CTs revealed hematoma absorption. Discharge CT showed a reduced hematoma volume of 35 × 45 mm., Conclusions: This case underscores the need for timely identification and precise manipulation of guidewires and guide-catheters through trans-radial access. The critical components of successful neuro-interventional techniques include timely examination, rapid identification, proper therapy, and diligent monitoring., (© 2024. The Author(s).)

Background: At present, neurointerventional surgery requires angiographers to perform operations in the digital subtraction angiography (DSA) room. Ionising radiation and chronic joint damage are still unavoidable for angiographers. Therefore, we researched and developed a neurointerventional robot-assisted system, which is operated by angiographers in an operating room outside the DSA room. We have conducted a prospective, multicentre, randomised controlled trial to evaluate the safety and efficacy of a robot-assisted system in human cerebral angiography. In the future, this research will provide a platform for the research and development of an intelligent surgical system and bring revolutionary progress in neurointerventional surgery., Methods: From December 2020 to December 2021, 260 patients were enrolled from three medical centres, who were randomly and equally divided into a robot-assisted system group and a clinical routine cerebral angiography group. The success rate of angiography, the rate of the catheter reaching the target vessel, the operation time, X-ray radiation exposure and the incidence of related adverse events were compared between the two groups., Results: A total of 257 patients completed this trial; baseline characteristics of the two groups did not differ significantly. The success rate of angiography in both the control group and the experimental group was 100%. The rate of the catheter reaching the target vessel was 99.23% and 100.00% in the control and experimental groups, respectively. For the control versus experimental groups, the angiographic operation time was 48.59±25.60 min versus 47.94±27.49 min, respectively; the X-ray radiation dose was 735.01±554.77 mGy versus 821.65±705.45 mGy, respectively; and the incidence of adverse events was 23.44% versus 22.48%, respectively. No statistical differences were present between the two groups., Conclusion: The robot-assisted surgical system is more convenient for cerebral angiography and is as safe and effective as the traditional cerebral angiography., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Neurointerventional robotic systems have potential to reduce occupational radiation, improve procedural precision, and allow for future remote teleoperation. A limited number of single institution case reports and series have been published outlining the safety and feasibility of robot-assisted diagnostic cerebral angiography., Methods: This is a multicenter, retrospective case series of patients undergoing diagnostic cerebral angiography at three separate institutions - University of California, Davis (UCD); University of California, Los Angeles (UCLA); and University of California, San Francisco (UCSF). The equipment used was the CorPath GRX Robotic System (Corindus, Waltham, MA)., Results: A total of 113 cases were analyzed who underwent robot-assisted diagnostic cerebral angiography from September 28, 2020 to October 27, 2022. There were no significant complications related to use of the robotic system including stroke, arterial dissection, bleeding, or pseudoaneurysm formation at the access site. Using the robotic system, 88 of 113 (77.9%) cases were completed successfully without unplanned manual conversion. The principal causes for unplanned manual conversion included challenging anatomy, technical difficulty with the bedside robotic cassette, and hubbing out of the robotic system due to limited working length. For robotic operation, average fluoroscopy time was 13.2 min (interquartile range (IQR), 9.3 to 16.8 min) and average cumulative air kerma was 975.8 mGY (IQR, 350.8 to 1073.5 mGy)., Conclusions: Robotic cerebral angiography with the CorPath GRX Robotic System is safe and easily learned by novice users without much prior manual experience. However, there are technical limitations such as a short working length and an inability to support 0.035" wires which may limit its widespread adoption in clinical practice., Competing Interests: Competing interests: ST previously consulted for Corindus Vascular Robotics in 2018 and 2019 but currently has no relationship or stock options with the company. BW was a consultant for Siemens/Corindus in 2020 but currently has no relationship or stock options with the company., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Diagnostic cerebral digital subtraction angiography (DSA) is an invasive examination that involves catheterization of the major supra-aortic arterial trunks and evaluation of intracranial vessels for diagnostic purposes. Although considered the gold standard method for investigating cerebrovascular diseases, DSA carries measurable and potentially serious complication rates. This report describes the frequency of neurological and non-neurological complications of DSA performed in five hospitals in the state of São Paulo, Brazil, and analyzes them in different disease subgroups. It has a special focus on thromboembolic cerebral complications., Methods: We retrospectively reviewed clinical records of all adult patients who underwent DSAs between January 2019 and December 2022. Demographic variables, DSA reports, CT/MRI reports, and clinical follow-up notes were reviewed., Results: Twenty-four patients experienced some type of complication among 2,457 diagnostic DSAs (0.97%). Thromboembolic complications were recorded in 9 patients (0.36%), and access site hematomas larger than 5 cm were registered in six patients (0.24%). There was a statistical trend for thromboembolic complications in patients with cervical and/or intracranial atherosclerosis (p = 0.07), but age was not associated with them (p = 0.93). Patients who received heparin had lower rates of embolic complications than those who did not receive it, but there was no statistically significant difference (p = 0.17). Intravenous administration of heparin showed a trend toward significance with groin hematoma (p = 0.10)., Conclusion: Diagnostic catheter DSAs have low complication rates., (© 2024. Fondazione Società Italiana di Neurologia.)

Background: Rotational vertebrobasilar artery syndrome, or bow hunter syndrome, is a rare yet well-documented pathology. This study presents a surgical approach to a latent manifestation of dynamic, extension-only, bilateral codominant vertebral artery compression in the V3 segment, associated with craniocervical instability and central canal stenosis., Methods: The clinical presentation involves the treatment of positional vertigo resulting from left and high-grade right vertebral artery stenosis during neck extension only. Diagnosis was confirmed through a formal angiogram under provocative maneuvers. Surgical intervention, detailed in this section, employed a multidisciplinary approach, including intraoperative angiograms to ensure patent vertebral arteries precraniocervical fusion., Results: The surgical treatment demonstrated success in addressing extension-only vertebrobasilar syndrome and associated complications of C1-2 pannus and craniocervical instability. Intraoperative angiograms confirmed vertebral artery patency pre- and postsurgical positioning, ensuring the effectiveness of the multidisciplinary approach., Conclusions: This study concludes by highlighting the successful multidisciplinary surgical treatment of a patient with nonunion of a C1 Jefferson fracture, leading to extension-only vertebrobasilar syndrome complicated by C1-2 pannus and craniocervical instability. The importance of considering vertebral artery dynamic stenosis in cases of positional vertigo or transient neurological symptoms following an injury is emphasized. Surgical stabilization, particularly when conservative measures prove ineffective, is recommended, with careful attention to pre- and postsurgical positioning to verify vertebral artery patency and posterior vasculature integrity., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: We report a patient with extensive subarachnoid hemorrhage caused by the rupture of a middle cerebral artery pseudoaneurysm from a foreign body that had been left for two decades., Case Presentation: A 74-year-old male patient from Han nationality was admitted to the emergency department of our hospital with impaired consciousness for 1 hour. Cranial computed tomography examination indicated a massive subarachnoid hemorrhage with intraventricular blood accumulation, and a high-density short strip dense shadow was seen in the M1 segment of the right middle cerebral artery, considering the possibility of a foreign body. Subsequently, a cerebral angiography was suggested; the foreign body was seen through the right middle cerebral artery, and the aneurysm was seen in the lower wall, so a pseudoaneurysm was considered. The emergent surgical intervention involved the clipping of the pseudoaneurysm and intracranial extraction of the foreign body. Unfortunately,the patient ultimately expired due to severe pulmonary infection., Conclusion: Intracranial pseudoaneurysm caused by foreign body has been rarely reported previously, and microsurgical treatment of an intracranial pseudoaneurysm caused by a foreign body is a good choice., (© 2024. The Author(s).)

Hidden bow hunter's syndrome (HBHS) is a rare disease in which the vertebral artery (VA) occludes in a neutral position but recanalizes in a particular neck position. We herein report an HBHS case and assess its characteristics through a literature review. A 69-year-old man had repeated posterior-circulation infarcts with right VA occlusion. Cerebral angiography showed that the right VA was recanalized only with neck tilt. Decompression of the VA successfully prevented stroke recurrence. HBHS should be considered in patients with posterior circulation infarction with an occluded VA at its lower vertebral level. Diagnosing this syndrome correctly is important for preventing stroke recurrence.

Aims: The aim of this study is to examine the association between diabetes mellitus and postoperative urinary retention on cerebral angiography (including intravascular interventional therapy)., Methods: We collected data on the demographic characteristics and comorbidities, imaging and routine laboratory data, surgical information, and medications of patients who underwent cerebral angiography. Multivariate logistic regression was used to explore the correlation between diabetes and the incidence of postoperative urinary retention., Results: A total of 932 patients were included, with a mean age of 59.7 years (74.1% men). Postoperative urinary retention occurred in 40.8% of the diabetes mellitus group and 30.3% of the group without diabetes. Compared with the group without diabetes, those with diabetes were more likely to experience postoperative urinary retention. Patients with higher glycosylated hemoglobin A1c levels had a higher risk of developing postoperative urinary retention., Conclusions: Diabetes was independently linked to postoperative urinary retention following cerebral angiography and patients with glycosylated hemoglobin A1c levels > 6% were more likely to experience postoperative urinary retention. Therefore, clinically regulating blood glucose levels may help to reduce the likelihood of postoperative urinary retention after cerebral angiography., (© 2023 Wiley Periodicals LLC.)

Purpose: To retrospectively evaluate the total complication rates and type of complications after diagnostic cerebral and spinal catheter angiography., Methods: Data from 2340 patients undergoing diagnostic angiography over a period of 10 years in a neuroradiologic center were retrospectively evaluated. Local, systemic, neurological, and technical complications were analyzed., Results: A total of 75 clinically noted complications occurred. The risk for clinical complications was increased when the angiography was performed under emergency conditions (p = 0.009). The most common complication was groin hematoma (1.32%). Neurological complications occurred in 0.68% of patients, of which 0.13% were stroke with permanent disability. Technical complications without noticeable clinical symptoms of the patients occurred in 2.35% of the angiographic procedures. Deaths caused by angiography did not occur., Conclusion: There is a definite risk for complications after diagnostic angiography. Although a very broad spectrum of complications was considered, complications in the individual subgroups showed a low incidence., (© 2023. The Author(s).)

Intracranial aneurysms are focal pathological dilatation of the arteries with a prevalence of 3.2%. Fusiform aneurysms are rare and mainly due to dissection or atherosclerosis. They may manifestas as stroke, cranial nerve palsies, brainstem compression and Sub-arachnoid hemorrhage. A diameter greater than 10 mm is a risk factor for rupture and warrants early intervention.

BACKGROUND Moyamoya disease is a rare and progressive cerebrovascular disorder caused by narrowed or blocked arteries supplying the brain. First described in Japan, the disease's incidence is higher in Asian countries and primarily affects children, although adults can also be afflicted. Following a literature review, very little was found regarding non-Asian ethnicities and the lack of typically associated risk factors that are known correlates of Moyamoya disease. CASE REPORT We present the case of a 41-year-old Hispanic woman with a history of type 1 diabetes mellitus and asthma who presented to the Emergency Department with concerns of recurrent transient episodes of left upper extremity weakness and paresthesia followed by confusion. The patient's blood pressure on arrival was 215/134 mmHg, and heart rate was 124 beats per min. Computed tomography of the head was unremarkable, but a computed tomography angiogram of the head demonstrated several areas of severe and bilateral stenosis with radiographic appearances, suggestive of Moyamoya disease. Magnetic resonance imaging of the brain would later illustrate two 6×2-mm ischemic infarcts in the right posterior centrum semiovale. CONCLUSIONS Moyamoya disease in the non-Asian population is rarely reported. We present a case of this condition in a patient of Hispanic ethnicity. Although it is generally considered a non-atherosclerotic disease, some literature suggests that atherosclerotic disease may also contribute to the development and possible acceleration of clinical features of Moyamoya disease. Given our patient's risk factors, we postulated that our patient's presentation was likely multifactorial, with both non-sclerotic and atherosclerotic disease.

A middle-aged adult presented to the hospital with a high-grade aneurysmal subarachnoid hemorrhage. The patient was treated with endovascular coil embolization of a ruptured basilar tip aneurysm. Angiography demonstrated multiple other aneurysms, including type I persistent primitive olfactory artery aneurysm. After complete recovery and return to independence, the patient underwent elective treatment of the persistent primitive olfactory artery aneurysm with endovascular placement of a flow diversion stent. Persistent primitive olfactory artery is an extremely rare variant of the anterior cerebral artery with an incidence of 0.14% and a known increased risk of aneurysm formation., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: The course of the vertebral artery and its relationship to the C 0-1-2 structures render it particularly vulnerable to mechanical trauma. In the present study, we investigated the course of vertebral arteries along the craniovertebral junction (CJ) to cast light on the biomechanical aspects of aneurysm formation, focusing mainly on the relation of the vertebral artery injuries to the CJ bony landmarks. Herein, we report our experience with fourteen cases of craniovertebral junction vertebral artery (CJVA) aneurysms and their presentations, management, and outcomes., Materials and Methods: We extracted from 83 vertebral artery aneurysms only those 14 cases whose aneurysms were located at the C 0-1-2 . We reviewed all medical records, including operative reports and radiologic images. We divided the CJVA into 5 segments and then carefully reviewed the cases, largely focusing on the CJVA segments involved in the aneurysm. Angiographic outcomes were determined by angiography, which was scheduled at 3-6 months, 1, 2.5, and 5 years postoperatively., Results: A total of 14 patients with CJVA aneurysms were included in the present study. 35.7 % had cerebrovascular risk factors, while 23.5 % had other predisposing factors such as an AVM, an AVF, or a foramen magnum tumor. Predisposing factors in the form of neck trauma, both direct and indirect, were identified in 50 % of cases. The segmental distribution of aneurysms was as follows: three (21.4 %) at CJV 1, one (7.1 %) at CJV 2, four (28.6 %) at CJV 3, two (14.3 %) at CJV 4, and four (28.6 %) isolated to the CJV 5 segment. Of the 6 indirect traumatic aneurysms, 1 (16.7 %) was located at CJV 1, 4 (66.7 %) were located at CJV 3 and 1 (16.7 %) was located at CJV 5. The 1/1 direct traumatic aneurysm (100 %) from the penetrating injury was located at CJV 1. 100 % of cases with cerebrovascular risk factors, the affected vessels were on the dominant side. 42.9 % of cases presented symptoms of a vertebrobasilar stroke. All 14 aneurysms were managed only endovascularly. 85.8 % of patients we implemented flow diverters only. 57.1 % of follow-up cases were completely occluded angiographically, and 42.9 % of cases were near-completely or incompletely occluded at 1, 2.5, and 5-year follow-ups., Conclusions: The current article is the first report of a series of vertebral artery aneurysms located in CJ. Herein, the association of vertebral artery aneurysm, hemodynamics, and trauma is well established. We clarified all segments of the CJVA and showed that the segmental distribution of CJVA aneurysms significantly differs between traumatic and spontaneous cases. We showed that treatment with flow diverters should be the mainstay of CJVA aneurysm treatment., Competing Interests: Competing interests The authors declare that they have no competing interests during the writing or submission of this article., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Diagnostic Criteria Study BACKGROUND: The morbidity and mortality associated with ischemic stroke attributable to blunt cerebrovascular injury (BCVI) warrant aggressive screening. The Denver Criteria (DC) and Expanded Denver Criteria (eDC) have imprecise elements that can be difficult and subjective in application and can delay or prevent screening. We hypothesize these screening criteria lack adequate ability to consistently identify BCVI and that the use of a liberalized screening approach with CT angiography (CTA) is superior without increasing risk of acute kidney injury (AKI)., Methods: This was a multi-institutional retrospective cohort study of trauma patients who presented between 2015-2020 with radiographically confirmed BCVI diagnosed using each institutions' liberalized screening protocol, defined as automatic CTA of the head and neck for all patients undergoing head and neck CT. Outcomes of interest included AKI, stroke, and death due to BCVI. Outcomes were reported as frequency, percent, and 95% confidence interval as calculated by the Clopper-Pearson method. Incidence of medical follow-up within 1 year of first medical visit was quantified as the median and inter-quartile range of days to follow-up visit., Results: We identified 433 BCVI patients with a mean age of 45.2 (standard deviation 18.9) years, 256 men and 177 women, 1.73 m (0.10) tall, and weighed 80.3 kg (20.3). Forty-one patients had strokes (9.5% [95% confidence interval 6.9, 12.6] and 12 patients (2.8% [1.4, 4.5]) had mortality attributable to BCVI. Of 433 total cases, 132 (30.5% [26.2, 35.1]) would have been missed by DC and 150 (34.6% [30.2, 39.3]) by eDC. Incidence of AKI in our BCVI population was 6 (1.4% [0.01, 3.0])., Conclusions: BCVI would be missed over 30% of the time using the DC and eDC compared to liberalized use of screening CTA. Risk of AKI due to CTA did not occur at a clinically meaningful level, supporting liberal CTA screening., (Copyright © 2023. Published by Elsevier Ltd.)

Background: Cerebral myxomatous aneurysms (CMA) are intracranial aneurysms caused by cardiac myxoma. The exact mechanism underlying their development has not yet been elucidated. And an optimal treatment method has not yet been established because of rarity of the disease. In addition, most existing reports have had a short follow-up period or lack of follow-up imaging test results. The aim of this study was to provide better insights into the course and treatment options of CMAs., Methods: We describe 4 CMA patients treated in our hospital and literature search was performed using PubMed and Embase databases. Keywords used were as follows: "cerebral myxomatous aneurysm", "myxomatous aneurysm", "cardiac myxoma", and "intracranial aneurysm". Only publications in English and related to this disorder with adequate follow-up periods and aneurysmal wall biopsy results were included. Clinical, radiological, pathological, and treatment characteristics were analyzed., Results: A total of 149 CMA cases were managed conservatively that included 9 enlargements, 6 regressions, and 134 stable aneurysms, which were identified for a total of 453.33 aneurysm years (1.91% per aneurysm year, 1.27% per aneurysm year, and 28.76% per aneurysm year, respectively). Poor outcome rate was high in cases with hemorrhage (either parenchymal or subarachnoidal hemorrhage) due to rupture of the CMA (46.67%, 7 out of 15). Thirteen cases had aneurysm biopsy results of which 11 showed tumor invasion on the aneurysm wall., Conclusions: Even though the natural course of unruptured, benign-looking CMAs appears to be favorable, the presence or absence of viable tumor cells in the aneurysm may promote an unfavorable disease course. In the case of large, symptomatic, and enlarging CMAs, surgical, endovascular, or combined treatment should be considered as the mortality and morbidity due to rupture might be high., (Copyright © 2023 Elsevier Inc. All rights reserved.)

An optimal treatment strategy for subcortical hematomas caused by dural arteriovenous fistulae (dAVF) is important because of the high rebleeding rate. However, it is very difficult to diagnose that on admission. Therefore, an early sensitive predictive marker for subcortical hemorrhage caused by dAVF is necessary, especially during the first contact on admission. S-shaped dilated vessels around the hematoma (bold-S sign) on computed tomography angiography (CTA) performed during admission could be one such marker. Herein, we evaluated the characteristics of these vessels. Among 273 patients with intracerebral hemorrhage between April 2012 and March 2020, 67 patients with subcortical hematomas who underwent CTA on admission without arteriovenous malformations were included. The patients in the dAVF group (n = 7) showed fewer disturbances in consciousness, milder neurological deficits, and more frequent seizures than patients without dAVF (without dAVF group, n = 60). All patients in the dAVF group had dilated S-shaped vessels (2.59 ± 0.27 mm) around the hematomas, and only 20% of the patients in the without dAVF group had these vessels (1.69 ± 0.22 mm). The ratio of the ipsilateral S-shaped/contralateral largest vessels was 1.80 ± 0.29 in the dAVF group and 1.07 ± 0.16 in the group without dAVF. We called the dilated S-shaped vessels the "bold-S sign," with a cutoff ratio of 1.5. Bold-S sign findings are novel and help in diagnosing subcortical hematomas caused by dAVF on admission.

Background: Intracranial blister aneurysms are a rare and an historically difficult to treat subset of aneurysms. They are distinct from typical saccular aneurysms with different pathophysiology and treatment options., Methods: A prospectively maintained database of subarachnoid hemorrhage patients was queried for those presenting prior to the pandemic (2017-2019), and those presenting during the height of the pandemic in our locality (2021). Aneurysm characteristics and patient demographics associated with rupture risk/formation were collected., Results: 334 aneurysmal subarachnoid hemorrhage patients were reviewed. 86 of these patients presented in 2021, with a statistically significant increase in the proportion of ruptured ICA blister aneurysms as compared to 2017-2019 (7/86, 8% vs 5/248, p = .02). Mean patient age, presenting grade, other aneurysm location proportions, aneurysm size, and incidence of delayed cerebral ischemia were not different between the groups., Conclusions: Patients presenting with SAH during the height of the SARS-CoV-2 pandemic in 2021 were more likely to have ICA blister type aneurysms., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Introduction: The approach to oculomotor nerve palsies involves the exclusion of compressive, infective, inflammatory, or ischemic lesions. Dural arteriovenous fistulae, including carotid-cavernous fistulae (CCF), are known causes of third nerve palsy. However, diagnosis can sometimes be delayed or missed due to the various clinical presentations. CCF remains a rare but treatable cause of third nerve palsy., Case Report: A 63-year-old Chinese female presented to our unit with gradual onset horizontal diplopia. Clinical examination revealed a partial left oculomotor nerve palsy without congestive eye symptoms. A cerebral angiogram revealed a left indirect CCF supplied by the inferolateral trunk of the left internal carotid artery. She underwent successful transvenous embolization. She improved postprocedure and was discharged well on day 10 of her admission. She was reviewed at 2 months follow-up and had recovered completely., Conclusion: Our case is a classic description of a CCF with posterior drainage into the inferior petrosal sinus. We hope this case and a review of the literature can serve as a reminder to clinicians of the varied presentations of CCF. We believe this case adds value to the clinicians in contributing to their diagnostic process and to our interventional colleagues in highlighting a case with a successful postembolization outcome., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Aim: To investigate the safety and applicability of two main methods for treating mirror intracranial aneurysms, based on correlations in their geometric characteristics., Material and Methods: We conducted a retrospective analysis on 125 patients who underwent 138 surgical interventions for MCA aneurysms and were treated with microsurgical clipping and endovascular embolization at the Department of Neurosurgery in the University Hospital "St. Iv. Rilski", Sofia, in 2013-2019. In six of these cases, we observed mirror MCA aneurysms., Results: All six patients with "mirror" aneurysms were female. In one case, a third aneurysm was observed on the anterior communicating artery; hence, a total of 13 aneurysms were treated. The average age of the group was 48.16 years. All patients had known risk factors, such as high blood pressure and tobacco smoking. Four patients presented with aneurysmal subarachnoid hemorrhage (aSAH). All patients underwent surgical treatment in two stages-with obliteration of the intracranial aneurysm leading to subarachnoid bleeding in the first stage and planned surgical intervention within a month in the second stage to exclude unruptured aneurysms. During the one-month interval, there were no SAH incidents. However, we observed one patient with a postoperative neurological deficit and one with recanalization of the aneurysm on follow-up at 3 months, requiring re-embolization. In both cases, endovascular treatment was performed despite the unfavorable anatomical features (aspect ratio ≤1.5 and neck size ≥4 mm). The clinical outcome, in all operated patients, for "mirror" aneurysms of the MCA was reasonable (mRS: 0-2)., Conclusion: The choice of treatment for "mirror" aneurysms should be determined on an individual basis by the clinical manifestations and morphological characteristics of intracranial aneurysms. In cases of aSAH, where "mirror" aneurysms are present, both can be treated safely via microsurgical clipping or endovascular embolization after thorough investigation and ensuring prioritization of the offending lesion.

The article describes a 45-year-old female patient with recurrent transient ischemic attacks and ischemic stroke due to spontaneous spasm of the middle cerebral artery, the anterior cerebral artery and distal part of the internal cerebral artery on the left, verified by MR angiography and CT angiography. It is assumed that the spasm caused damage to the vascular wall, an increase in its permeability, the development of edema, inflammation and subsequent fibrosis, therefore a complete restoration of the arterial lumen did not occur.

Background: The aim of the study was to investigate the impact of fetal-type posterior cerebral artery (fPCA) variant on morphological parameters of posterior communicating artery (PComA) aneurysms for rupture risk assessment., Materials and Methods: A total of 98 PComA aneurysms (62 ruptured and 36 unruptured) in 98 consecutive patients were reviewed. Morphological parameters were calculated including aneurysm size, aspect ratio (AR), size ratio (SR), dome-to-neck ratio, bottleneck factor and inflow angle. Performances of morphological parameters to discriminate rupture status were compared between aneurysms with or without fPCA., Results: Fetal-type posterior cerebral artery variant was determined in 39 (39.8%, 25 ruptured and 14 unruptured) lesions. The ruptured group revealed a significantly larger size (p = 0.004), AR (p = 0.003), SR (p = 0.001), and inflow angle (p < 0.001). For the aneurysms without fPCA, all morphological parameters were significantly different between ruptured and unruptured aneurysms (p < 0.05); for the aneurysms with fPCA, only inflow angle (p = 0.001) was significantly related with the rupture status. Multivariate analysis showed that SR (p = 0.035 and p = 0.011) and inflow angle (p = 0.001 and p = 0.028) were independent rupture risk factors for the total cohort and the aneurysms without fPCA; while only inflow angle (p = 0.004) revealed to be independently related with rupture status of aneurysms without fPCA., Conclusions: The performances of morphological parameters to discriminate rupture status were different between PComA aneurysms with and without fPCA variants. Inflow angle might be a reliable predictor for rupture risk of PComA aneurysms.

Introduction: Primary central nervous system (CNS) vasculitis is a rare immune inflammatory disease confined to the blood vessels of the brain and spinal cord. The total number reported in the world is about 500[1]. Most are negative in cerebral angiography or vascular stenosis and only 1 case of aortic aneurysms reported., Patient Concerns: A 12-year-old female experienced sudden headache and vomiting. Previous findings of vascular stenosis. Diagnosed as a ruptured aneurysm bleeding. The aneurysm recurred a short time after treatment., Diagnosis: Multiple recurrent aneurysms with angiitis of the central nervous system., Interventions: The patient underwent 2 aneurysm clipping operations, both of which completely clipped the aneurysm., Outcomes: The patient recovered well after surgery. Three months after discharge, DSA reexamination in our hospital showed that the aneurysm was completely clipped without recurrence., Conclusion: Subarachnoid hemorrhage after acute cerebral infarction is rare. In addition, the patient had recurrent aneurysms after the first aneurysm clipping, which emphasized the importance of postoperative drug therapy and blood pressure control., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Bow hunter's stroke is a rare cause of vertebrobasilar infarction. There is no consensus regarding the optimal treatment. We herein report a case of bow hunter's stroke successfully treated by endovascular treatment. A 70-year-old man presented with central vertigo. Magnetic resonance imaging (MRI) showed posterior circulation infarcts. Dynamic angiography revealed thrombus formation and hypoperfusion of the right vertebral artery upon head rotation to the left. Endovascular parent artery occlusion of the right vertebral artery was performed, and there was no recurrence at follow-up MRI. Endovascular parent artery occlusion might be a useful treatment for bow hunter's stroke.

Introduction: Intra- or peri-procedural aneurysm rupture is one of the most feared adverse effects associated with embolization. Our aim was to report the characteristics of patients suffering intra- or peri-procedural ruptures during embolization of cerebral aneurysms., Patients and Methods: Between March 1994 and October 2021, 648 consecutive cerebral aneurysms were treated by endovascular procedure at our facility. Medical records were reviewed retrospectively with emphasis on procedure description, potential risk factors, and clinical outcomes related to intra- or peri-procedural rupture., Results: Of the 648 patients, 17 (2.6%) suffered an intra- or peri-procedural hemorrhagic event. The most common location was the anterior communicating artery. There was no significant difference between previously ruptured and unruptured aneurysms in the incidence of bleeding. In four patients, bleeding was evident within 24 h after the procedure. The clinical evolution at three months was poor and only four patients presented a positive evolution. There were 11 deaths (64.71%). Balloon remodeling was associated with an increased frequency of ruptures, while stenting was a safer treatment., Conclusion: Aneurysmal rupture during endovascular therapy is unpredictable, and its occurrence can be devastating. The incidence is quite low although the outcome is frequently poor. Early detection and proper management, including prompt occlusion of the aneurysm, are important to achieve a positive outcome. Anterior communicating artery aneurysms and those treated with balloon catheters have a higher incidence of rupture. A small number of ruptures of uncertain origin occur that go unnoticed in digital subtraction angiograms., (© 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

We analyzed aneurysm morphology, demographic and clinical characteristics in patients with anterior communicating artery (ACoA) aneurysms to investigate the risk factors contributing to aneurysm rupture. A total of 219 patients with ACoA aneurysms were admitted to our hospital between January 2016 and December 2020, and morphological and clinical characteristics were analyzed retrospectively in 153 patients (112 ruptured and 41 unruptured). Medical records were reviewed to obtain demographic and clinical data on age, gender, presence of hemorrhage, history of hypertension, diabetes, heart disease, and kidney disease. Morphological parameters examined on 3-dimensional digital subtraction angiography included aneurysm size, neck diameter, aspect ratio, size ratio, bottleneck ratio, height/width ratio, aneurysm angle, (in)flow angle, branching angle, number of aneurysms per patient, shape of the aneurysm, aneurysm wall morphology, variation of the A1 segment, and direction of the aneurysm. Male gender, aspect ratio, height/width ratio, non-spherical and irregular shape were associated with higher odds of rupture, whilst controlled hypertension was associated with lower odds of rupture, when tested using univariate logistic regression model. In multivariate model, controlled hypertension, presence of multiple aneurysms, and larger neck diameter reduced the odds of rupture, while irregular wall morphology increased the risk of rupture. Regulated hypertension represented a significant protective factor from ACoA aneurysm rupture. We found that ACoA aneurysms in male patients and those with greater aspect ratios and height/width ratios, larger aneurysm angles, presence of daughter sacs and irregular and non-spherical shapes were at a higher risk of rupture.

Background: Spontaneous intracerebral hemorrhage is a potentially devastating cause of brain injury, often occurring secondary to hypertension. Contrast extravasation on computed tomography angiography (CTA), known as the spot sign, has been shown to predict hematoma expansion and worse outcomes. Although hypertension has been associated with an increased rate of the spot sign being present, the relationship between spot sign and blood pressure has not been fully explored., Methods: We retrospectively analyzed data from 134 patients (40 women and 94 men, mean age 62.3 ± 15.73 years) presenting to a tertiary academic medical center with spontaneous supratentorial subcortical intracerebral hemorrhage from 1/1/2018 to 1/4/2021., Results: A spot sign was demonstrated in images of 18 patients (13.43%) and correlated with a higher intracerebral hemorrhage score (2.61 ± 1.42 vs. 1.31 ± 1.25, p = 0.002), larger hematoma volume (53.49cm 3  ± 32.08 vs. 23.45cm 3  ± 25.65, p = 0.001), lower Glasgow Coma Scale on arrival (9.06 ± 4.56 vs. 11.74 ± 3.65, p = 0.027), increased risk of hematoma expansion (16.67% vs. 5.26%, p = 0.042), and need for surgical intervention (66.67% vs. 15.52%, p < 0.001). We did not see a correlation with age, sex, or underlying comorbidities. The presence of spot sign correlated with higher modified Rankin scores at discharge (4.94 ± 1.00 vs. 3.92 ± 1.64, p < 0.001). We saw significantly higher systolic blood pressure at the time of CTA in patients with a spot sign (184 mm Hg ± 43.11 vs. 153 mm Hg ± 36.99, p = 0.009) and the highest recorded blood pressure (p = 0.019), although not blood pressure on arrival (p = 0.081). Performing CTA early in the process of blood pressure lowering was associated with a spot sign (p < 0.001)., Conclusions: The presence of spot sign correlates with larger hematomas, worse outcomes, and increased surgical intervention. There is a significant association between spot sign and systolic blood pressure at the time of CTA, with the highest systolic blood pressure being recorded prior to CTA. Although the role of intensive blood pressure management in spontaneous intracerebral hemorrhage remains a subject of debate, patients with a spot sign may be a subgroup that could benefit from this., (© 2022. The Author(s).)

Background: Aneurysmal subarachnoid hemorrhage (SAH) remains a devastating condition with a case fatality of 36% at 30 days. Risk factors for mortality in SAH patients include patient demographics and the severity of the neurological injury. Pre-existing conditions and non-neurological medical complications occurring during the index hospitalization are also risk factors for mortality in SAH. The magnitude of the effect on mortality of pre-existing conditions and medical complications, however, is less well understood. In this study, we aim to determine the effect of pre-existing conditions and medical complications on SAH mortality., Methods: For a 25% random sample of the Greater Montreal Region, we used discharge abstracts, physician billings, and death certificate records, to identify adult patients with a new diagnosis of non-traumatic SAH who underwent cerebral angiography or surgical clipping of an aneurysm between 1997 and 2014., Results: The one-year mortality rate was 14.76% (94/637). Having ≥3 pre-existing conditions was associated with increased one-year mortality OR 3.74, 95% CI [1.25, 9.57]. Having 2, or ≥3 medical complications was associated with increased one-year mortality OR, 2.42 [95% CI 1.25-4.69] and OR, 2.69 [95% CI 1.43-5.07], respectively. Sepsis, respiratory failure, and cardiac arrhythmias were associated with increased one-year mortality. Having 1, 2, or ≥3 pre-existing conditions was associated with increased odds of having medical complications in hospital., Conclusions: Pre-existing conditions and in-hospital non-neurological medical complications are associated with increased one-year mortality in SAH. Pre-existing conditions are associated with increased medical complications.

Background: The cerebral angiography result is negative for an underlying vascular lesion in 15-20% of patients with nontraumatic subarachnoid hemorrhage (SAH). Patients with angiogram-negative SAH include those with perimesencephalic SAH and diffuse SAH. Consensus suggests that perimesencephalic SAH confers a more favorable prognosis than diffuse SAH. Limited data exist to contextualize the clinical course and prognosis of diffuse SAH in relation to aneurysmal SAH in terms of critical care complications, neurologic complications, and functional outcomes. Here we compare the clinical course and functional outcomes of patients with perimesencephalic SAH, diffuse SAH, and aneurysmal SAH to better characterize the prognostic implications of each SAH subtype., Methods: We conducted a retrospective cohort study that included all patients with nontraumatic SAH admitted to a tertiary care referral center between January 1, 2012, and December 31, 2017. Bleed patterns were radiographically adjudicated, and patients were assigned to three groups: perimesencephalic SAH, diffuse SAH, and aneurysmal SAH. Patient demographics, complications, and clinical outcomes were reported and compared., Results: Eighty-six patients with perimesencephalic SAH, 174 with diffuse SAH, and 998 with aneurysmal SAH presented during the study period. Patients with aneurysmal SAH were significantly more likely to be female, White, and active smokers. There were no significant differences between patients with diffuse SAH and perimesencephalic SAH patterns. Critical care complications were compared across all three groups, with significant between-group differences in hypotension and shock (3.5% vs. 16.1% vs. 38.4% for perimesencephalic SAH vs. diffuse SAH vs. aneurysmal SAH, respectively; p < 0.01) and endotracheal intubation (0% vs. 26.4% vs. 48.8% for perimesencephalic SAH vs. diffuse SAH vs. aneurysmal SAH, respectively; p < 0.01). Similar trends were noted with long-term supportive care with tracheostomy and gastrostomy tubes and length of stay. Cerebrospinal fluid diversion was increasingly required across bleed types (9.3% vs. 54.6% vs. 76.3% for perimesencephalic SAH vs. diffuse SAH vs. aneurysmal SAH, respectively, p < 0.001). Vasospasm and delayed cerebral ischemia were comparable between perimesencephalic SAH and diffuse SAH but significantly lower than aneurysmal SAH. Patients with diffuse SAH had intermediate functional outcomes, with significant rates of nonhome discharge (23.0%) and poor functional status on discharge (26.4%), significantly higher than patients with perimesencephalic SAH and lower than patients with aneurysmal SAH. Diffuse SAH similarly conferred an intermediate rate of good functional outcomes at 1-6 months post discharge (92.3% vs. 78.6% vs. 47.3% for perimesencephalic SAH vs. diffuse SAH vs. aneurysmal SAH, respectively; p < 0.016)., Conclusions: We confirm the consensus data that perimesencephalic SAH is associated with a more benign clinical course but demonstrate that diffuse SAH confers an intermediate prognosis, more malignant than perimesencephalic SAH but not as morbid as aneurysmal SAH. These results highlight the significant morbidity associated with diffuse SAH and emphasize need for vigilance in the acute care of these patients. These patients will likely benefit from continued high-acuity observation and potential support to avert significant risk of morbidity and neurologic compromise., (© 2021. Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society.)

Delayed cerebral ischemia (DCI) is a major etiology of poor neurologic outcomes after aneurysmal subarachnoid hemorrhage (aSAH). Although the development of DCI is certainly multifactorial, the presence of vasospasm is strongly correlated with it. Cerebral angiography remains the gold standard for evaluation of vasospasm, though it is not always practical or cost-effective. In this study, the authors assess the utility of automated MRI Perfusion imaging, with or without MR Angiography (MRA), as a confirmatory tool for suspected angiographic vasospasm. All patients admitted to a single institution with aneurysmal subarachnoid hemorrhage between January 2014 and February 2020 and who underwent MR Perfusion imaging with or without MRA for suspected vasospasm no >24 h prior to an angiogram were identified. 43 subjects were identified. 29 of these patients (67%) underwent simultaneous MRA. 25 patients (53%) received intra-arterial treatment for symptomatic vasospasm. The sensitivity, specificity, PPV, and NPV of MR Perfusion were 43%, 82%, 53%, and 75% for any angiographic vasospasm and 57%, 81%, 42%, and 89% for treated vasospasm. The sensitivity, specificity, PPV, and NPV of MR Perfusion in conjunction with MRA were 61%, 81%, 59%, and 82% for any angiographic vasospasm and 62%, 74%, 35%, and 89% for treated vasospasm. The sensitivity, specificity, PPV, and NPV of transcranial Dopplers (TCDs) in these patients were 35%, 93%, 71%, and 75% for angiographic vasospasm and 42%, 90%, 47%, and 88% for treated vasospasm. Automated MR Perfusion imaging demonstrated relatively low sensitivity and PPV for detection of angiographic and treated vasospasm in this subset of patients after aSAH., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Rationale: Distal middle cerebral artery aneurysms are very rare in the clinic, and craniotomy clipping is the better treatment after diagnosis. However, patients can also have repeated acute intracerebral hemorrhage after craniotomy for aneurysm, which has not been previously reported., Patient Concerns: A 24-year-old male patient was admitted to our hospital with headache, nausea, and vomiting. He was well before, had no family history of cerebrovascular disease or hypertension, and had no history of trauma., Diagnoses: Computer tomography and digital subtraction angiography of the brain revealed intracranial hematoma and an aneurysm located at the M4 segment of the left middle cerebral artery., Interventions: The patient underwent 2 surgeries to treat the aneurysm, followed by 2 operations for acute cerebral hemorrhage., Outcomes: Despite repeated surgical treatments, the patient had a poor prognosis and eventually died of respiratory and circulatory failure after repeated brain bleeding., Lessons: Briefly, it is of great importance to consider the risk factors of cerebral hemorrhage, and provide individualized treatment and psychological counseling for patients with intracerebral hemorrhage., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: To investigate the feasibility and safety of transradial cerebral angiography (TRCA) in comparison to transfemoral cerebral angiography (TFCA) in the pediatric population., Materials and Methods: We retrospectively reviewed pediatric patients who underwent TRCA between January 2019 and July 2020. Patients with TFCA experience were examined. Pre- and post-procedural Doppler ultrasonography was performed to evaluate TRCA complications. To evaluate differences in radiation exposure between TRCA and TFCA, we investigated the radiation dose, dose area product (DAP), fluoroscopy time, and examination time., Results: Thirty-five patients (mean age, 13.8 years; 22 male) underwent TRCA, with 18 (mean age, 13.0 years; 10 male) experiencing TFCA. TRCA was successful in all cases without technical failure. Radiation exposure including radiation dose and DAP were significantly higher in the TRCA group (474.1 mGy and 8299.6 μGy m 2 ) compared with the TFCA group (347.8 mGy and 6342.0 μGy m 2 ). Fluoroscopy time and total examination time were significantly longer (145.1% and 32.6%) in TRCA (15.2 and 38.6 min) group compared with the TFCA group (6.2 and 29.1 min). Among the 26 patients who underwent post-procedural Doppler ultrasonography, five (19.2%) had complications after TRCA. Two (7.7%) patients showed radial artery stenosis, two (7.7%) had hematoma at the puncture site, and one (3.8%) showed thrombotic occlusion., Conclusion: Although TRCA is a technically feasible and safe method in pediatric patients, high radiation exposure to TFCA must be considered. Therefore, it should be considered as an alternative method in those with unfavorable clinical situations for performing TFCA., Level of Evidence: Level 4, Case Series., (© 2022. Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE).)

Background: Posterior cerebral artery (PCA) aneurysms are rare, and most are giant, dissecting, or fusiform in morphology. Proximal occlusion of the PCA without revascularization causes high risk of ischemic complications. This study aimed to evaluate the safety and validity of using superficial temporal artery (STA)-PCA bypass through zygomatic anterior temporal approach in complex PCA aneurysms., Methods: Trapping or resecting of aneurysms and reconstruction of distal PCA through a zygomatic anterior temporal approach were performed in 6 patients from June 2017 to August 2020. Postoperative angiography confirmed obliteration of aneurysms and patency of bypass artery. Neurological function was assessed by the modified Rankin Scale (mRS)., Results: Patients were 4 men and 2 women with a mean age of 43.8 years (range, 21-58 years). Subarachnoid hemorrhage occurred in 5 patients. Hunt and Hess grade was IV in 3 patients, III in 2 patients, and I in 1 patient. All PCA aneurysms were treated with trapping or resection of the aneurysms and revascularization of distal PCA. Postoperatively, all aneurysms were eliminated, and no new permanent neurological deficit was found. During follow-up, mRS score of all patients improved: 2 patients had mRS score 0, 1 patient had mRS score 1, 1 patient had mRS score 3, and 2 patients had mRS score 4. Long-term graft patency rate was 100%., Conclusions: STA-PCA bypass appears to be safe and effective for the treatment of complex PCA aneurysms requiring supplementation of blood flow in the area of the PCA. We established a surgical route, allowing the procedure to be done through the zygomatic anterior temporal approach. This approach provides adequate operative field exposure and reduces retraction of temporal lobe., (Copyright © 2021 Elsevier Inc. All rights reserved.)

There are proximal, distal and intranidal AVM-associated aneurysms (G. Redekop, 1998)., Objective: To evaluate treatment outcomes in 120 patients with AVM-associated aneurysms., Material and Methods: We analyzed treatment outcomes in 639 patients with cerebral AVM who underwent 1992 endovascular procedures between 2010 and 2019. AVM-associated aneurysms were found in 120 (18.8%) cases: 81 (67.5%) patients with 69 proximal and 29 distal aneurysms, 33 (27.5%) AVMs with intranidal aneurysms and 6 (5%) aneurysms without hemodynamic connection with AVM. One hundred and one malformations (16.9%) out of 596 supratentorial AVMs and 19 (44.2%) out of 43 subtentorial AVMs were associated with aneurysms., Results: Intracranial hemorrhage occurred in 349 (53.3%) out of 639 patients with AVM: 97 (80.8%) out of 120 patients with AVM-associated aneurysms and 252 (48.6%) out of 519 ones with AVM and no aneurysms. All 33 patients with intranidal aneurysms in the AVM structure and 18 (94.7%) out of 19 patients with AVM-associated aneurysms and AVM in posterior cranial fossa had intracranial hemorrhage. There were 98 aneurysms in 81 patients with AVM-associated aneurysms. Eighty-nine (90.8%) ones underwent endovascular treatment, 6 (6.1%) patients with proximal aneurysms required microsurgery. Three distal aneurysms were not repaired. Thirty-four aneurysms were embolized with spirals. Embolization with spirals and balloon assistance was performed for 41 aneurysms, spirals with stent-assistance - for 9 aneurysms (including 1 distal MCA aneurysm in hemorrhagic period). Implantation of a flow-diverting stent was performed for 5 aneurysms (1 distal and 4 proximal aneurysms). There were 8 (8.9%) complications after embolization of 89 AVM-associated aneurysms (5 thromboembolic and 3 hemorrhagic events)., Conclusion: According to our data, intranidal aneurysms require exclusion of the parent AVM segment due to high risk of hemorrhage. Treatment of proximal AVM-associated aneurysms should be carried out prior to AVM embolization. Distal aneurysms do not regress after definitive AVM treatment and should be operated on after total AVM embolization.

Purpose: Pediatric intracranial aneurysms (PIA) are rarer and more complex when compared to adult aneurysms. In general, the clinical presentation of PIA is due to a mass effect, but the presenting symptoms can be also related to ischemia, subarachnoid hemorrhage (SAH), or in a combination of different symptoms. This paper aimed to report a single-center experience with clinical and angiographic aspects of brain aneurysm in children., Methods: We retrospectively reviewed our prospectively maintained database for patients with intracranial aneurysms in our institution from July 2015 to February 2021. Among these, all patients under 18 years of age submitted to a diagnostic or therapeutic procedure for an intracranial aneurysm were included., Results: Twelve patients were submitted to diagnostic or therapeutic procedures in our department. Three of them had multiple aneurysms, and in total, 17 intracranial aneurysms were assessed in this study. The most frequent location was in the middle cerebral artery (7 cases/41%). Five out of twelve children (42%) presented SAH due to ruptured aneurysm. Three patients (25%) had symptoms due to the mass effect from large aneurysms, with compression of cranial nerves or brainstem. Aneurysms diameters ranged from 1.5 mm to 34 mm (mean 14.2 mm), with six aneurysms being giant and eight being nonsaccular/fusiform. Twelve aneurysms were submitted to endovascular treatment, with one treatment-related clinical complication and later death., Conclusion: PIAs are rare diseases that can arise from a variety of different underlying pathological mechanisms. The management of these conditions requires a detailed understanding of the pathology and a multidisciplinary approach. Despite the availability of new technologies, parent vessel occlusion remains a valid option for aneurysms in the pediatric population., (© 2022 S. Karger AG, Basel.)

Background: Distal transradial access (dTRA) has several advantages compared with proximal transradial access (pTRA) for cerebral angiography. The learning curve for transitioning from pTRA to dTRA has not been described., Methods: Retrospective analysis of the first 75 diagnostic cerebral angiograms performed with dTRA by a single operator was performed. Outcomes included time for sheath insertion, sheath to first vessel time, procedure duration, fluoroscopy time, radiation dose, and contrast volume. Their associations with procedure number were evaluated with multivariate linear regressions, segmented linear regression, and locally weighted regression (LOESS)., Results: The mean age of patients was 56.1 years and 61.3% were female. Seventy-four of 75 angiograms were successfully completed with dTRA. There were 3 minor and no major complications. After adjusting for covariates, sheath to first vessel time (β = -0.50, P < 0.001) and procedure duration (β = -0.26, P = 0.002) were associated with procedure number. Time for sheath insertion, fluoroscopy time, radiation dose, and contrast volume were not associated with procedure number. Segmented linear regression identified break-points of 33 for sheath to first vessel time and 11 for procedure duration, which corresponded to the procedure number after which these outcomes trended down. LOESS models for time to sheath placement, procedure duration, fluoroscopy time, and radiation dose predicted minimum values between procedures 40-50., Conclusions: Transitioning from pTRA to dTRA for diagnostic cerebral angiography is feasible and safe. The learning curve is overcome between procedures 11 and 33, and further refinement in performance occurs through procedures 40-50., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Rationale: A special case of transient oculomotor nerve palsy after cerebral angiography., Patient Concerns: A 55-year-old man developed oculomotor nerve dysfunction after right radial artery puncture angiography., Diagnoses: Cerebral angiography-induced oculomotor nerve palsy., Interventions: According to the patient's disease state, intravenous drip of dexamethasone 10 mg/d., Outcomes: Magnetic resonance imaging (MRI) showed no abnormalities, and the patient recovered completely after 48 hours of hormone therapy., Lessons: Transient eye palsy caused by contrast agent encephalopathy is a clinically rare neurological dysfunction caused by adverse effects of contrast agents. Early prevention and correct treatment are critical., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: We sought to develop a model to predict the risk of small intracranial aneurysm (SIA; ≤5 mm) rupture among Chinese adults and to compare the score predicted by our model with the PHASES (population, hypertension, age, size, earlier subarachnoid hemorrhage, aneurysm site) score., Methods: From August 2011 to June 2015, 366 patients with 394 SIAs were retrospectively evaluated and followed up for ≥5 years. The clinical characteristics of the patients were reviewed from their medical records, and the SIA features were evaluated from the imaging studies. The independent risk factors for SIA rupture were studied using multiple Cox proportional hazards regression analysis. The diagnostic value of the PHASES score for the prediction of SIA rupture was also calculated., Results: Six SIAs in 6 different patients had ruptured during a mean follow-up of 6.4 years. An irregular shape (odds ratio [OR], 31.464), a high aspect ratio (OR, 40.573), and a high size ratio (OR, 20.541) increased the risk of rupture. The predictive score incorporated these three factors. The threshold was 1.5, and the area under the curve, sensitivity, and specificity were 0.986, 100%, and 94.6%, respectively. For the PHASES score, the area under the curve, sensitivity, and specificity were 0.702, 83.3%, and 62.1%, respectively., Conclusions: An irregular shape, a high aspect ratio, and a high size ratio were associated with SIA rupture in the Chinese population. Our predictive score is of great value in predicting the risk of SIA rupture., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Contrast-induced encephalopathy (CIE) is a rare complication of contrast agent use. We herein report a case of acute lacunar infarction in a 70-year-old woman. During diagnostic cerebral angiography for asymptomatic common carotid stenosis, she experienced transient drowsiness. After angiography, generalized tonic-clonic seizures occurred in her left arm and leg, with eye deviation to the left. The patient was diagnosed with CIE due to the acute onset of symptoms during angiography and characteristic computed tomography findings of high-density signaling in the cortex. Our findings suggest that it is important to pay close attention to acute neurological symptoms during and immediately after examinations, even with small amounts of contrast agents.

Background: Aneurysms associated with fenestrations of intracranial arteries are exceptionally rare findings. Management strategies for these aneurysms are not well-defined, especially regarding endovascular treatment. We sought to investigate the strategies and feasibility of endovascular treatment approaches for various fenestration-associated intracranial aneurysms., Methods: We performed a retrospective chart review of 2000 aneurysms treated endovascularly, identifying 8 aneurysms located at arterial fenestrations. The technical details and procedural outcomes were reviewed to identify common management approaches, technical nuances, and treatment outcomes., Results: There were 3 (37.5%) aneurysms associated with fenestrations of the basilar artery or vertebrobasilar junction. All 3 were successfully treated with a previously undescribed coil-assisted flow-diversion technique, resulting in complete obliteration. Three (37.5%) aneurysms were associated with fenestrations of the anterior communicating artery. Of those, 2 were successfully treated with stent-assisted coil embolization and 1 with coil embolization alone. One (12.5%) aneurysm was associated with a fenestration of the paraclinoid internal carotid artery and 1 (12.5%) aneurysm found was at the takeoff of the posterior inferior cerebellar artery at a fenestration of the vertebral artery. Both were successfully treated with coil-assisted flow diversion. There were no permanent procedural complications. Major considerations for endovascular management of these aneurysms were the dominance of fenestration trunks, aneurysms arising from the fenestration apex or a fenestration limb, amenability to flow diversion, and anticipation of vascular remodeling., Conclusions: Fenestration-associated aneurysms are very rare. We have identified common factors to help guide decision-making for endovascular approaches and demonstrate successful aneurysm treatment using these methods., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Relative risk is insufficient to guide treatment decision-making for unruptured intracranial aneurysms. Our objective was to introduce a novel risk assessment methodology called the Rupture Criticality Index (RCI), which allows for concurrent evaluation of groups of risk factors (RFs)., Methods: From a retrospective database of saccular aneurysms, we identify 915 patients and delineate 50 potential RFs for aneurysms in 11 unique locations. RF combinations for multivariable analysis were defined by aneurysm size, location, and a third variable from the study design. Data analysis was performed by applying frequency distribution methods to define the RCI of each RF combination., Results: RF combinations at greatest risk were small (4.8-8.2 mm) or medium (8.3-14.5 mm) anterior communicating aneurysms (ACoA) in male individuals (RCI 9.87-10), small ACoA in those ≤37 years or 38-55 years (RCI 8.67-8.99), medium basilar tip aneurysms (BTAs) in male individuals (RCI 10), and large (14.6-22.5 mm) BTA in Caucasians or those aged 38-55 years (RCI 9.25, 9.35, respectively)., Conclusions: We introduce the concept of RCI and compare how RF combinations are associated with aneurysmal rupture. This novel approach to aneurysmal rupture identifies high-risk clinical presentations and can be used to guide clinical decision-making in patients with non-traditional risks., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Radial access has become popular among neurointerventionalists because it has favorable risk profiles compared with femoral access. Difficulties in accessing or navigating the radial artery have been viewed as a reason to convert to femoral access, but ulnar artery access may prevent complications associated with transfemoral procedures., Objective: To evaluate the safety and feasibility of ulnar access for neurointerventions and diagnostic neuroangiographic procedures., Methods: Consecutive patients who underwent diagnostic angiography or neurointerventional procedures via ulnar access between July 1, 2019 and April 15, 2020 were included. Data recorded were demographics, procedure indication, devices, technique, and complications. Descriptive analysis was performed., Results: Ulnar artery access was obtained for 21 procedures in 18 patients (mean age 70.3±7.8 years; nine men). Procedures included 13 diagnostic angiograms and eight neurointerventions (3 left middle meningeal artery embolization, 1 of which was aborted; 2 carotid artery stenting; 2 angioplasty; 1 mechanical thrombectomy for in-stent thrombosis). A right-sided approach with ultrasound guidance was used for all cases except one. Indications included small caliber radial artery (n=9), radial artery occlusion (n=10), and radial artery preservation for potential bypass (n=2). A 5-French slender sheath was used for diagnostic angiography; a 6-French slender sheath was used for neurointerventions. No case required conversion to femoral access. Two patients had minor hematomas after the procedure; one other had ulnar artery occlusion on 30-day ultrasonography., Conclusion: Ulnar access is safe and feasible for diagnostic and interventional neuroangiographic procedures. It provides a useful alternative to radial access, potentially avoiding complications associated with femoral access., Competing Interests: Competing interests: EIL: shareholder/ownership interests: NeXtGen Biologics, RAPID Medical, Claret Medical, Cognition Medical, Imperative Care (formerly the Stroke Project), Rebound Therapeutics, StimMed, Three Rivers Medical; national principal investigator/steering committees: Medtronic (merged with Covidien Neurovascular) SWIFT Prime and SWIFT Direct Trials; honoraria: Medtronic (training and lectures); consultant: Claret Medical, GLG Consulting, Guidepoint Global, Imperative Care, Medtronic, Rebound, StimMed; advisory board: Stryker (AIS Clinical Advisory Board), NeXtGen Biologics, MEDX, Cognition Medical, Endostream Medical; site principal investigator: CONFIDENCE study (MicroVention), STRATIS Study—Sub I (Medtronic). AHS: financial interest/investor/stock options/ownership: Adona Medical, Inc, Amnis Therapeutics (purchased by Boston Scientific October 2017), Blink TBI Inc., Buffalo Technology Partners Inc., Cerebrotech Medical Systems, Inc., Cognition Medical, Endostream Medical Ltd., Imperative Care, International Medical Distribution Partners, Neurovascular Diagnostics Inc., Q’Apel Medical Inc, Rebound Therapeutics Corp. (purchased 2019 by Integra Lifesciences, Corp), Rist Neurovascular Inc., Sense Diagnostics, Inc., Serenity Medical Inc., Silk Road Medical, Spinnaker Medical, Inc., StimMed, Synchron, Three Rivers Medical Inc., Vastrax, LLC, VICIS, Inc., Viseon Inc; consultant/advisory board: Amnis Therapeutics, Boston Scientific, Canon Medical Systems USA Inc., Cerebrotech Medical Systems Inc., Cerenovus, Corindus Inc., Endostream Medical Ltd., Imperative Care, Inc. Integra LifeSciences Corp., Medtronic, MicroVention, Minnetronix Neuro, Inc., Northwest University–DSMB chair for HEAT Trial, Penumbra, Q’Apel Medical Inc., Rapid Medical, Rebound Therapeutics Corp. (purchased by Integra LifeSciences Corp.), Serenity Medical Inc., Silk Road Medical, StimMed, Stryker, Three Rivers Medical, Inc., VasSol, W.L. Gore & Associates; principal investigator/steering committee for the following trials: Cerenovus NAPA and ARISE II; Medtronic SWIFT PRIME and SWIFT DIRECT; MicroVention FRED & CONFIDENCE; MUSC POSITIVE; and Penumbra 3D Separator, COMPASS, INVEST, TIGER.JMD: research grant: National Center for Advancing Translational Sciences of the National Institutes of Health under award number KL2TR001413 to the University at Buffalo. Consulting: Medtronic; honoraria: Neurotrauma Science, LLC; shareholder/ownership interests: Cerebrotech, RIST Neurovascular., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)