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IntroductionUnruptured intracranial aneurysms (UIA) are common in the adult population, but only a relatively small proportion will rupture. It is therefore essential to have accurate estimates of rupture risk to target treatment towards those who stand to benefit and avoid exposing patients to the risks of unnecessary treatment. The best available UIA natural history data are the PHASES study. However, this has never been validated and given the known heterogeneity in the populations, methods and biases of the constituent studies, there is a need to do so. There are also many potential predictors not considered in PHASES that require evaluation, and the estimated rupture risk is largely based on short-term follow-up (mostly 1 year). The aims of this study are to: (1) test the accuracy of PHASES in a UK population, (2) evaluate additional predictors of rupture and (3) assess long-term UIA rupture rates.Methods and analysisThe Risk of Aneurysm Rupture study is a longitudinal multicentre study that will identify patients with known UIA seen in neurosurgery units. Patients will have baseline demographics and aneurysm characteristics collected by their neurosurgery unit and then a single aggregated national cohort will be linked to databases of hospital admissions and deaths to identify all patients who may have subsequently suffered a subarachnoid haemorrhage. All matched admissions and deaths will be checked against medical records to confirm the diagnosis of aneurysmal subarachnoid haemorrhage. The target sample size is 20 000 patients. The primary outcome will be aneurysm rupture resulting in hospital admission or death. Cox regression models will be built to test each of the study’s aims.Ethics and disseminationEthical approval has been given by South Central Hampshire A Research Ethics Committee (21SC0064) and Confidentiality Advisory Group support (21CAG0033) provided under Section 251 of the NHS Act 2006. The results will be disseminated in peer-reviewed journals.Trial registration numberISRCTN17658526.

OBJECTIVE Intracranial minimally invasive procedures imply working in a restricted surgical corridor surrounded by critical structures, such as vessels and cranial nerves. Any damage to them may affect patient outcome. Neuronavigation systems may reduce the risk of such complications. In this study, the authors sought to compare standard neuronavigation (NV) and augmented reality (AR)–guided navigation with respect to the integrity of the perifocal structures during a neurosurgical approach using a novel model imitating intracranial vessels. METHODS A custom-made box, containing crisscrossing hard metal wires, a hidden nail at its bottom, and a wooden top, was scanned, fused, and referenced for the purpose of the study. The metal wires and an aneurysm clip applier were connected to a controller, which counted the number of contacts between them. Twenty-three naive participants were asked to 1) use NV to define an optimal entry point on the top, perform the smallest craniotomy possible on the wooden top, and to use a surgical microscope when placing a clip on the nail without touching the metal wires; and 2) use AR to preoperatively define an ideal trajectory, navigate the surgical microscope, and then perform the same task. The primary outcome was the number of contacts made between the metal wires and the clip applier. Secondary outcomes were craniotomy size, and trust in NV and AR to help avoid touching the metal wires, as assessed by a 9-level Likert scale. RESULTS The median number of contacts tended to be lower with the use of AR than with NV (AR, median 1 [Q1: 1, Q3: 2]; NV, median 3 [Q1: 1, Q3: 6]; p = 0.074). The size of the target-oriented craniotomy was significantly lower with the use of AR compared with NV (AR, median 4.91 cm2 [Q1: 4.71 cm2, Q3: 7.55 cm2]; and NV, median 9.62 cm2 [Q1: 7.07 cm2; Q3: 13.85 cm2]). Participants had more trust in AR than in NV (the differences posttest minus pretest were mean 0.9 [SD 1.2] and mean −0.3 [SD 0.2], respectively; p < 0.05). CONCLUSIONS The results of this study show a trend favoring the use of AR over NV with respect to reducing contact between a clip applier and the perifocal structures during a simulated clipping of an intracranial aneurysm. Target-guided craniotomies were smaller with the use of AR. AR may be used not only to localize surgical targets but also to prevent complications associated with damage to structures encountered during the surgical approach.

International audience; Background: The safety and efficacy of flow diversion among distal anterior circulation aneurysms must be proved.Purpose: Our aim was to analyze the outcomes after flow diversion among MCA, anterior communicating artery, and distal anterior cerebral artery aneurysms.Data sources: A systematic search of 3 databases was performed for studies published from 2005 to 2018.Study selection: According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies reporting flow diversion of distal anterior circulation aneurysms.Data analysis: Random-effects meta-analysis was used to pool aneurysm occlusion and complication rates. From the individual patient data, univariate and multivariate analyses were used to test predictors of occlusion and complications.Data synthesis: We included 27 studies (484 aneurysms). The long-term adequate occlusion rate (O'Kelly-Marotta scale, C-D) was 82.7% (295/364; 95% CI, 77.4%-87.9%; I2 = 52%). Treatment-related complications were 12.5% (63/410; 95% CI, 9%-16%%; I2 = 18.8%), with 5.4% (29/418; 95% CI, 3.2%-7.5%; I2 = 0%) morbidity. MCA location was an independent factor associated with lower occlusion (OR = 0.5, P = .03) and higher complication rates (OR = 1.8, P = .02), compared with anterior communicating artery and distal anterior cerebral artery aneurysms. The Pipeline Embolization Device (versus other stents) gave better occlusion rates (OR = 2.6, P = .002), whereas large/giant aneurysms were associated with higher odds of complications (OR = 2.2, P = .03). The rates of occlusion and narrowing of arteries covered by flow-diverter stents were 6.3% (29/283; 95% CI, 3.5%-9.1%; I2 = 4.2%) and 23.8% (69/283; 95% CI, 15.7%-32%; I2 = 80%), respectively. Symptoms related to occlusion and narrowing of the jailed arteries were 3.5% (6/269; 95% CI, 1.1%-5%; I2 = 0%) and 3% (6/245; 95% CI, 1%-4%; I2 = 0%), respectively.Limitations: We reviewed small and retrospective series.Conclusions: Flow diversion among distal anterior circulation aneurysms is effective, leading to adequate aneurysm occlusion in 83% of cases. However, this strategy has some limitations among MCA and larger lesions, especially related to the higher rate of complications. Compared with the other devices, the Pipeline Embolization Device seems to be associated with a higher occlusion rate

To perform a systematic review of the techniques for transient circulatory arrest during intracerebral aneurysm surgery according to the PRISMA guidelines. Search of PubMed and Google Scholar using the following: ("heart arrest" OR "cardiac standstill"[All Fields]) AND ("intracranial aneurysm" OR "intracranial"[All Fields] AND "aneurysm"[All Fields]). A total of 41 original articles were retrieved, of which 17 were excluded (review articles, editorials and single-case reports). A total of 24 separate articles published between 1984 and 2018 were included in the final analysis, where the majority of patients harbored anterior circulation giant or large aneurysms. Adenosine-induced cardiac arrest gave a short, temporary asystole. The method had benefits in aneurysm with a broad neck, a thin wall, in specific localizations with narrow surgical corridors or in case of intraoperative rupture. Rapid ventricular pacing (RVP) allows a longer and more easily controlled hypotension. Its use is largely limited to elective cases. Deep hypothermic circulatory arrest required a complex infrastructure, and fatal procedure complications lead to a 11.5-30% 30-day mortality rate, limiting its application to giant or complex aneurysm of the basilar artery or to residual posterior circulation aneurysm after endovascular treatment. Adenosine and RVP are both effective options to facilitate clipping of complex aneurysms. However, their use in patient with ischemic heart disease and cardiac arrhythmias should be avoided, and their safety in the context of subarachnoid hemorrhage is yet to be determined. Today, deep hypothermic circulatory arrest is almost obsolete due to endovascular alternatives.

The aim of this study was to evaluate surgical outcome of unruptured intracranial aneurysms (UIAs) in a low-volume hospital and compare the results with the recent literature.

The treatment of ruptured dissecting aneurysms of the intracranial vertebral artery (VA) with parent vessel preservation is a challenge for neurosurgeons and interventional neuroradiologists.To propose an indication for flow-diverting treatment for reconstruction of a dissecting VA with acute subarachnoid hemorrhage.Two male patients transferred after acute subarachnoid hemorrhage and dissecting aneurysm on the V4 segment of the dominant VA. An occlusion test was not performed because of their poor clinical state. A flow-diverting stent represented by the Pipeline embolization device was suggested to both patients.Three Pipeline embolization devices were deployed in each VA. One dissecting aneurysm was excluded immediately after 3 stents, and 1 patient had complete exclusion demonstrated at the 48-hour control. No morbidity directly related to the procedure was observed. No recanalization and no rebleeding occurred during the 3 months of follow-up.A flow-diverting stent may be considered an option to treat ruptured dissecting aneurysms of the VA, providing remodeling of the parent vessel and complete exclusion of the aneurysm.